31

Cytology of Malignant
Mesothelioma
Richard M. DeMay

Because patients with mesotheliomas frequently present with effusions,

cytologic examination of the effusion uid may be the rst diagnostic
study. The uid is often yellowish, but many are bloody (13). It is
characteristically thick and mucoid owing to hyaluronic acid content.
The cell count is high, and typically remains high after repeated taps,
which is unusual in benign effusions.
In theory, the diagnosis of mesothelioma is easy, based on malignant
cells that look like mesothelial cells (Figs. 31.1 and 31.2). There is no
foreign, alien, extra, or discrete population of tumor cells, in contrast
with metastatic malignancy (47). Instead, there is a morphologic
kinship of the malignant cells with native mesothelial cells, forming a
continuous spectrum from apparently benign to atypical to malignantappearing mesothelial cells (413).
In practice, the diagnosis of mesothelioma can be difcult. For
example, the kinship that is so characteristic of mesothelioma is a
two-edged sword (4). This same morphologic feature that makes the
diagnosis possible can also make the diagnosis impossible in some
cases. Some mesotheliomas show only subtle cytologic abnormalities
(5,9,14). The malignant cells can be indistinguishable from benign, reactive mesothelial cells or even macrophages (12,15,16). At the other end
of the spectrum, in poorly differentiated tumors, the diagnosis of malignancy may be obvious, but the mesothelial origin may not be (4).
A key observation in the cytologic diagnosis of mesotheliomaone
that can be made at low microscopic poweris the presence of more
and bigger cells, in more and bigger clusters (4). Extreme mesothelial
cellularity suggests the diagnosis of mesothelioma (911,17,18), although abundant mesothelial cells can also occur in some benign conditions and not all mesotheliomas yield highly cellular specimens (4).
Furthermore, too many large clusters of cells suggest a diagnosis of
malignancy, particularly in pleural effusions, although again, not every
case has this feature (19).
Cell groups can range from small to large; large groups are sometimes
composed of hundreds of cells (12,13,20). Single cells are usually present
in mesothelioma, and predominate in some cases (6,8,9,11,12,14,21).
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Chapter 31 Cytology of Malignant Mesothelioma

Figure 31.1. Malignant mesothelioma: malignant mesotheliallike cells. Pap

stain (400).

When single cells predominate, the diagnosis can be more difcult; a

possible clue may be the sheer number of mesothelial cells (14).
Cell aggregates in mesothelioma characteristically are large, and
have knobby, ower-like, berry-like, or highly complex contours (Fig.
31.3) (4,11,17). In contrast, cell aggregates in benign effusions are fewer,
smaller, and less complex (13,18). Cell aggregates in adenocarcinoma
can be large, but tend to have smooth, community borders (5). The clus-

Figure 31.2. Malignant mesothelioma: malignant mesotheliallike cells. Romanovsky stain (400).

R.M. DeMay

Figure 31.3. Malignant mesothelioma: complex aggregate of malignant mesothelial cells. Pap stain (200).

ters are usually solid in mesothelioma, but can be hollow, mimicking

glandular acini (5,11,18). True acinar formation is characteristic of adenocarcinoma. Cell aggregates with central cores of collagen usually
indicate mesothelial cells (benign or malignant) (22). Collagen cores are
rare in adenocarcinoma. The collagenous material is homogeneous and
translucent. It stains cyanophilic in the Papanicolaou (Pap) stain and
is slightly metachromatic in Romanovsky stains (Fig. 31.4). Papillary
aggregates, though nonspecic, are more common in mesothelioma
than in either adenocarcinoma or benign effusions (16,21,23).
Cell-in-cell patterns (also known as cell-embracing, pincer-like
grip, cell engulfment, and cannibalism) (Fig. 31.5) are more

Figure 31.4. Malignant mesothelioma: metachromatic collagen core. Romanovsky stain (400).

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Chapter 31 Cytology of Malignant Mesothelioma

Figure 31.5. Malignant mesothelioma: cell-in-cell pattern, pincer-like grip,

characteristic of mesothelial cells. Pap stain (400).

common and more complex in mesothelioma than benign effusions

(4,5,7,14,17,23). Windows (openings between adjacent cells) are a
characteristic feature of (benign or malignant) mesothelial cells, and are
more common in mesothelioma than in adenocarcinoma (24) (Fig. 31.1).
Unfortunately, there are exceptions to these general rules presented
above, such as community borders in mesothelioma and knobby contours in adenocarcinoma (5).
Malignant mesothelial cells are typically more variable in size than
benign mesothelial cells and frequently larger and sometimes even
giant (Fig. 31.6) (5,25). However, frankly bizarre-appearing cells favor

Figure 31.6. Malignant mesothelioma: giant mesothelial cell. Pap stain (400).

R.M. DeMay

a diagnosis of carcinoma. Classically, the nucleus (N) and cytoplasm

(C) tend to change in size proportionately, so that the N/C ratio
remains relatively constant. This imparts a certain degree of uniformity
to mesothelioma, not usually seen in adenocarcinoma (4,26).
The cytoplasm of mesothelial cells is characteristically dense in the
center (endoplasm) and delicate toward the edges (ectoplasm) (Figs.
31.1 and 31.2) (9). A characteristic two-tone staining pattern is sometimes seen, in which the endoplasm stains pink to orange and the ectoplasm blue to green (4,9,19). Sometimes, dense, coagulated mummied
cells (similar to Councilman bodies in the liver) are seen in mesothelioma. These cells look a bit like dyskeratocytes, with pink-to-orange
cytoplasm and dark, pyknotic nuclei (Fig. 31.7) (4). Though rare, they
are a marker for mesothelioma (exclude squamous cell carcinoma)
(14,19).
Microvilli can sometimes be appreciated in the Pap stain as ne cytoplasmic projections that are metachromatic (pink) in Romanovsky
stains (4). Microvilli are rarely seen on adenocarcinoma cells in effusions, and even when they are, the microvilli are stubby and only
present on the luminal surface (in cell blocks). Similarly, cytoplasmic
blebs (prominent cytoplasmic outpouchings, probably degenerated
microvilli that coalesce) are often accentuated in malignant mesothelial cells, compared with benign ones, and are uncommonly seen in
adenocarcinomas (23).
Several kinds of vacuoles can be seen in mesothelioma, including
tiny lipid vacuoles, larger glycogen vacuoles, hard-edged hyaluronic
acid vacuoles, and clear, degenerative vacuoles. Both the number of
vacuoles and the number of vacuolated cells are highly variable. Adenocarcinoma can also have lipid, glycogen, mucin, or degenerative
vacuoles. Cytoplasmic vacuoles are often best appreciated with

Figure 31.7. Malignant mesothelioma: mummied mesothelial cell. Pap

stain (400).

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Chapter 31 Cytology of Malignant Mesothelioma

Romanovsky stains (4,12,23,27). Special stains can be helpful in differential diagnosis of vacuoles.
Mesothelial nuclei are usually located near the center of the cell,
while eccentrically located nuclei are more characteristic of adenocarcinoma (4,8,12). Binucleation and trinucleation are fairly common,
and multinucleation occurs, although these are nonspecic ndings.
Although the usual nuclear criteria of malignancy (pleomorphism,
enlargement, abnormal chromatin, nucleoli, etc.) apply in the diagnosis of mesothelioma (19), nuclear atypia can be subtle in some cases
(6,18). Conversely, marked nuclear atypia can be seen in benign conditions such as hepatitis, uremia, pancreatitis, and postradiation, as
well as adenocarcinoma. Degeneration can cause changes that mimic
malignancy.
Marked nuclear membrane irregularity is associated with malignancy, but may not be a prominent feature. Irregular nuclear membranes can also be seen in benign mesothelial cells, particularly in
washing specimens (daisy cells). Intranuclear cytoplasmic invaginations, rare in benign mesothelial cells, can be seen in either mesothelioma or adenocarcinoma (4,12,28,29). Chromatin abnormalities range
from subtle to obvious. However, marked hyperchromasia is usually
absent, unless the cells are degenerated (which usually gives the chromatin a smudgy, homogeneous appearance) (14). Nucleoli are usually
seen in mesothelioma and may be enlarged, multiple, or irregular in
outline (30). Macronucleoli, if present, suggest malignancy (19).
Mitoses are uncommon, and not helpful in diagnosis unless they are
clearly abnormal (9,12,14).
The hyaluronic acid that is characteristic of mesothelioma can sometimes be seen in cytologic specimens as a occulent material in the
background of the slide (4,9). In Romanovsky stains it resembles synovial uid: coarsely granular, pink (metachromatic) precipitate (16). In
the Pap stain, it ranges from granular to uffy to bubbly in appearance
(Fig. 31.8) (31).
Psammoma bodies or marked lymphocytic inltration can occur in
mesothelioma (12,32); both are nonspecic (23). Necrosis and debris are
not common in mesothelioma, but favor malignancy when seen (with
exceptions, particularly infections) (12,33).
False-negative diagnoses are well known in mesothelioma. Most
false negatives are due to inadequate sampling (i.e., unsatisfactory
specimens with few or no mesothelial cells) (19,34). Sarcomatous
mesothelioma is rarely diagnosed in exfoliative cytology, since few or
no diagnostic cells are exfoliated (35,36). Benign mesothelial proliferations with reactive (atypical) mesothelial cells can be difcult to
distinguish from mesotheliomas (see below) (30). Conversely, cytologically bland mesotheliomas, composed of cells resembling benign
mesothelial cells or histiocytes, are difcult to recognize as malignant
(15,16,37). At the other extreme, sometimes the malignant cells are
highly abnormal appearing, with clearly malignant features. In such
cases, the diagnosis of malignancy may be obvious, but the cell of
origin may not be evident (13,38).

R.M. DeMay

Figure 31.8. Malignant mesothelioma: occulent background, hyaluronic acid.

Pap stain (400).

False-positive diagnoses of mesothelioma are rare, but can occur

(14,19). Although large clusters of benign mesothelial cells can occasionally be seen in benign effusions, particularly in pericardial
effusions or ascites, they are unusual (19,3942). Diagnosis of mesothelioma based on complex aggregates of atypical mesothelial cells is reliable, but diagnosis based on single atypical mesothelial cells is more
difcult (19).

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