The influence of the wet-fixed Papanicolaou and the air-dried Giemsa techniques on nuclear parameters in breast cancer cytology: a cytomorphometric study

Rehydration of Air-Dried Smears with Normal Saline: An Alternative for Conventional Wet Fixation Method in Cervical Cytological Study

Context:

Papanicolaou (Pap) smear is an effective exfoliative cytological investigation done for early recognition of cervical cancer. It also plays role in diagnosis of inflammatory lesions of cervix.

Aims:

The aim of this study is (1) to compare the cytomorphological features in conventional Pap smear (C-PAPS) and rehydrated air-dried Pap smear (RADPS) and (2) to evaluate the efficacy of RADPS in cytodiagnosis of cervical lesion by comparing with cytomorphological features of conventional wet-fixed Pap smear.

Subjects and Methods:

Paired cervical smears were prepared for 247 patients. One was labeled as C-PAPS and another was labeled as RADPS. Comparison of both smears was done for various cytomorphological parameters.

Results:

Out of 247 smears, 2.4% RADPS and 7.3% C-PAPS were reported as unsatisfactory. Red blood cell (RBC) background was present in 2% of RADPS and 42% of C-PAPS. Cytolysis and air-drying artifact were observed more in C-PAPS amounting to 2% and 4% in RADPS and 11% and 15% in C-PAPS. Cytoplasmic staining (97% RADPS vs. 94% C-PAPS) was superior in RADPS. Cell border, nuclear border, and chromatin of squamous and endocervical cells were better appreciated on RADPS compared to C-PAPS, and also statistically significant difference was observed.

Conclusion:

Rehydrated air-dried technique can be satisfactory alternative for conventional wet fixation method which can be followed routinely or in conjugation with C-PAPS, especially in cervical screening programs.

Association between Breast Cancer Recurrence and Cellular Dissociation Assessed Using Fine-Needle Aspiration

OBJECTIVE

To determine the associations between breast cancer recurrence and cytological findings of fine-needle aspiration cytology (FNAC).

STUDY DESIGN

The study included 117 women who had undergone a modified radical mastectomy for invasive ductal carcinoma of the breast. FNAC samples of these patients were reexamined, and cytological findings, such as cellular dissociation, nuclear pleomorphism, nuclear atypia, chromatin pattern, and nuclear size, were scored. Uni- and multivariate analyses were performed to determine the prognostic significance of the cytological findings. Corresponding cancer tissues were immunostained for estrogen receptor, progesterone receptor, human epidermal growth factor 2 (HER2), p53, and E-cadherin to determine their associations with cytological findings. Coexpression of Arp2 and WAVE2 was also examined immunohistochemically as a cell locomotion signal.

RESULTS

Cellular dissociation (p = 0.0259) and nuclear size (p = 0.0417) were significantly associated with cancer recurrence. Multivariate analysis showed that cellular dissociation and histological grade were significant independent predictors of cancer recurrence. Cellular dissociation was found to be associated with coexpression of Arp2 and WAVE2 (p = 0.0356) and HER2 (p = 0.0469).

CONCLUSION

The cytological finding of cell dissociation was associated with the activation of Arp2 and WAVE2 signals and was an independent predictor of recurrence.

Expansion of Masood's cytologic index for breast carcinoma and its validity

BACKGROUND

The incidence of breast carcinoma is increasing in developing countries due to adoption of western life-style. Fine-needle aspiration cytology is the initial method to evaluate the palpable breast lesions. The neoadjuvant therapy is helpful in treating high grade rather than low grade breast carcinomas. Masood cytologic index (MCI) delineates all the breast lesions into four groups. The carcinoma group is not graded further.

AIM

The present study proposes a method for the expansion of carcinoma group into three grades.

MATERIALS AND METHODS

A total of 50 breast carcinoma cases were prospectively studied by comparing expansion of MCI with modified bloom Richardson (MBR) grading over a period of 3 years.

RESULTS

Altogether 43/50 cases (86%) had concordance with histopathological grading. The analysis revealed a R2 value of 60%, which was significant. The P value of anisonucleosis, nucleoli and chromatin pattern were 0.001, 0.049 and 0.02 respectively, which were significant.

CONCLUSIONS

The present study with the expansion of carcinoma category of MCI into three grades similar to MBR will help the treating surgeon to plan the management accordingly. The results obtained in this study need to be subjected to multicentric study with a large number of cases.

Rapid-air-dry papanicolaou stain in canine and feline tumor cytology: a quantitative comparison with the Giemsa stain

The Papanicolaou stain is a gold-standard staining method for tumor diagnosis in human cytology. However, it has not been used routinely in veterinary cytology, because of its complicated multistep procedure and requirement for wet fixation. Currently, a rapid Papanicolaou stain using air-dried smears is utilized in human cytology, but usefulness of this rapid-air-dry Papanicolaou (RAD-Pap) stain in the veterinary field has not been fully evaluated. The purpose of this study was to evaluate the usefulness of the RAD-Pap stain by using quantitative analysis. Air-dried impression smears were collected from tumor specimens and stained with RAD-Pap and Giemsa. Twelve parameters representing the criteria of malignancy were quantitated, and characteristics of the RAD-Pap were evaluated statistically. The RAD-Pap stain could be applied to all the smears, and images of nucleoli and chromatin patterns were clear and detailed. In quantitative analysis with the RAD-Pap stain, but not with the Giemsa stain, dispersion of nucleolus size and dispersion of nucleolus/nucleus ratio in malignant tumors were significantly higher than those in benign tumors. These findings demonstrated that the RAD-Pap stain was useful for obtaining detailed nuclear information, and the ability to differentiate benignity and malignancy by nucleolus findings was a principal advantage of this stain. This RAD-Pap stain could be routinely used as a supportive staining method in veterinary diagnostic cytology.

Prognostic/Predictive Factors in Breast Cancer

This can be an exciting time for pathologists and cytopathologists as we refine or knowledge of prognostic/predictive factors in breast cancer. We can become more visible in our role as consultants to the other physicians, and more engaged in our role as re-searchers. Recent advances in computer science, coupled with the availability of new biological markers, now provide unique opportunities for us to expand our diagnostic abilities and also predict the biologic behavior of a given tumor. Thus, we must become more familiar with emerging concepts and technologies in different disciplines.

Cytomorphology of Common Malignant Tumors of the Breast

A definitive cytologic diagnosis of breast cancer is usually possible when using the six major criteria of malignancy (cellularity, dyshesion, monomorphism, anisonucleosis, irregular nuclear membranes, prominent nucleoli) as part of the triple test. Carcinomas of special type have unique clinical and cytologic features that pathologists need to consider, because these may confuse interpretation. Complete subtyping of carcinomas may not always be possible by fine needle aspiration. Diagnostic accuracy for breast carcinoma is excellent. False-negative diagnoses are infrequent and chiefly due to sampling issues. False-positive diagnoses are extremely rare. Uniform report terminology should be used to ensure that diagnostic information is conveyed appropriately and consistently to guide the next diagnostic or treatment step.

Cytopathological grading, as a predictor of histopathological grade, in ductal carcinoma (NOS) of breast, on air-dried Diff-Quik smears

Fine-needle aspiration cytology (FNAC) is a widely practiced technique in the diagnosis of breast carcinoma, and it is the only diagnostic procedure performed before definitive treatment, at most institutions. While the histological grading of breast carcinoma has become routine in many centers worldwide, the cytopathological grading of breast carcinoma is not commonly used. Grading of breast carcinoma, while the tumor is still in vivo, would be the most ideal and desirable situation, as it would be helpful in the selection of patients for appropriate therapy. The objective of this study, therefore, was to devise a simple system for grading breast carcinoma, based on the cytological features alone. We reviewed 125 cases of breast carcinoma retrospectively, which were initially diagnosed by FNAC, with subsequent histopathological confirmation. These included 105 ductal, 6 lobular, 2 tubular, 1 papillary, and 1 medullary carcinoma. There was 1 ductal carcinoma in situ. Nine cases were rendered insufficient for grading. Thus 105 cases of ductal carcinoma (NOS) were evaluated for final cytological grading. Air-dried Diff-Quik-stained smears were reviewed at least twice independently by four histopathologists and were then compared with the original histological grades. Six cytological features used for grading were found to be statistically significant: cellular pleomorphism, nuclear size, nuclear margin, nucleoli, naked tumor nuclei, and mitoses. A scoring system based on these six essential parameters was used, to classify ductal carcinoma into three cytological grades, which showed close correlation with the established histological grades. In addition, two less consistent, but still important, features were the presence or absence of necrosis and stromal invasion. Another six parameters, including smear cellularity, degree of cell dispersion or clustering, lymphoplasmacytic infiltrate, presence of tubular structures, cytoplasmic appearance of the tumor cells, and smear background, were not statistically significant. However, these additional parameters were found helpful in assigning the correct grade, in cases with borderline scores. The concordance rate with histology was 100% for grade 1, 98% for grade 2, and 93% for grade 3.

Cytological grading of breast cancer in Giemsa-stained fine needle aspiration smears

A potential cytological nuclear grading based on a semi-quantitative evaluation of three basic nuclear features, size of cell nuclei, anisonucleosis and the proportion of nucleoli-containing-nuclei, was tested on 74 Giemsa-stained fine needle aspiration of breast smears for its reliability in establishing the malignant potential of breast cancer. The prognostic impact of DNA-ploidy and S-phase fraction was also assessed. A good correlation between the three basic nuclear features, DNA-ploidy, S-phase fraction, cytological nuclear grade and histological grade, was shown. Using the cytological nuclear grade proposed, correct classification of cases between low histological grade (HG I) and high histological grade (HG II + HG III) was achieved in 79.73%. A statistically significant difference in 5-year survival rate was also observed between low malignancy grade and high malignancy grade breast cancer patients, regardless of the grading method used. DNA-ploidy and S-phase fraction were not statistically significant in establishing the malignant potential of breast cancer.

Prognostic factors in breast cancer: use of cytologic preparations

There is increasing evidence that certain morphological features and biological markers found in breast tumors may provide prognostic information by predicting the risk of recurrence and metastasis in early breast cancer. This information may also be important in choosing therapeutic options in patients with advanced disease. Prognostic testing is commonly performed on surgically excised lesions. However, there are clinical conditions in which a surgical specimen may not be suitable or available for such analysis. In these circumstances, fine-needle aspiration biopsy and imprint preparation provide an attractive sample for prognostic testings. This review summarizes the current approach to the use of cytologic preparation for assessment of established and newly recognized prognostic factors.

Prognostic factors from the fine-needle aspirate: breast carcinoma nuclear grade

Two of the most important microscopically derived morphologic prognostic factors for breast carcinoma patients are histologic type of tumor and nuclear grade. The recent literature stresses the importance of including these parameters in the surgical pathology report, yet there is little information in the cytology literature regarding the reporting of the nuclear grade of breast carcinomas from fine-needle aspirate biopsies (FNAB). In this retrospective study, we examined 104 ductal carcinomas of the breast in order to determine whether the FNAB derived nuclear grade and morphologic aspects of histological grading such as tubule formation and mitoses could accurately correlate with the same parameters on the tissue specimens. There was a correlation of 87% between the nuclear grade assigned by FNAB and the nuclear grade assigned to the tissue sample. Both the Diff-Quik and the Papanicolaou staining methods were assessed in this study and both gave comparable nuclear grade results. Tubule formation was difficult to assess on the cytologic samples and mitoses showed no correlation between cytologic and tissue specimens. The FNAB sample was not representative of the tissue nuclear grade in only 4.8% of the cases. Nuclear grade is especially important in patients treated with chemotherapy prior to definitive therapy for breast carcinoma. We conclude that the nuclear grading of breast carcinomas is performed with ease, correlates well with tissue nuclear grade, and, as a fundamental cytologic parameter, should be included in the fine-needle aspirate biopsy report whenever possible.

Prognostic value of cytological grading of fine-needle aspirates from breast carcinomas

Because neoadjuvant therapy, including preoperative chemotherapy and tamoxifen, is becoming increasingly common for early breast cancer, it is desirable to grade tumours before surgery so that the most appropriate medical regimen can be selected. We have used a cytological grading system for ductal carcinoma of type not otherwise specified (NOS). Wet-fixed Papanicolaou-stained breast aspirates are examined for the extent of cell dissociation, cell size and uniformity, and the appearance of nucleoli, the nuclear margin, and chromatin. 377 invasive breast carcinomas were removed after preoperative diagnostic fine-needle aspiration cytology (FNAC) during the 25 months of the study. 286 tumours were ductal carcinomas NOS on histology. We established three cytological grades and found that cytological grade corresponded well with the established histological grades (Elston's modified Bloom and Richardson method). All cytological features included in the score were equally important on regression analysis. This study shows that grading of breast cancer on FNAC is feasible and reproducible. Cytological grade may substitute for histological grade, so a combination of FNAC and mammography can provide information on tumour type, grade, and size before surgery. We recommend this grading system to centres that use FNAC for the diagnosis of breast cancers.

Practical aspects of fixatives in high resolution nuclear image analysis

Three different methods of fixation (ethanol/Carbowax, formaldehyde, and Carnoy) and four different protocols (without Böhm post-fixation on an uncoated slide, and with Böhm post-fixation on Poly-L-Lysine coated slide, an uncoated slide and a previously Papanicolaou stained slide) were evaluated for their application in high resolution image analysis of Feulgen stained nuclei. The aim of the study was to find a combination with the best reproducibility and the least variance under normal laboratory conditions. Care was taken not to exclude any "normal" laboratory variability. The combinations were evaluated for densitometric, geometric, as well as texture features. Selected features were determined on a CAS-100 using the Cell Measurement Program (Cell Analysis Systems, Inc. Lombard, IL). Diploid and tetraploid rat liver nuclei were used. Ethanol/Carbowax fixation-with Böhm post-fixation proved most stable. This fixation method also gave feature values for previously Papanicolaou stained slides that were comparable to direct Feulgen stained nuclei. Acceptable results were achieved with all three fixatives and the various combinations if one adhered strictly to protocol. In routine practice this usually does not happen. Therefore Ethanol/Carbowax fixation with Böhm post-fixation was considered most suited for routine determination of feature values on the CAS-100.