Developing a Prediction Score for the Diagnosis of Malignant Pleural Effusion: MPE Score.

BACKGROUND: The objective of this study was to develop a diagnostic prediction model for diagnosis of malignant pleural effusion (MPE) from pleural fluid cytology (MPE score). MATERIALS AND METHODS: Retrospective analysis of pleural fluid cytology was conducted in patients with MPE between 2018 and 2020. Multivariable logistic regression was used to explore the potential predictors. The selected logistic coefficients were transformed into a diagnostic predictive scoring system. Internal validation was done using the bootstrapping procedure. RESULTS: The data of pleural fluid cytology from 155 MPE patients were analyzed. Seventy-eight positive pleural cytology patients were found (50.32%). Lung cancer was the cancer most commonly sent for pleural fluid testing, with 66.67% positive cytology.  The predictive indicators included pleural fluid protein > 4.64 g/dL, pleural fluid LDH > 555 IU/L, and pleural fluid sugar > 60 mg/dL. Lung mass from imaging and double tap for pleural cytology were used for the derivation of the diagnostic prediction model. The score-based model showed that the area under the receiver operating characteristic curve was 0.74 (95% CI 0.66-0.82). The developed MPE score ranged from zero to 17. The cut-off point was 15 with 88.31% of specificity, 37.18% of sensitivity, positive predictive value of 0.76, and negative predictive value of 0.58. The measurement of the calibration was illustrated using a calibration plot (p-value = 0.49 for the Hosmer-Lemeshow based goodness of fit). Internal validation with 1,000 bootstrap resampling showed a good discrimination. CONCLUSIONS: The MPE score, as the diagnostic prediction model can be used in planning for more efficient diagnosis of MPE in patients with cancer under MPE.

Performance of Abbott Alinity hq hematology analyzer for automated cell counting of body fluids.

INTRODUCTION: Body fluid cell counting and differentiation provide essential information for diagnosis and monitoring of diverse pathologies. We evaluated the performance of the newly launched Abbott Alinity hq hematology analyzer for automated cell counting in body fluids and compared red blood cell (RBC) and total nucleated cell (TNC) counts with the Cell-Dyn Sapphire automated hematology analyzer. Differential counts were compared with microscopic differentiation on cytocentrifuged preparations. METHODS: Background concentration limits, limit of detection (LOD), linearity, imprecision, functional sensitivity and carryover were evaluated. For method comparison, we collected 172 body fluids (17 continuous ambulatory peritoneal dialysis fluids, 56 cerebrospinal fluids and 99 serous fluids). RESULTS: Background concentration limits were ≤1000 cells/µL for RBC counts and ≤3 cells/µL for TNC counts. The LOD was 1000 RBC/µL and 5 TNC/µL. Results from linear regression analysis revealed excellent linearity. Functional sensitivity was 3000 cells/µL for RBC counts and 50 cells/µL for TNC counts. Carryover was 0.6% and 0.1% for TNC and RBC, respectively. The Alinity hq shows good clinical performance. CONCLUSION: We demonstrated comparable performance for body fluid cell counting between the Alinity hq analyzer and the Cell-Dyn Sapphire. The Alinity hq can be very useful as a screening tool for body fluid cell counting.

Effusion fluid cytology and COVID-19 infection.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is responsible for coronavirus disease 2019 (COVID-19), is known to cause severe respiratory infections with occasional accompanying pleural effusion (PE), pericardial effusion (PCE), or peritoneal effusion (PTE). The effect of COVID-19 on effusion cytology is not yet known. This study aimed to examine the cytomorphologic features and workup of effusion fluids in patients with active COVID-19 infection versus those in recovery. METHODS: PE (n = 15), PCE (n = 1), and PTE samples (n = 20) from hospitalized patients with a SARS-CoV-2 infection (from June 1, 2020, to December 30, 2020) were reviewed. Effusion fluids with metastatic carcinoma were excluded. Differential cell counts, cytomorphology, and relevant immunostains for effusion fluids were retrospectively evaluated and compared between patients with active infection (positive on a SARS-CoV-2 nucleic acid amplification test [NAAT] within 2 months; n = 23) and those in the recovery phase from COVID-19 (negative on a SARS-CoV-2 NAAT for >2 months; n = 13). RESULTS: The cytology diagnoses were negative for malignancy (n = 31), atypical (n = 4), and suspicious for malignancy (n = 1). Active infection cases showed more atypical mesothelial cells than recovery cases (P < .05); some had enlarged nuclei, prominent nucleoli, occasional multinucleation, and bizarre nuclei. Immunostains were performed more often in active infection cases than recovery cases (47.8% vs 7.7%; P < .05). Differential cell counts (available for 28 cases) showed no significant differences between the active infection and recovery groups. CONCLUSIONS: This study found atypical and bizarre mesothelial cells more often in effusions of cases with active COVID-19 infection in comparison with patients in recovery. It is important for cytopathologists to become familiar with the cytomorphologic effects of SARS-CoV-2 on effusion cytology so that these cases can be properly triaged.

Cytologic analysis of vitreous fluids: A retrospective review of our 24 years of experience.

BACKGROUND: Cytologic analysis of vitreous fluid is an important component in diagnosis of vitreitis. No standard reporting guidelines exist for these specimens. This study chronicles our 24 years experience and proposes a tentative diagnostic model. METHODS: Retrospective cytology reports review and database study. Clinical indications, cytologic patterns, ancillary studies performed, and diagnoses were recorded. RESULTS: 176 samples from 160 patients were included and main cytologic patterns are reflected in Table 1. Most fluids were negative for malignancy (88%) and patterns IIB (53%) and IIA (19%) were dominant. The non-diagnostic rate was 7%; atypical and suspicious categories represented <0.5% of fluids tested and only 2% were positive for malignancy (3 intraocular lymphoma and one melanoma). Clinical indications for fluid examination were infection/inflammation (59%), to rule out lymphoma (11%), amyloidosis (3%), melanoma (2%), or to investigate intraocular hemorrhage. Fungal elements were demonstrated in 7 cases. No viral inclusions were appreciated; however, one case was positive for HSV 2 by IHC and 2 were negative by PCR. One case had Gram + cocci. Flow cytometry studies were suboptimal in 6 fluids, negative for an aberrant lymphocyte population in 11, and positive for high grade lymphoma in 3 cases. Atypical, suspicious and positive for melanoma were reported in 3 samples. Amyloid was identified in 1 aspirate. CONCLUSIONS: Cytologic analysis of vitreous fluid is a useful tool. Modern techniques like flow cytometry and PCR testing further expand the diagnostic possibilities. Standardization of diagnostic terminology will aid clinicians caring for patients suffering from ocular disease.

A sample-preparation-free, automated, sample-to-answer system for cell counting in human body fluids.

While many clinical laboratory tests are now highly automated, body fluid cell counting, particularly in low-cellularity samples such as cerebral spinal fluid (CSF), is often performed manually. Here, we report a simple, cost-effective method to obtain white and red blood cell counts from human body fluids such as CSF. The method consists of a compact, automated, and low-cost fluorescence microscope system, coupled to a sample chamber containing all of the necessary reagents in dry form to stain and prepare the sample. Sample focus and scanning are handled automatically, and the acquired multimodal images are automatically analyzed to extract cell counts. Comparison with manual counting on over 200 clinical samples shows excellent agreement. As the system counts a substantially larger image region than a standard manual cell count, we find our sensitivity to extremely low cellularity samples to potentially be higher than the manual gold standard, evidenced by our system recording images of cells in samples whose cell count was registered as "0" by a trained user. Thus, our system holds promise for routine, automated, and sensitive analysis of body fluids whose cellularity extends across a wide dynamic range.

Characterization of Coelomic Fluid Cell Types in the Starfish Marthasterias glacialis Using a Flow Cytometry/Imaging Combined Approach.

Coelomocytes is the generic name for a collection of cellular morphotypes, present in many coelomate animals, and highly variable among echinoderm classes. The roles attributed to the major types of these free circulating cells present in the coelomic fluid of echinoderms include immune response, phagocytic digestion and clotting. Our main aim in this study was to characterize coelomocytes found in the coelomic fluid of Marthasterias glacialis (class Asteroidea) by using a combination of flow cytometry (FC), imaging flow cytometry (IFC) and fluorescence plus transmission electron microscopy (TEM). Two coelomocyte populations (P1 and P2) identified through flow cytometry were subsequently studied in terms of abundance, morphology, ultrastructure, cell viability and cell cycle profiles. Ultrastructurally, P2 diploid cells were present as two main morphotypes, similar to phagocytes and vertebrate thrombocytes, whereas the smaller P1 cellular population was characterized by low mitotic activity, a relatively undifferentiated cytotype and a high nucleus/cytoplasm ratio. In the present study we could not rule out possible similarities between haploid P1 cells and stem-cell types in other animals. Additionally, we report the presence of two other morphotypes in P2 that could only be detected by fluorescence microscopy, as well as a morphotype revealed via combined microscopy/FC. This integrative experimental workflow combined cells physical separation with different microscopic image capture technologies, enabling us to better tackle the characterization of the heterogeneous composition of coelomocytes populations.

A comparison of the analysis of 3 types of body fluids using the XN-350 hematology analyzer versus light microscopy assessment.

ABSTRACT: We evaluated the capacity of the XN-350 instrument to analyze 3 different types of body fluid samples under "body fluid mode."The performance of XN-350 was evaluated in terms of precision, carryover, limit of blank, limit of detection, limit of quantification, and linearity. Cell enumeration and differential data produced by the XN-350 were compared to manual chamber counting results in 63 cerebrospinal fluid (CSF), 51 ascitic fluid, and 51 pleural fluid (PF) samples. Comparisons between XN-350 versus Cytospin data were also performed in PF samples.The precision, carry-over, limit of blank, and linearity of the XN-350 were acceptable. The limits of detection for white blood cells (WBCs) and red blood cells were 1.0/µL, and 1,000.0/µL, respectively; the corresponding limits of quantitation (LOQs) were 5.0/µL and 2,000.0/µL, respectively. The XN-350's cell enumeration and differential counting correlated well with those of manual chamber counting for all 3 sample types (except for differential counting in CSF samples), particularly parameters involving monocytes (r = 0.33) and mononuclear cells (MO- body fluid [BF]; r = 0.26), as well as total cell (TC-BF) enumeration (r = 0.50) and WBC-BF (r = 0.50) in PF samples. The MO-BF in CSF samples differed significantly from manual chamber counting results, but neither TC-BF nor WBC-BF in PF samples did. The XN-350 also showed good correlations with Cytospin analyses for differential counting of neutrophils, lymphocytes, and monocytes in PF samples. The differential counting of eosinophils via the XN-350 and Cytospin were not significantly correlated, but the difference between them was not significant.The XN-350 is an acceptable alternative to manual fluid analysis. Samples with low cellularity around the LOQ should be checked manually. Moreover, manual differential counting should be performed on CSF samples, particularity those with low cell numbers.

Ber-EP4 staining in effusion cytology: A potential source of false positives.

The distinction between reactive mesothelium and carcinoma in serous effusions can be very difficult. Immunocytochemistry (ICC) is the most widely used tool to improve the diagnostic accuracy of body fluid cytology, with several ICC markers being proposed. Ber-EP4 antibody has shown high sensitivity and specificity rates for diagnosing metastatic carcinoma. In our department, we have detected Ber-EP4 positivity in mesothelium in some cytological specimens. We reviewed all articles on Ber-EP4 staining in effusion cytology, summarized current findings and analyzed the staining pattern of all cases expressing Ber-EP4. Some cases showing Ber-EP4 positivity in mesothelium have been reported, most of which showed only weak Ber-EP4 staining or staining of less than 50% of mesothelial cells. However, some cases may show strong positivity both in cytological and histological specimens. Clinicians and pathologists should be aware of this source of misdiagnosis, and ICC results in mesothelium should be always interpreted cautiously and correlated with clinical tests, other ICC markers and patient's previous history.

Improving Malignancy Detection Rates in Body Fluids Submitted to the Hematology Laboratory for Nucleated Cell Count and Differential: A Quality Improvement Study.

CONTEXT.­: Body fluid specimens are regularly submitted to the hematology laboratory for cell count and differential. Unless there is high clinical suspicion for malignancy, most cases lack concurrent cytology review and may not benefit from more focused examination for malignancy. OBJECTIVE.­: To compare rates of malignancy detection before and after fluid-focused training for hematology technologists as part of a quality improvement initiative. DESIGN.­: During an 8-week pretraining period, body fluids submitted to the cytology laboratory were correlated with concurrent hematology specimens. After slide review and training sessions for the hematology technologists, the same data were collected for a 4-week period. Discrepant cases were reviewed by hematology laboratory supervisors and pathologists. RESULTS.­: We collected 465 pretraining and 249 posttraining body fluids with concurrent cytology and hematology evaluation. In the pretraining cohort, 48 cases (10.3%) were diagnosed as malignant by cytology; of those, 33 were detected by hematology. In the posttraining cohort, 30 cases (12.0%) were diagnosed as malignant by cytology of which 27 were detected by hematology. Of the 18 discrepant cases (all carcinomas), hematology slide review showed definite features of malignancy in 15 and no tumor cells in 3. The malignancy detection rate by the hematology laboratory significantly improved after training (68.8% versus 90.0%, P = .01). CONCLUSIONS.­: We demonstrate the comparatively lower malignancy detection rate for body fluid specimens processed in our hematology laboratory, particularly for carcinomas. Hematology technologist education/training improved the malignancy detection rate, an important quality improvement given the large proportion of body fluids undergoing hematology evaluation without concurrent cytology reviews.

Rho/SMAD/mTOR triple inhibition enables long-term expansion of human neonatal tracheal aspirate-derived airway basal cell-like cells.

BACKGROUND: Bronchopulmonary dysplasia remains one of the most common complications of prematurity, despite significant improvements in perinatal care. Functional modeling of human lung development and disease, like BPD, is limited by our ability to access the lung and to maintain relevant progenitor cell populations in culture. METHODS: We supplemented Rho/SMAD signaling inhibition with mTOR inhibition to generate epithelial basal cell-like cell lines from tracheal aspirates of neonates. RESULTS: Single-cell RNA-sequencing confirmed the presence of epithelial cells in tracheal aspirates obtained from intubated neonates. Using Rho/SMAD/mTOR triple signaling inhibition, neonatal tracheal aspirate-derived (nTAD) basal cell-like cells can be expanded long term and retain the ability to differentiate into pseudostratified airway epithelium. CONCLUSIONS: Our data demonstrate that neonatal tracheal aspirate-derived epithelial cells can provide a novel ex vivo human cellular model to study neonatal lung development and disease. IMPACT: Airway epithelial basal cell-like cell lines were derived from human neonatal tracheal aspirates. mTOR inhibition significantly extends in vitro proliferation of neonatal tracheal aspirate-derived basal cell-like cells (nTAD BCCs). nTAD BCCs can be differentiated into functional airway epithelium. nTAD BCCs provide a novel model to investigate perinatal lung development and diseases.

Development of a technique for evaluating the presence of malignant cells in prostatic fluid during robotic prostatectomy.

INTRODUCTION: To develop a technique to collect fluid expressed during robot-assisted radical prostatectomy (RARP) to assess whether malignant cells may have been inadvertently introduced into the surgical field. METHODS: Men with clinically localized grade group 2 to 5 prostate adenocarcinoma undergoing RARP were identified. Following bladder neck division, fluid expressed via prostatic urethra during seminal vesicle dissection was aspirated (specimen A). After specimen removal, an ex vivo seminal vesicle aspiration was performed as well (specimen B). Specimens were prepared with ThinPrep (Hologic, Marlborough, MA) and stained with 4 immunohistochemical markers: keratin-7, PAX-8, prostate-specific antigen (PSA), and prostatic acid phosphatase (PACP). RESULTS: Between December 2018 and May 2019, 15 men undergoing RARP were included. Median age was 60 years (range: 47-77), median PSA 8.5 ng/ml (range 5.1-24), and 7 (47%) had AUA high-risk disease. Specimen A had adequate cellularity in 13 patients (87%). Five patients were excluded from assessment of malignancy due to acellularity of specimen A (n = 2) or specimen B (n = 3). Three of the remaining 10 patients (30%) had cytologic features suspicious for malignancy on specimen A. Immunohistochemistry supported prostatic origin with positive PSA and PACP staining and negative PAX8 stains. Specimen B was not suspicious in any patient. CONCLUSION: We report a technique for intraoperative collection of fluid expressed during RARP. Three patients with adverse pathologic features had evidence of cancer cells within the operative field. Further work is needed to confirm this observation and to determine whether these cells are associated with adverse oncologic outcomes.

Liquid biopsy as a perioperative biomarker of digestive tract cancers: review of the literature.

Tissue biopsies are the gold-standard for investigating the molecular characterization of tumors. However, a "solid" biopsy is an invasive procedure that cannot capture real-time tumor dynamics and may yield inaccurate information because of intratumoral heterogeneity. In this review, we summarize the current state of knowledge about surgical treatment-associated "liquid" biopsy for patients with digestive organ tumors. A liquid biopsy is a technique involving the sampling and testing of non-solid biological materials, including blood, urine, saliva, and ascites. Previous studies have reported the potential value of blood-based biomarkers, circulating tumor cells, and cell-free nucleic acids as facilitators of cancer treatment. The applications of a liquid biopsy in a cancer treatment setting include screening and early diagnosis, prognostication, and outcome and recurrence monitoring of cancer. This technique has also been suggested as a useful tool in personalized medicine. The transition to precision medicine is still in its early stages. Soon, however, liquid biopsy is likely to form the basis of patient selection for molecular targeted therapies, predictions regarding chemotherapy sensitivity, and real-time evaluations of therapeutic effects.

Autologous culture method improves retention of tumors' native properties.

No current in vitro tumor model replicates a tumor's in vivo microenvironment. A culturing technique that better preserves a tumor's pathophysiological conditions is needed for some important clinical applications, including personalized drug-sensitivity/resistance assays. In this study, we utilized autologous serum or body fluid to build a 3D scaffold and grow a patient's tumor. We named this technique "3D-ACM" (autologous culture method). Forty-five clinical samples from biopsies, surgically removed tumor tissues and malignant body fluids were cultured with 3D-ACM. Traditional 3D-FBS (fetal bovine serum) cultures were performed side-by-side for comparison. The results were that cells cultured in 3D-ACM rebuilt tissue-like structures, and retained their immuno-phenotypes and cytokine productions. In contrast, the 3D-FBS method promoted mesenchymal cell proliferation. In preliminary chemo drug-sensitivity assays, significantly higher mortality was always associated with FBS-cultured cells. Accordingly, 3D-ACM appears to more reliably preserve a tumor's biological characteristics, which might improve the accuracy of drug-testing for personalized cancer treatment.

Exosomes and GPI-anchored proteins: Judicious pairs for investigating biomarkers from body fluids.

Exosomes are 50-100 nm membranous vesicles actively released by cells which can be indicative of a diseased cell status. They contain various kinds of molecule - proteins, mRNA, miRNA, lipids - that are actively being studied as potential biomarkers. Hereafter I put forward several arguments in favor of the potential use of glycosylphosphatidylinositol-anchored proteins (GPI-APs) as biomarkers especially of cancerous diseases. I will briefly update readers on the exosome field and review various features of GPI-APs, before further discussing the advantages of this class of proteins as potential exosomal biomarkers. I will finish with a few examples of exosomal GPI-APs that have already been demonstrated to be good prognostic markers, as well as innovative approaches developed to quantify these exosomal biomarkers.

Electrospun, synthetic bone void filler promotes human MSC function and BMP-2 mediated spinal fusion.

INTRODUCTION: Synthetic bone grafts are often used to achieve a well-consolidated fusion mass in spinal fusion procedures. These bone grafts function as scaffolds, and ideally support cell function and facilitate protein binding. OBJECTIVE: The aim was to characterize an electrospun, synthetic bone void filler (Reb) for its bone morphogenetic protein (BMP)-2 release properties and support of human mesenchymal stem cell (hMSC) function in vitro, and its efficacy in promoting BMP-2-/bone marrow aspirate-(BMA)-mediated posterolateral spinal fusion (PLF) in vivo. METHODS: BMP-2 release kinetics from Reb versus standard absorbable collagen sponge (ACS) was determined. hMSC adhesion and proliferation on Reb was tested using cell counting, fluorescence microscopy and MTS. Cell osteogenic differentiation was quantified via cellular alkaline phosphatase (ALP) activity. For in vivo analysis, 18 Lewis rats were treated during PLF surgery with the following groups: (I) Reb + BMA, (II) Reb + BMA + BMP-2 and (III) BMA. A safe, minimally effective dose of BMP-2 was used. Fusion consolidation was followed for 3 months using radiography and micro-CT. After sacrifice, fusion rate and biomechanical stiffness was determined using manual palpation, biomechanical tests and histology. RESULTS: In vitro, BMP-2 release kinetics were similar between Reb versus ACS. MSC proliferation and differentiation were increased in the presence of Reb. At 3 months post-surgery, fusion rates were 29% (group I), 100% (group II), and 0% (group III). Biomechanical stiffness was higher in group II versus I. Micro-CT showed an increased bone volume and connectivity density in group II. Trabecular thickness was increased in group I versus II. H&E staining showed newly formed bone in group II only. CONCLUSIONS: Reb possesses a high protein binding affinity and promotes hMSC function. Combination with BMA and minimal dose BMP-2 allowed for 100% bone fusion in vivo. This data suggests that a minimally effective dose of BMP-2 can be used when combined with Reb.

The diagnosis of primary thyroid lymphoma by fine-needle aspiration, cell block, and immunohistochemistry technique.

AIM: Primary thyroid lymphoma (PTL) is a rare malignant disease. Its prognosis depends on early diagnosis. The role of fine-needle aspiration (FNA), including smear cytology, cell block (CB) techniques, and immunohistochemistry (IHC) sections in the diagnosis of PTL is still unclear. Here we reported 19 cases of PTL and literature review to evaluate the diagnostic accuracy for lymphoma by cytology. METHODS: Our study retrospectively reviewed 19 patients diagnosed with PTL at the affiliated hospital of Southwest Medical University in China from June 2011 to May 2019. According to the Bethesda system for reporting thyroid cytopathology, the CB sections were evaluated for the presence of single tumor cells. IHC was performed on CB. RESULTS: The diagnostic accuracy for PTL of FNA, CB with smears, and the joint application of the three methods (FNA + CB + IHC) of our study with 19 cases was 68.4% (13/19), 83.3% (15/18), and 100% (17/17), respectively. CONCLUSION: The present study demonstrates that FNA has low sensitivity in diagnosing PTL, but the joint application of FNA, CB, and IHC might provide high diagnostic accuracy for lymphoma and should be applied in all cases where the clinical suspicion is high regardless of the FNA findings.

An alternative method for smear preparation of fine-needle aspiration cytology of cystic thyroid lesions: Evaluation of sample adequacy.

BACKGROUND: Cystic thyroid lesions represent one of the most common causes of unsatisfactory fine-needle aspiration sampling. Thus, it is important to access the maximum number of follicular cells from cystic fluid in order to reduce unsatisfactory rates. We compared the traditional method of smearing with an alternative one. METHODS: For each thyroid nodule, two smears were collected. Each smear was prepared using a distinct approach: either using the traditional technique or the alternative. Clinical data were taken from cytopathological request forms. The cytological aspects of the smears (eg, adequacy and number of cells) were observed during microscopy analysis. No cases were found to be suspicious for malignancy during ultrasound analysis (categories TR1 or TR2 according to ACR TI-RADS). RESULTS: Thirty-five cases were analyzed. For smears prepared using both the traditional and the alternative techniques, 20 and 4 cases, respectively, were unsatisfactory. In the 20 unsatisfactory traditional smear cases, 9 (45%) showed enough cells for diagnosis in cytospin and/or cell block samples; the four unsatisfactory alternative method cases showed the same. There was a statistical difference between the two methods of collecting a smear concerning sample adequacy (P < .001), but there was no statistical difference regarding the cellularity (P = .842). CONCLUSION: In our data, the alternative method of using only one slide and the needle tip had higher rates of adequate sampling. Since it is cost effective and does not change the cytological analysis, this proposed alternative method can be useful in cases of cystic thyroid lesions.

Exosomes as a Multicomponent Biomarker Platform in Cancer.

Cancer is a complex disease that is associated with genetic aberrations and subsequent cellular and noncellular host responses. Tumors harbor diverse cell types that engage in a dynamic interplay to sustain cancer-specific signaling networks. A component of such cellular communication is the production and exchange of various types of extracellular vesicle (EV). Exosomes are small EVs with growing recognition for their role in cancer progression and resistance to therapy. The unique biogenesis of exosomes, their ubiquitous production by all cell types, and their biological features in liquid biopsies have generated excitement for their potential as cancer biomarkers. Here, we discuss the challenges and utility of exosomes as multiparameter biomarker platforms for the detection of cancer. Exosomes reflect heterogeneous biological changes associated with growing tumors, potentially offering a more comprehensive assessment of cancer diagnosis, prognosis, and progression.