Endoscopic brushing cytology and biopsy in the diagnosis of upper gastrointestinal tract lesions. A study of 350 cases

Direct-vision endoscopic examination conducted on 4,000 patients for persistent upper gastrointestinal (GI) complaints over a period of five years revealed 350 visible lesions that were subjected to brushing cytology and biopsy. Cytologic examination of brushing smears from all 350 cases showed malignant cells in 67 (19.14%), cells suggesting benign polypoid neoplasms in 4 (1.14%), ulcerative and reparative features with attendant atypias in 186 (53.14%), inflammatory findings in 91 (26%) and false-negative findings in 2 cases (0.57%). Only 259 (74%) of the visible lesions were also subjected to endoscopic biopsy. Of the 67 patients with positive cytology, 52 were judged positive on the biopsy specimen; the 2 false-negative cytologic reports were confirmed as positive by biopsy. In four patients with gastric ulcers, malignant cells were seen along with gastric repair cells. This study indicates that brushing cytology is very useful in detecting benign ulcerative lesions with their atypias, a feature that could be useful in monitoring and controlling lesions in high-risk groups of patients, such as in India. In this study, endoscopic brushing cytology gave a better diagnostic yield than did endoscopic tissue biopsy. However, the two techniques are complementary for the diagnosis of upper GI malignancies.     

Endoscopic "salvage" cytology in neoplasms metastatic to the upper gastrointestional tract

Endoscopic "salvage" cytology was the only successful nonoperative diagnostic method in two patients with malignancy metastatic to the upper gastrointestinal tract. Smears and cell blocks of centrifuged material aspirated from the endoscope channel provided diagnoses of malignancies when other diagnostic techniques had been nonproductive. The results in these cases support the general utility of this technique and indicate its successful application in this specific clinical setting.     

Endoscopic cytology and biopsy in the diagnosis of gastroesophageal malignancy

Direct-vision endoscopic cytologies and biopsies were performed on 1,437 patients during a five-year period, and the incidence, correct typing and diagnosis of gastroesophageal cancer were studied. At the first cytology, malignant cells were diagnosed in 80 cases, all of which were confirmed by the endoscopic biopsy; in 30 cases, despite suspicious cytology, no malignancy was seen at the first biopsy. At repeat endoscopic cytology and biopsy, however, 21 of these 30 cases were correctly correlated for malignancy, resulting in a final correct correlation in 101 of the 110 cases (91.8%) and a diagnostic discrepancy in 9 cases (8.2%). It thus appears that the procedure is useful in diagnosing gastroesophageal cancer in the majority of cases. In the cases of discrepancies, gastric ulcers were found later; the repeatedly suspicious cytologies were due to the cytologic atypia of the cells from regenerating hyperplastic and/or metaplastic epithelium at the margins of the ulcers. Such cells showed a wide spectrum of changes, ranging from mild atypia to severe atypia mimicking adenocarcinoma of the upper gastrointestinal tract.     

FISHing for pancreatobiliary tract malignancy in endoscopic brushings enhances the sensitivity of routine cytology

Pancreatobiliary tract carcinoma is a lethal disease with low survival rates and limited treatment options. Diagnosis is complicated by benign conditions that can mimic malignancy on radiological studies (e.g. primary sclerosing cholangitis or PSC) and the suboptimal sensitivity of endoscopic biopsy/brushings obtained by endoscopic retrograde cholangiopancreatography (ERCP). The detection of multiple chromosomal gains by fluorescence in situ hybridization (FISH), referred to as polysomy, has demonstrated improved sensitivity over routine cytological evaluation. The evaluation of brushings by both routine cytology and FISH in our cytopathology laboratory has been in clinical practice since 2003. Strong morphological and screening skills enable cytotechnologists to become proficient in the assessment of FISH slides, which translates into cost and time savings. Multiple reports from various institutions have demonstrated the utility of FISH for patients with and without PSC. The incorporation of routine cytology and FISH results into the management algorithm for patients under suspicion for pancreatobiliary malignancy is a testament to the clinical success of these cytological assays.     

Acute upper gastrointestinal tract bleeding and recent alcohol ingestion

Alcohol ingestion is a reason for hospital admission for what may be termed trivial or even spurious gastrointestinal bleeding. This clinical entity can be recognized and hospital admission avoided. It is suggested that in the case of men under the age of 40 who present with a history of hematemesis and who are intoxicated to a variable degree but without a history of recent salicylate ingestion or previous dyspepsia, and in whom the hemoglobin level is above 13.0 g/dl it is acceptable management to send them home with instructions to seek help only if there is fresh, authenticated bleeding. This attitude is further supported by a normal blood volume measurement and the absence of blood from a gastric aspirate.     

Cytologic features of premalignant glandular lesions in the upper gastrointestinal tract

The cytologic findings in 13 endoscopic brushing specimens from biopsy-proven premalignant glandular lesions (PGLs) of the upper gastrointestinal tract were reviewed retrospectively. The specimens were from ten patients: three with dysplasia in Barrett's esophagus, four with gastric adenomas and three with duodenal adenomas. One dysplasia in Barrett's esophagus and four adenomas (two gastric and two duodenal) had coexisting adenocarcinomas. Most pure PGLs were characterized cytologically by cohesive three-dimensional clusters of cells with more-or-less uniformly enlarged nuclei and an increased nuclear/cytoplasmic ratio. Crowding and molding were present within these clusters; however, the cells were arranged in a somewhat orderly or palisading fashion, instead of entirely haphazardly. In cases of carcinoma coexisting with adenoma or dysplasia, the atypical cells tended to be more pleomorphic and dyshesive. In one specimen from an adenocarcinoma arising in an adenoma, the adenomatous and carcinomatous components could be distinguished cytologically.     

Cytodiagnosis of in situ and early carcinoma of the upper gastrointestinal tract

Three cases of adenocarcinoma of the stomach, two in situ and one superficially invasive, and one of superficially invasive squamous-cell carcinoma of the esophagus are presented to illustrate the problems encountered in the diagnosis of early lesions of the upper gastrointestinal (GI) tract and the contribution that cytodiagnosis can make. The symptomology and roentgenographic findings in these cases were largely nonspecific. While endoscopic biopsies were repeatedly negative in three of the four cases, endoscopic brushing cytology consistently indicated the presence of a malignancy. Surgery was finally performed on the basis of the cytologic findings, confirming the presence of early malignancy. The cytologic findings, with histologic correlations, are presented in an effort to define some specific criteria for the diagnosis of early malignancy of the upper GI tract.     

Urinary tract cytology

Tumors of the urinary tract are relatively inaccessible to direct biopsy and are often multifocal. Since urine is easily ortained and washes over the entire mucosal surface, urine cytology is, in theory, the perfect specimen to examine to detect a tumor. Unfortunately, interpretation of urine cytology is difficult, and both false-negative and false-positive results are very well known. Diagnostic accuracy increases with the grade of the tumor. Low-grade noninvasive papillary tumors are the sources of most false-negatives. Reactive and degenerative changes due to conditions such as inflammation, stones, prostatic hyperplasia, and therapy are responsible for most false-positives. This lecture will review basic urine cytology and give some pointers to help avoid diagnostic pitfalls.     

Biliary tract brush cytology

OBJECTIVE: To prospectively review brush smears obtained during endoscopic retrograde cholangiopancreatography (ERCP) primarily from the biliary tree. STUDY DESIGN: A total of 175 specimens from 147 patients were included in the study. The smears, prepared directly from the endoscopic brush, were stained by the Papanicolaou technique and analyzed for standard cytologic features. RESULTS: The smears were categorized into benign/reactive, significant atypia and suspicious/positive. The consistent features seen in suspicious or positive smears were tightly cohesive, small, three-dimensional cell clusters that formed cell balls. The cells in the clusters displayed features of malignant cells. CONCLUSION: ERCP-guided brushing is a safe diagnostic procedure for the evaluation of biliary tree lesions. Small, three-dimensional epithelial clusters with marked atypia signify malignancy and warrant the diagnosis of a malignant neoplasm even when only one or two such clusters are seen in the smears. Single cells, cytoplasmic vacuoles and prominent nucleoli are not essential for a diagnosis of malignancy.