PART TWO
Diagnostic Cytology
Fig. 19.48 Smear of pleural effusion containing lymphocytes and two
plasma cells (Papanicolaou x HP).
Fig. 19.49 Smear of pleural effusion containing a normal megakaryocyte
derived from blood that had oozed from the pulmonary parenchyma into
the pleural cavities (Papanicolaou x HP).
to be touching each other, but the contact, involving only a
small segment of the periphery of each cell, is reminiscent of
a tentative kiss, whereas the contact between cells of small-cell
carcinoma is more of an embrace. This property of lymphoid
cells being separated from each other is obvious even in cell-
block preparations.
In contrast to purulent effusions, those dominated by non-
neoplastic lymphoid cells contain only a very small percent of
necrotic cells. A prolonged search under high power is usually
needed to find what seems to be a necrotic lymphocyte. Such a
necrotic lymphocyte may show the type of karyorrhexis consist-
ing of tiny round particles reminiscent of a dispersed drop of
mercury (mercury drop karyorrhexis). This type of karyorrhexis,
difficult to find in benign lymphocytic effusions, is frequently
seen in effusions containing lymphoma cells.71
Key features of lymphoid cells
• Small, round, with usually undetectable cytoplasm
and nucleoli;
• Non-coalescent; and
• Rarely necrotic in inflammatory lesions.
Megakaryocytes
Morphologically normal megakaryocytes are a rare find in
serous fluids. Almost all of the reported examples were associ-
ated with a myeloproliferative disorder, lymphoma, or meta-
static carcinoma, situations in which bone marrow was replaced
by either neoplastic cells or fibrous connective tissue, resulting
in extramedullary hematopoiesis immediately adjacent to a
serous cavity.72-79
We know of only one reported case in which the presence
of megakaryocytes in a serous fluid was clearly not associated
with extramedullary hematopoiesis.80 The patient developed
hemorrhagic pleural effusion caused by an overdose of anti-
coagulant, and the effusion contained megakaryocytes. Because
necropsy did not reveal myeloid metaplasia or a myeloprolifera-
tive disorder, their presence in the effusion was attributed to the
hemorrhagic condition of the lung, which enabled megakaryo-
cyte-containing blood from pulmonary capillaries (where meg-
akaryocytes are normally found) to enter the pleural cavity. The
megakaryocytes in this case were of the classic giant cell type,
with abundant cytoplasm and multilobed nuclei (Fig. 19.49),
similar to those in bone marrow.
Key features of megakaryocytes
• Rarely seen in serous effusions;
• Usually associated with a myeloproliferative disorder;
and
• Large cells with large polymorphous nuclei.
Detached Ciliary Tufts
In 1953, Ebner described motile ciliated cellular fragments
in fluid obtained from benign ovarian cysts;81 other research-
ers have also described the presence of such cellular fragments,
detached ciliary tufts (DCTs), in nonascitic fluid aspirated from
the peritoneal cavity by laparotomy or laparoscopy or in peri-
toneal dialysate.82-88 The phenomenon has been likened to
ciliocytophthoria
(CCP), a term Papanicolaou coined to describe
degenerated ciliated respiratory epithelial cells in sputum.89 CCP
is morphologically different from DCTs, a normal, physiologic
phenomenon that consists of anucleated fragments of ciliated
columnar epithelial cells derived from the fallopian tube. In
contrast, cells included under the term CCP may still contain
nuclei, and they frequently contain eosinophilic cytoplasmic
inclusions, a manifestation of degeneration. Neither nuclei nor
cytoplasmic inclusions are seen in DCTs. The terms DCT and
CCP should not be used synonymously; they refer to fundamen-
tally different though morphologically similar processes.
Cytology
In all of the reported cases of DCTs in fluid from the peritoneal
cavity, the patients were female, and all of them had their fal-
lopian tubes in situ, evidence of the tubal origin of DCTs. Very
occasionally a peritoneal washing may contain a large fragment
of ciliated glandular epithelium, presumably derived from a
fallopian tube.
DCTs are visible in toluidine blue-stained wet films as tiny,
ciliated, non-nucleated cellular fragments. If the specimen is
fresh, they may be seen to execute a jerky rotating and linear
movement. Because of this, they have been mistaken for a para-
site.88-91 Figure 19.50 illustrates DCTs in a stained wet film of
fluid from the cul-de-sac of a woman undergoing laparotomy
534
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