School of Health Sciences

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Ascitic Fluid Enigma Effusion
Yahong Lin
School of Health Sciences UT MD Anderson Cancer
Center
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66 yr old man presented with a 4 month history of
abdominal complaints. Imaging studies (CT in
June 2006) demonstrated ascites and peritoneal
carcinomatosis, presumed to be of appendiceal or
colonic origin.
Paracentesis was performed under ultrasound
guidance and 3 liters of clear yellow fluid was
removed.
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Ascites, Pap-stain, 40x
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Ascites, Pap-stain, 200x
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Ascites, Pap-stain, 400x
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Ascites, Pap-stain, 400x (condenser open)
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Ascites, DQ-stain, 200x
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HE
Mucin
Cell Block, 200x
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CK7
CK20
Cell Block, 200x
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Calretinin
Cdx2
Cell Block, 200x
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Immunoperoxidase Stains
Mesothelial hyperplasia (Calretinin/
CK7- positive CDx2/ CK20- negative) Adenocarcinom
a (CDx2/ CK20- positive Calretinin/
CK7- negative)
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Discussion

• Two processes are represented in this fluid- one
  malignant and one reactive
• Adenocarcinoma appears mostly confined to a
  subset of the 3-D cell clusters, covered by a
  layer of mesothelium

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The patient had radiological response to
chemotherapy. Three months after the
paracentesis, he had cytoreductive surgery (right
hemicolectomy, omentectomy, splenectomy,
peritonectomies, segmental small bowel resection)
with hyperthermic intraperitoneal chemotherapy.
Appendix
1 cm.
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Appendiceal Serosa
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Serosa
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Postulations
-Tumorlets infiltrate, but cannot breakthrough
mesothelium, causing papillary projections, which
eventually break off -Tumor causes adhesions
(from inflammation and/or mucin blisters) and
tumorlets subsequently infiltrate
adhesions -Tumorlets infiltrate mesothelium, but
the proliferation of the tumor is less than the
regeneration of the mesothelium
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Appendiceal Carcinomas

• Appendiceal carcinomas are uncommon, accounting
  for 1 of colorectal cancer cases in the USA
• approximately 1,500 cases per year
• The primary tumor is usually small, but often
  perforates and disseminates throughout the
  abdominal cavity (peritoneal carcinomatosis)

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Follow-Up

• CT shows no definitive evidence of disease (as of
  February 2008, 12 months after surgery)

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References

• DeMay Richard M. The Art Science of
  Cytopathology. ChicagoASCP Press. 1996. p.
  257-325.
• Kende Al, Carr NJ, Sobin. Expression of
  cytokeratins 7 and 20 in carcinomas of the
  gastrointestinal tract. Histopathology. 2003 Feb
  42(2)137-40.
• 3. Misdraji J, Yantiss RK, Graeme-Cook FM, Balis
  UJ, Young RH. Appendiceal mucinous neoplasms a
  clinicopathologic analysis of 107 cases. Am J
  Surg Pathol. 2003 Aug 27(8)1089-103.
• 4. Young RH Pseudomyxoma peritonei and selected
  other aspects of the spread of appendeceal
  neoplasms. Semin Diagn Patho. 2004 May
  21(2)134-50.
• 5. Nonaka D, Kusamura S, Baratti D, Casali P,
  Younan R, Deraco M. CDX-2 expression in Pseudo
  myxoma peritonei a clinicopathological study of
  42 cases. Histopathology. 2006 Oct 49(4)381-7.

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Acknowledgements
Pathologist John Stewart, MD Instructor
Stephanie A. Hamilton, EdD
Catherine Murphy, MS Fellow students in
cytotechnology program from SHS
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Thank You