Imprint cytology in the diagnosis of ovarian lesions

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1 Interntionl Journl of Reserch in Medicl Sciences Sushm et l. Int J Res Med Sci Dec;3(12): pissn eissn Reserch Article DOI: Imprint cytology in the dignosis of ovrin lesions Sushm 1 *, Sthihi Pnicker 2 1 Deprtment of Pthology, Government T D Medicl College, Alppuzh, Kerl, Indi 2 Deprtment of Pthology, Pushpgiri Institute of Medicl Sciences nd Reserch, Thiruvll, Kerl, Indi Received: 22 Octoer2015 Accepted: 20 Novemer 2015 *Correspondence: Dr. Sushm, E-mil: drsushmkini@gmil.com Copyright: the uthor(s), pulisher nd licensee Medip Acdemy. This is n open-ccess rticle distriuted under the terms of the Cretive Commons Attriution Non-Commercil License, which permits unrestricted non-commercil use, distriution, nd reproduction in ny medium, provided the originl work is properly cited. ABSTRACT Bckground: Ovrin neoplsms constitute mjor ulk of surgicl pthology specimens. Histopthology is the gold stndrd in dignosis. Of the mny options ville for rpid intr-opertive dignosis imprint cytology hs mny dvntges. This study therefore imed to study the imprint cytology of ovrin lesions nd compre with the histopthology findings nd nlyze the sttisticl effectiveness of this study s rpid intr-opertive dignostic tool. Methods: 200 lesions resected over 2 yer period were included in the study. Lesions were isected when fresh. Clen glss slides touched firmly over the representtive res. Immedite fixtion ws in 95% ethnol nd stining ws y Rpid Ppnicolou method. Of the 200 cses studied, 5 were lost to follow up, nd hence were excluded from the study. Results: The 195 cses were clssified rodly ccording to WHO system into 4 groups nd the lesions were sttisticlly nlyzed. 122 surfce epithelil tumors showed 97.5%sensitivity nd 94.5%specificity in dignosis with n overll ccurcy of 96.4%. 8 sex cord stroml tumors hd 98.5% dignostic ccurcy with specificity of 99.5%. There ws 100 % sensitivity nd specificity in dignosing the 25 germ cell tumors. The tumor like lesions showed dignostic ccurcy of 97% with specificity of 100%. Conclusions: Imprint cytology is n inexpensive nd firly sensitive tool for rpid intr-opertive dignosis. Keywords: Imprint cytology, Intr-opertive dignosis, Ovrin lesions INTRODUCTION Histopthology is the gold stndrd in dignosis of resected specimens. Rpid intr-opertive opinion is required to stge the disese nd to modify the surgicl [1] procedure. Mny options re ville. 2-4 Frozen section is most frequently resorted to. A mjor ulk of histopthology specimens is comprised of ovrin lesions. Preopertive nd rpid intr-opertive consulttion is often clled for. 5-8 In gynecologic surgeries frozen section is not often clled for. However there is n increse in the preopertive FNA dignosis eing sought. 5 Knowing the cyto-morphology of ovrin lesions will help in dignosing lesions on FNA. Imprint cytology, s lso scrpe cytology offers the dvntge of viewing the gross, giving seril cuts, tking multiple, representtive smples nd most importntly, eing inexpensive nd logisticlly un-demnding. This study ws undertken with the following ojectives: 1. To study the imprint cytology of ovrin lesions compring with their histopthology. 2. To evlute the sttisticl implictions of imprint cytology in dignosing ovrin lesions. METHODS A totl of 200 resections of ovrin neoplsms performed in our Gynecology Deprtment over period of 2 yers were included in the study. The lesions were isected when fresh, seril cuts mde, when necessry. The Interntionl Journl of Reserch in Medicl Sciences Decemer 2015 Vol 3 Issue 12 Pge 3770

2 Sushm et l. Int J Res Med Sci Dec;3(12): surfce ws mopped dry off fluid or lood. Clen nd dry glss slides were touched firmly to the cut surfce. Representtive res were imprinted. The slides were immeditely fixed in 95% ethnol or its equivlent 80% isopropyl lcohol. Stining ws y the Rpid Ppnicolou method. The results were compred to histopthology. The sttisticl prmeters studied included: sensitivity, specificity, positive predictive vlue nd overll ccurcy of dignosis. This ws done using SPSS method. The clcultion ws s shown in Tle1. Tle 1: Sttisticl prmeters studied. Histopthology positive negtive totl Imprint Positive TP () FP() cytology Negtive FN(c) TN(d) totl Where, TP = true positive, FP = flse positive, TN = true negtive, FN = flse negtive So, Sensitivity = /+c *100 Specificity = d/d+*100 Positive predictive vlue = /+*100 And, overll ccurcy = +d/n*100 Where, n = numer of lesions studied. RESULTS Figure 2: ) orderline serous tumor with cells in ppillroid clusters (Pp, x 400). ) Borderline mucinous tumor with columnr cells in tight nd ppillroid clusters (Pp, x200). Figure 3: ) serous cystdenocrcinom showing smll cells in rnching ppillry pttern (Pp, x 200) ) mucinous cystdenocrcinom showing columnr cells in three dimensionl clusters with nucler pleomorphism (Pp, x 400). Of the 200 lesions imprinted, 5 were lost to follow up in the deprtment, nd hence, were excluded from the study. The 195 cses thus included were rodly ctegorized ccording to WHO clssifiction [9] s 1. Surfce epithelil stroml tumors 2. Sex cord stroml tumors 3. Germ cell tumors nd 4. Miscellneous Figure 4: ) grnulos cell tumor showing cells in clusters nd microfolliculr pttern. The cells hve scnty cytoplsm nd nucleus with grooves nd nucleoli (Pp, x 400) ) firom-thecom shows elongted cells in n morphous ckground (Pp, x 400). Figure 1: ) imprint smer showing serous cystdenom with monolyered sheet of cuoidl cells with uniform nucleus (pp, x400). ) mucinous cystdenom with columnr cells in monolyered sheet showing honey-com ppernce nd peripherl plisding (pp, x400). Figure 5: ) mture cystic tertom showing nucleted squmes nd hir shft (Pp, x 200) ) dysgerminom with lrge round cells in discohesive clusters with round nucleus showing prominent nucleoli. Bckground shows lymphocytes. (Pp, x 400). Interntionl Journl of Reserch in Medicl Sciences Decemer 2015 Vol 3 Issue 12 Pge 3771

3 Sushm et l. Int J Res Med Sci Dec;3(12): dignostic tool. However, it requires costly equipments, nd more technicl expertise. Figure 6: endometriosis with endometril stroml cells nd hemosiderin lden mcrophges. (Pp, x 400). There were 122 surfce epithelil tumors. These included, 56 serous, 55 mucinous, 5 endometrioid, nd 2 cses of cler cell tumors. Of these, 119 could e correctly interpreted. Of the 8 cse of sex cord stroml tumors, 4 cses of firom-thecom nd 1 cse of grnulos cell tumor could e interpreted correctly. There were 25 cses of germ cell tumors, of which 23 were mture cystic tertoms, nd 1 ws dysgerminom. There were 31 cses of tumor like lesions including endometriotic cyst, folliculr cyst etc. There were 9 cses which could not e ctegorized on imprint nd were leled inconclusive. They could e dignosed on histology. DISCUSSION Preopertive nd intr-opertive dignostic cytology is finding incresing use in the present dy when the ptient cre nd mngement hs ecome very individulized. [1] The vrious methods include Fine Needle Aspirtion Cytology, frozen section nd imprint smer cytology. Scrpe cytology hs lso een dvocted s comprle tool for rpid dignosis. 2,8 FNA of oth superficil nd deep lesions from vrious sites is n ccepted dignostic modlity. However, its use in gynecologic prctice hs een limited to investigtion of suspected pelvic recurrences in ptients treted for cncers. Its use in preopertive nd intr-opertive dignosis of ovrin lesions is controversil for the following resons: 1. Fer of spillge of tumors contents into peritonel cvity nd secondry implnttion Cpsule rupture leding to upstging of the tumor. 3. It is lso felt tht preopertive FNA of ovrin lesions my e unnecessry since surgicl explortion is mndtory. Another prolem with FNA of ovrin lesion is the lck of representtiveness of smple, especilly, in lesions with vriegted ppernce nd in cystic msses with multiple locules. Multiple punctures from multiple sites my e needed. The cellulr yield from cystic lesions is low nd this cn e improved y iochemicl nlysis of the cyst fluid. 10 Frozen section is rpid Imprint smer is nother technique which is simple, rpid nd relile dignostic modlity [14, 15]. Moreover, cellulr yield is more with this technique, different sites of the tumor cn e ssessed nd it preserves the rchitecture etter. Another dvntge of imprint over FNA is tht the gross morphology of the ovrin lesions cn e studied in detil while prepring imprint. Imprint smers cn e used to study the cytology of ovrin tumors, type them s enign or mlignnt nd, further clssify them. They lso help in the stging of ovrin tumors studying the cytology of lymph nodes, omentum nd peritoneum. 7 Out of 122 cses of surfce epithelil stroml tumors, 119 were correctly dignosed y imprint. There were 56 serous tumors, 48 enign cyst denoms, one orderline tumor nd 7 cystdenocrcinoms. There were difficulties in interpreting 4 enign cses giving low ccurcy of dignosis nd positive predictive vlue. Study of the gross ws very helpful in dignosing orderline nd mlignnt cses. Mucinous tumors formed the next lrge group with 55 cses consisting of 47 enign tumors, 5 orderline tumors nd 3 cystdenocrcinoms. Benign nd most of the orderline could e dignosed on cytology ut 2 mlignnt tumors were mistken s orderline on cytology cses of endometrioid tumors were otined in the study mteril, 4 eing endometrioid denocrcinom, interpreted correctly on cytology nd one ws Mlignnt Mixed Mullerin Tumor which ws interpreted s poorly differentited serous crcinom. There were two cses of cler cell crcinoms, oth of which could e dignosed y imprint. Of the 8 cses of sex cord stroml tumors, there were five firom-thecoms, one grnulos cell tumor nd two Sertoli cell tumors. 16 Leiomyom ws in one cse misinterpreted s firom. Hence, the positive predictive vlue of dignosing sex cord stroml tumor on imprint ws 85.7%, with sensitivity nd specificity of 75% nd 99.5% resp. Germ cell tumors were the most esily dignosed lesions due to their clssic gross nd cytologic picture nd included 23 mture cystic tertoms, 1 dysgerminom nd 1 mlignnt germ cell tumor. 17 Miscellneous lesions or the tumor like lesions numered 31, which included 16 endometriotic cysts. Some of these were interpreted wrongly on cytology. Tle 2 shows the sttisticl nlysis of the vrious ovrin tumors. Interntionl Journl of Reserch in Medicl Sciences Decemer 2015 Vol 3 Issue 12 Pge 3772

4 Sushm et l. Int J Res Med Sci Dec;3(12): Tle 2: Sttisticl nlysis of the 195 ovrin neoplsms ccording to their WHO clssifiction. Lesions surfce epithelil stroml sex cordstroml germ cell tumor Miscellneous CONCLUSION Sensitivity Specifcity Positive predictive vlue Accurcy 97.5% 94.5% 96.7% 96.4% 75% 99.5% 85.7% 98.5% 100% 100% 100% 100% 80.6% 100% 100% 97% Thus, to conclude, the present study showed 96.4% ccurcy in dignosing surfce epithelil lesions, lmost 100% ccurcy in identifying germ cell tumors nd 98.5% ccurcy in ctegorizing sex cord stroml tumors. It hd n ccurcy of 97% in identifying the vrious tumor-like lesions. Imprint cytology, though not very specific in ll cses, is very useful dignostic tool in the intr-opertive consulttion of ovrin tumors. It is simple, rpid, inexpensive nd relile technique requiring out 5-10 minutes, when rpid stining technique is used. It lso does not need costly infrstructure or technicl expertise nd does not hve the risk of instrument contmintion. So it cn e used s n lterntive to frozen section s rpid intr-opertive dignostic tool. ACKNOWLEDGEMENTS I offer my pryers to the lmighty for my life, ll the ctions nd ll their fruits. I express my sincere nd deep grtitude to Dr. Sthihi Pnicker, Professor, Deprtment of Pthology, Pushpgiri Institute of Medicl Science And Reserch, Thiruvll, for her vlule guidnce nd support throughout this study. My sincere thnks re due to Dr. V Rjsekhrn Nir, former Professor, Deprtment of Ostetrics nd Gynecology, Dr. B. Prsnn, former Professor, Deprtment of Pthology, Dr. Nndkumr G, Associte Professor, Deprtment of Pthology, Govt. Medicl College, Trivndrum, nd Dr. S Snkr, Professor, Deprtment of Pthology, Govt. Medicl College, Kottym, for encourging me to proceed with this study nd offering vlule suggestions. I sincerely thnk Dr. Mnoj Pndey, presently, Professor, Surgicl Oncology, BHU, Vrnsi, for helping me in crrying out the sttisticl nlysis nd Dr. Hirn KR, for his help in prepring the photomicrogrphs. Funding: No funding sources Conflict of interest: None declred Ethicl pprovl: The study ws pproved y the Institutionl Ethics Committee REFERENCES 1. Scop CD, Melchrinou M, Bonikos D. Tissue imprints in surgicl pthology rpid intropertive dignostic id. Dign Cytopthol. 1990;6(1): Shidhm VB, Drvid NV, Grover S, Kher AV. Role of scrpe cytology in rpid intropertive dignosis : vlue nd limittions. Act Cytol. 1984;28(4): Helpp B, Tschuel K. Comprison etween frozen section, histology nd touch cytology of the rest: Fortschr Med. 1977;95(25) Arms J, Steven G, Silvererg. The role of intropertive cytology in the evlution of gynecologic diseses. Pthology Annul; Souk S, Kmel M, Rocc M. El-Assi, Heeishy N, Sheir SH. The comined use of cytologicl imprint nd frozen section in the intr-opertive dignosis of ovrin tumors- Interntionl Journl of Gynecology nd Ostetrics. 1990;31(1): Michel CW, Lwrence WD, Bedrossin CW. Intropertive consulttion in ovrin lesion: comprison etween cytology nd frozen section. Dign Cytopthol. 1996;15(5): Anstsidis PG, Romnidis KN, Polichronidis A, Koutlki NG, Tmiolkis D, Simopoulos K. The contriution of rpid intropertive cytology to the improvement of ovrin cncer stging. Gynecol Oncol. 2002;86(3): Khunmornpong S, Siriunkgul S. Scrpe cytology of the ovries: Potentil role in intropertive consulttion of ovrin lesions. Dign Cytopthol. 2003;28(5): WHO Clssifiction of tumours- Tumours of the Brest nd Femle Genitl Orgns Powers CN: Complictions of fine needle spirtion iopsy; the relity ehind the myths. In Schmidt W A ed; Cyto pthology, ASCP press, Chicgo; 1996: Wojcik EM, Selvggi SM. Fine needle spirtion cytology of Cystic ovrin lesions. Dign.Cyto pthol. 11;1994: Higgins RV, Mtkins JF, Mrroum MC. Comprison of fine needle spirtion cytologic findings of ovrin cysts with ovrin histologic finding. Am J. Ostet Gynecol. 199;180(3): Trope C: The preopertive dignosis of mlignncy of ovrin cysts: Neoplsm 28; 1981: Kumri KC Ush. Imprints smers of ovrin tumors with histopthologicl correltion: Thesis sumitted for MD pthology, University of Kerl, Muller HA. Imprint cytology dvntges nd possiilities. Fortschr Med.1976;94(1):7-10. Interntionl Journl of Reserch in Medicl Sciences Decemer 2015 Vol 3 Issue 12 Pge 3773

5 Sushm et l. Int J Res Med Sci Dec;3(12): Nguyen GK, Redurn J. Aspirtion iopsy of grnulos cell tumor of the ovry: Cytologic findings nd differentil dignosis Dign. Cytopthol. 8;1992: Hees K, de Jonge, JPA, von Kortz fleisch, DHJ: Dysgerminom of ovry: Cytologic, histologic nd electron microscopic study of cse. Act Cytol. 35;1991: Cite this rticle s: Sushm, Pnicker S. Imprint cytology in the dignosis of ovrin lesions. Int J Res Med Sci. 2015;3: Interntionl Journl of Reserch in Medicl Sciences Decemer 2015 Vol 3 Issue 12 Pge 3774