Comparison of brush cytology before or after biopsy for diagnosis of gastric carcinoma

Role of cytopathology in the diagnosis and management of gastrointestinal tract cancers

Cytology of gastro-intestinal (GI) tract lesions can be used successfully to diagnose neoplastic and non-neoplastic conditions, especially when combined with biopsies. Cytologic evaluation is widely accepted as a cost-effective method that allows rapid interpretation and triaging of material. Technical advances over the years have allowed simultaneous visualization of abnormal tissue and procurement of needle aspirates, brushings and biopsies from mucosal and deeper seated lesions. Successful cytologic examination of the GI tract is highly dependent on the skill of the endoscopist, specimen preparation, the expertise of the pathologist, and the recognition of the limitations of cytology. This article reviews the key cytologic features of important GI tract lesions, differential diagnoses, and pitfalls, and addresses the advantages and limitations of different collection techniques.

Gastrointestinal tract cytology: advancing horizons

Tide and ebb of interest in gastrointestinal tract cytology has followed technical advances in this field over the last 60 years. Cytologic samples can be obtained using gastric lavage, abrasive balloons, mucosal brushing, and fine needle aspiration (under percutaneous image guidance, endoscope and endoscopic ultrasound guidance). These advances now allow simultaneous performance of brushing the abnormal mucosa, obtaining fine needle aspirates and excising mucosal biopsy samples for evaluation. Use of endoscopic ultrasound guided fine needle aspirates now help to obtain diagnosis of submucosal lesions, preoperative staging of gastrointestinal tract malignancies and help determine further management of patients. Such advances have brought pathologists to the forefront of the patient management team for the treatment of gastrointestinal tract lesions. This manuscript reviews the advantages and limitations of each cytology associated technique as well as reviews the salient diagnostic features, differential diagnosis and diagnostic pitfalls of gastrointestinal tract lesions. Finally, it suggests the modalities best suited to obtain diagnosis for various gastrointestinal tract lesions.

Comparison of brush before biopsy, suction cytology, brush after biopsy and endoscopic biopsy in the diagnosis of carcinoma oesophagus

A study was conducted on 40 patients of carcinoma oesophagus to compare the diagnostic yield of brush biopsy, suction cytology, brush after biopsy and endoscopic biopsy. The positive yield with brush before biopsy was 87.5%, with suction cytology 90%, with brush after biopsy 100% and with endoscopic biopsy 90%. Difference in the yield of brush after biopsy compared to other modalities was statistically insignificant (P > 0.05). However, the quantitative yield of the material was significantly high (P < 0.05) in the brush after biopsy compared to brush before biopsy. Of these three cytological modalities brush after biopsy appears to be the cytological technique of choice to be used as an adjunct to endoscopic biopsy.

Endoscopic review of patients who have had gastric surgery

Seventy one patients who had had operations on their stomachs over 15 years previously were examined by endoscopy and multiple mucosal biopsy sampling. Sixty six had histologically proved gastritis (56 chronic atrophic gastritis, 10 superficial gastritis), 38 intestinal metaplasia, and 11 epithelial dysplasia. In three cases the epithelial dysplasia was severe (carcinoma in situ). One patient had an infiltrating carcinoma and another, whose biopsy appearances were reported as severe dysplasia, developed a carcinoma of the stomach eight months later. All patients having undergone gastric surgery more than five years previously should be screened endoscopically and any found to have moderate dysplasia subjected to regular endoscopic screening thereafter. Patients with severe dysplasia (carcinoma in situ) should be considered for radical surgery.

Gastroscopic cytology and biopsies in diagnosis of gastric malignancies

The outcome in gastric malignancy has changed in recent years owing to its early and accurate diagnosis employing fiber-optic endoscopy and histocytology. One hundred and two subjects with endoscopic demonstration of various gastric lesions were subjected for brush cytology and multiple biopsies. Observing a high degree of specificity, the accuracy of brush cytology was 81% and histology 72% with cumulative diagnostic yield of 91%. There was no false-positive report with cytology; histology, however, gave three false-positive results. The present study thus confirms the high diagnostic accuracy of brush cytology combined with multiple biopsies in gastric malignancies.

Peroperative frozen section and cytology to assess proximal invasion in gastro-oesophageal carcinoma

Peroperative frozen sections and cytological material have been obtained in 39 consecutive gastro-oesophageal resections between October 1978 and February 1980. Material from the proximal edge of the resected specimen was unreliable because of 3 false positive cytology results and 1 false positive frozen section report. Frozen section (no errors) was shown to be significantly more accurate than cytology (6 errors) when material was obtained from the distal oesophagus. Fatal anastomotic dehiscence occurred in only 1 of 30 resections when the excision was adequate. Where the results of frozen section were acted upon, in 5 of 9 patients with an inadequate excision, only 1 fatal dehiscence occurred compared with fatal dehiscence in all 4 patients where a second excision was not performed. These results indicate that frozen section of the distal oesophagus should be used to determine the extent of oesophageal resection in operations for gastro-oesophageal cancer.

Evaluation of endoscopic brush and biopsy touch smear cytology and biopsy histology in the diagnosis of carcinoma of the lower oesophagus and cardia

A four-year prospective study of endoscopic cytology and histology was carried out on 64 patients suspected of having a malignant lesion at the junction of the lower oesophagus and cardia. The final diagnosis was malignant in 18 and benign in 46 cases. Biopsy touch smear cytology was the most accurate technique with a sensitivity of 100% compared with 82% for brush cytology and 89% for biopsy histology. There was one false positive endoscopic histology report, but no false positive cytology result. Biopsy touch smear cytology is at present a method little used in the digestive tract. This study demonstrates its value in the diagnostically difficult area of the gastro-oesophageal junction.

Three year trial of endoscopic cytology of the stomach and duodenum

The results of endoscopic cytology during the period 1974 to 1976 are presented. These consist of a pilot study on 76 patients and a main trial on 329 patients, of whom 61 proved to have malignant disease as the final diagnosis. Methods of cell collection, preparation, and reporting are given. Special emphasis was placed on making a definitive diagosis, especially the distinction between severe atypia and malignancy, and 'suspicious' reports were not issued. The overall accuracy achieved for all tumour types was 91.8%, with an accuracy of 98% in the diagnosis of adenocarcinoma of the stomach. There were no false positive cytology reports. Endoscopic histology on the same patients gave an accuracy of 68.9% and did not give a positive result in any of the five cases with false negative cytology. Adequate sampling, a variety of cell collection methods, and great care in technique are necessary in order to obtain optimum sensitivity and specificity in cytological diagnosis.