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ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 2  |  Page : 681-684

Diagnostic accuracy of endoscopic brush cytology in malignancies of upper gastrointestinal tract: A prospective study of 251 patients in North India


1 Department of Pathology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
2 Department of Gastroenterology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Date of Web Publication25-Jul-2016

Correspondence Address:
Reetika Sharma
Department of Pathology, Indira Gandhi Medical College, Shimla - 171 001, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.163738

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 > Abstract 


Aim: To find the spectrum and frequency of upper gastrointestinal malignancies and diagnostic accuracy of endoscopic brush cytology in their diagnosis.
Materials and Methods: This study was a prospective study carried out on 251 patients over 1-year in the Department of Pathology. Brushing material was smeared directly on to at least two clean glass slides and was stained with May–Grunwald–Giemsa stain. The endoscopic biopsies were examined grossly and were fixed in 10% formalin, processed, and stained with hematoxylin and eosin stain.
Observation and Results: The age range of the patients varied from 8 to 90 years, with the mean being 56 years. Male to female ratio was 2.5:1. On brush cytology, out of 251 cases, 110 had benign lesions and 97 had malignant lesions. Forty-four samples were considered suspicious of malignancy. On histopathology, benign lesions were present in 105 patients while malignant lesions were seen in 139 patients. In seven cases, results were inconclusive due to inadequate/superficial biopsy.
Statistical Analysis: Statistical analysis revealed the overall sensitivity of upper gastrointestinal brush cytology as 83.45% and specificity 80.95%. The accuracy of brush cytology came out to be 82.37% in upper gastrointestinal tract.
Conclusion: Brush cytology is a reliable, safe, inexpensive, and rapid method of diagnosing upper gastrointestinal lesions. Although endoscopic biopsies are established gold standard for diagnosing gastrointestinal malignancy, use of both biopsy and brushing together increases the diagnostic accuracy.

Keywords: Brush cytology, diagnostic accuracy, upper gastrointestinal malignancies


How to cite this article:
Kaur S, Sharma R, Kaushal V, Gulati A, Sharma B. Diagnostic accuracy of endoscopic brush cytology in malignancies of upper gastrointestinal tract: A prospective study of 251 patients in North India. J Can Res Ther 2016;12:681-4

How to cite this URL:
Kaur S, Sharma R, Kaushal V, Gulati A, Sharma B. Diagnostic accuracy of endoscopic brush cytology in malignancies of upper gastrointestinal tract: A prospective study of 251 patients in North India. J Can Res Ther [serial online] 2016 [cited 2019 Dec 16];12:681-4. Available from: http://www.cancerjournal.net/text.asp?2016/12/2/681/163738




 > Introduction Top


Malignancies of the gastrointestinal tract (GIT) are one of the leading causes of death worldwide. Early cancer is asymptomatic and curable. In India, esophageal and gastric cancers are the most common cancers found in men, while esophageal cancer ranks third among women after the carcinoma of breast and cervix.[1],[2] GIT lesions can be detected in many ways such as endoscopic-guided balloon abrasive technique, lavage, or fine needle aspiration performed under either endoscopic guidance, or computed tomographic guidance. However, brush cytology is the most frequently used means of obtaining a sample for the diagnosis of GIT lesions. The diagnostic value of upper GIT biopsy is well established, but the value of brush cytology is still a subject of controversy.[3] Advantages of brush cytology are that it covers a larger surface area, provides rapid interpretation, and early diagnosis. It is less invasive, and a risk-free technique compared to biopsy. It is more useful when the lesion is large or multiple or when patients refuse biopsy. It also has the advantage of penetrating to the basement membrane and collecting cells from all the epithelial cell layers of the mucosa.


 > Materials and Methods Top


This study was a prospective study carried out on 251 patients in the Department of Pathology. The samples were collected from outdoor/indoor patients attended the Department of Gastroenterology and Medicine in whom endoscopic findings were suggestive of malignancy. Brushing material was smeared directly onto at least two clean glass slides. The air-dried smears were stained with May–Grunwald–Giemsa stain. The endoscopic biopsies were examined grossly and were fixed in 10% formalin, processed and stained with hematoxylin and eosin stain. Special stains were used wherever required. Validation of cytological diagnosis was done on the basis of histological examination.


 > Observation and Results Top


The age range of the patients varied from 8 to 90 years, with the mean being 56 years. The maximum patients (73) were between 50 and 59 years. Male to female ratio was 2.5:1. On brush cytology, out of 251 cases, 110 had benign lesions and 97 had malignant lesions. Forty-four samples were considered suspicious of malignancy due to the scant cellular material or obscuring factors such as inflammation, blood, or mucus. On histopathology, benign lesions were present in 105 patients while malignant lesions were seen in 139 patients. In seven cases, results were inconclusive due to inadequate/superficial biopsy [Table 1]. Although biopsy and brush cytology was performed in 251 patients, 1 biopsy in the pharynx, 2 in the esophagus, 3 in stomach, and 1 in the small intestine were inadequate, so these were not included in statistical analysis.
Table 1: Cytohistological spectrum of upper GIT lesions

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Brush cytology and histopathological findings on biopsy were compared [Table 2], [Figure 1] and [Figure 2], and the accuracy of brush cytology for detection of benign and malignant lesions were evaluated taking histopathology as the reference standard test. The results were interpreted as follows:
Table 2: Comparison of brush cytology with biopsy

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Figure 1: (a) Squamous cell carcinoma of esophagus (May–Grunwald–Giemsa, ×400); (b) Adenocarcinoma of stomach (May–Grunwald–Giemsa, ×400); (c) Non-Hodgkin lymphoma of stomach (May–Grunwald–Giemsa, ×400); (d) Non-Hodgkin lymphoma of stomach (H and E, ×100)

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Figure 2: (a) Adenocarcinoma of esophagus (H and E, ×100); (b) Squamous cell carcinoma of cardia of stomach (H and E, ×100); (c) Gastrointestinal stromal tumor of stomach (H and E, ×100); (d) Signet ring carcinoma of stomach (H and E, ×400)

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True positive (TP) – Cytology correctly interprets a case as malignant.

True negative (TN) – Cytology correctly interprets a case as benign.

False positive (FP) – Cytology falsely interprets a case as malignant.

False negative (FN) – Cytology falsely interprets a case as not having a malignant lesion.

Sensitivity: Likelihood that patient with the disease has positive test results.



Specificity: Likelihood that patient without disease has negative test results.





Statistical analysis revealed sensitivity of brush cytology in esophagus and pharynx, gastroesophageal junction, stomach, and small intestine as 82.46%, 100%, 83.54%, and 100%, respectively and specificity as 90.41%, 100%, 84%, and 62.50%, respectively [Table 3] and [Table 4]. The overall sensitivity of upper GI brush cytology was 83.45% and specificity was 80.95%. The accuracy of brush cytology came out to be 82.37% in upper GIT.
Table 3: Results of brush cytology at various sites in upper GIT

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Table 4: Statistical analysis results according to site of lesion

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 > Discussion Top


In this study, the majority of the patients were in the age group of 50–59 years with the mean age being 57.62 years. The mean age is comparable to other studies conducted by Geramizadeh et al.[4] and Vidyavathi et al.[1] In this study, male to female ratio was 2.5:1. This ratio is in conformity with the findings of Farhat et al.[5] who reported a male: female ratio of 3:1. Out of 55 cases positive for malignancy on biopsy in esophagus, 35 (63.66%) were of squamous cell carcinoma (SCC), 18 (32.72%) were adenocarcinoma, and 1 case was of poorly differentiated carcinoma (1.81%) and dysplasia (1.81%) each. Earlier studies by Kawashima et al.[6] and others also showed that SCC is the most common malignancy in the esophagus. In our study, an increase in the incidence of esophageal cancer was found with age, with maximum number of malignant cases (21 of 55) occurring in the age group of 70–79 years. Kawashima et al.[6] also showed the median age of 72 years in patients of esophageal cancer.

The lesion was located in the upper third of the esophagus in three patients, middle third in 23 cases, and lower third in 52 cases. Shroff and Nanivadekar [7] also found lower third of esophagus as the predominant site of involvement in their study. However, Vidyavathi et al.[1] found middle one-third as the predominant site, whereas Bhargava and Verma [8] reported equal incidence of middle and lower one-third involvement in their study.

Stomach was the most common site of involvement accounting for 157 of the total 251 cases. Of these, 79 cases had gastric malignancy while 75 cases showed benign lesion; in 3 cases biopsy was inadequate for a definite opinion. Of the 79 biopsy proven cases of malignancy; 72 (91.1%) cases were of adenocarcinoma, 1 case of SCC (1.3%), gastrointestinal stromal tumor (1.3%), non-Hodgkin lymphoma (1.3%) each, and 2 cases of poorly differentiated carcinoma (2.5%) and dysplasia (2.5%) each. Chronic gastritis (23/75) was the most frequent benign lesion followed by gastric ulcer (14/75). Majority of lesions were located in the gastric antrum followed by body and cardia, respectively. This was comparable to earlier studies by Suvarna and Sasidharan,[9] Vidyavathi et al.,[1] and Afzal et al.[10]

In the small intestine, all three cases of malignancy were older than 50 years of age which is comparable to the findings of Farhat et al.[5] who showed the median age of small intestinal malignancy to be 56 years.

Overall sensitivity of upper GIT brush cytology in this study was 83.45% and specificity was 80.95%. Cook et al.[11] in their study found the sensitivity of combined cytology and biopsy to be 91%. According to the authors, brush cytology should be reserved for situations in which difficulty is encountered in obtaining adequate tissue for histological examination. In their study, O'Donoghue et al.[12] found that with additional use of cytology the sensitivity increased from 83.5% to 97.5% and hence cytology is a useful adjunct in patients with suspicious mucosal lesions. In a study by Qizilbash et al.[13] sensitivity was 95.4% with combined use of cytology and biopsy. Sensitivity was 100% with 98.5% specificity with combined use of cytology and biopsy of gastric malignancy in a study by Geramizadeh et al.[4] Vidyavathi et al.[1] in their study with 98% sensitivity results emphasized the usefulness of brush cytology as a screening procedure. They concluded that although definite surgical treatment is rarely based on a positive or suspicious smear, the inclusion of “suspicious” category alerts the clinician about the possibility of malignancy. Patient management is alerted in these situations so that a repeat endoscopy and biopsy becomes mandatory.

Presence of FP results found by brush cytology, e.g. regenerative epithelium in relation to biopsy indicates the need to include other investigative procedures in addition to biopsy. Use of only biopsy for the validation of brush cytology and the absence of other confirmatory tests such as barium roentgenography, surgery, follow-up or autopsy was a limitation of our study. The FN results were mainly due to lack of representative material and other factors such as obscuring inflammation, or due to ulceration of the site of the tumor. So, addition of both cytology and biopsy can reach to definite diagnosis that is, if one is negative due to any cause other will help to reach diagnosis.


 > Conclusion Top


Brush cytology is a reliable, safe, inexpensive, covers large area of the sample, and rapid method of diagnosing upper gastrointestinal lesions with minimal discomfort to the patient. However, it has some limitations such as inability to distinguish dysplasias/in situ carcinomas and invasive carcinomas. Though endoscopic biopsy is used as a routine procedure in the diagnosis of gastrointestinal lesions, brush cytology can be used as an adjunct to tissue biopsy during the investigation of patients with suspicious mucosal lesions of GIT. Regardless of the biopsy findings, patients with “suspicious” cytologic reports require careful reevaluation. This can act as a good screening procedure for high-risk population.

Financial support and sponsorship

Nil.

Conflicts of interest

There Are No Conflicts of Interest.

 
 > References Top

1.
Vidyavathi K, Harendrakumar ML, Lakshmana Kumar YC. Correlation of endoscopic brush cytology with biopsy in diagnosis of upper gastrointestinal neoplasms. Indian J Pathol Microbiol 2008;51:489-92.  Back to cited text no. 1
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2.
Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 2003;349:2241-52.  Back to cited text no. 2
    
3.
Jhala N, Jhala D. Gastrointestinal tract cytology. In: Atkinson BF, editor. Atlas of Diagnostic Cytopathology. 2nd ed. Philadelphia: Saunders; 2004.  Back to cited text no. 3
    
4.
Geramizadeh B, Shafiee A, Saberfirruzi M, Kumar PK, Shaheem A. Brush cytology of gastric malignancies. Acta Cytol 2002;46:693-6.  Back to cited text no. 4
    
5.
Farhat MH, Shamseddine AI, Barada KA. Small bowel tumors: Clinical presentation, prognosis, and outcome in 33 patients in a tertiary care center. J Oncol 2008;2008:212067.  Back to cited text no. 5
    
6.
Kawashima M, Ikeda H, Yorozu A, Niibe H, Teshima T, Fuwa N, et al. Clinical features of esophageal cancer in the octogenarian treated by definitive radiotherapy: A multi-institutional retrospective survey. Jpn J Clin Oncol 1998;28:301-7.  Back to cited text no. 6
    
7.
Shroff CP, Nanivadekar SA. Endoscopic brushing cytology and biopsy in the diagnosis of upper gastrointestinal tract lesions. A study of 350 cases. Acta Cytol 1988;32:455-60.  Back to cited text no. 7
    
8.
Bhargava DK, Verma K. Fiberoptic endoscopy, biopsy and directed brush cytology in esophageal carcinoma. Indian J Med Res 1981;73:246-50.  Back to cited text no. 8
    
9.
Suvarna N, Sasidharan VP. Histopathological and histogenetic study of carcinoma stomach in a high risk area. Indian J Cancer 1995;32:36-42.  Back to cited text no. 9
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10.
Afzal S, Ahmad M, Mubarik A, Saeed F, Rafi S, Saleem N, et al. Morphological spectrum of gastric lesions – Endoscopic biopsy findings. Pak Armed Forces Med J 2006;56:143-9.  Back to cited text no. 10
    
11.
Cook IJ, de Carle DJ, Haneman B, Hunt DR, Talley NA, Miller D. The role of brushing cytology in the diagnosis of gastric malignancy. Acta Cytol 1988;32:461-4.  Back to cited text no. 11
    
12.
O'Donoghue JM, Horgan PG, O'Donohoe MK, Byrne J, O'Hanlon DM, McGuire M, et al. Adjunctive endoscopic brush cytology in the detection of upper gastrointestinal malignancy. Acta Cytol 1995;39:28-34.  Back to cited text no. 12
    
13.
Qizilbash AH, Castelli M, Kowalski MA, Churly A. Endoscopic brush cytology and biopsy in the diagnosis of cancer of the upper gastrointestinal tract. Acta Cytol 1980;24:313-8.  Back to cited text no. 13
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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