| Abstract|| |
Background: The nasal cavity and paranasal sinuses - including the maxillary, ethmoid, sphenoid, and frontal sinuses are collectively referred to as the sinonasal tract. Fine needle aspiration (FNA) of paranasal sinus lesions for early diagnosis of neoplastic lesions is difficult due to closed architecture, and only one study has been documented in the literature.
Aims: To find the efficacy of intra-operative cytology and frozen section for frequently encountered tumor and tumor-like lesions of the nose and paranasal sinuses.
Materials and Methods: Thirty cases were included in this study. The material for cytologic examination and frozen sections were taken per-operatively. Cytological smears were prepared by imprint/squash methods from the representative tissue pieces and stained with Leishman-Giemsa and Papanicolaou. Frozen section and paraffin-embedded section were stained with hematoxylin and eosin stain. A rapid opinion regarding the benign or malignant nature of the lesion and the type of tumor was given.
Results: The sensitivity, specificity, and positive predictive value of imprint cytology, squash cytology, and frozen section were 100%, 100%, and 100%; 100%, 96.15%, and 80.0%; and 100%, 96.15%, and 80.0%, respectively. Overall diagnostic accuracy of imprint smears, squash smears, and frozen section was100%, 96.7%, and 96.7%, respectively. Imprint smears had better specificity as cells morphology could be more accurately appreciated.
Conclusions: Intra-operative cytology and frozen section examinations of lesions of nose and paranasal sinuses are useful, quick, and reliable diagnostic technique for rapid diagnosis in the operation theatre and can be used as an adjunct to histopathology for better management of patients.
Keywords: Nose; paranasal sinuses; tumors; tumor like lesions; imprint smears
|How to cite this article:|
Nigam J S, Misra V, Dhingra V, Jain S, Varma K, Singh A. Comparative study of intra-operative cytology, frozen sections, and histology of tumor and tumor-like lesions of nose and paranasal sinuses. J Cytol 2013;30:13-7
|How to cite this URL:|
Nigam J S, Misra V, Dhingra V, Jain S, Varma K, Singh A. Comparative study of intra-operative cytology, frozen sections, and histology of tumor and tumor-like lesions of nose and paranasal sinuses. J Cytol [serial online] 2013 [cited 2014 Dec 26];30:13-7. Available from: http://www.jcytol.org/text.asp?2013/30/1/13/107506
| Introduction|| |
The nasal cavity and paranasal sinuses-including the maxillary, ethmoid, sphenoid, and frontal sinuses are collectively referred to as the sinonasal tract. The sinonasal tract is anatomically and embryologically distinct from the nasopharynx. Although the sinonasal tract and nasopharynx have identical-appearing ciliated respiratory epithelium, the epithelium of the sinonasal tract is ectodermally derived, while that of nasopharynx is endodermally derived. This embryologic difference may be a factor in the development of certain epithelial lesions unique to this surface. 
Carcinomas of the nasal cavity and paranasal sinuses account for 0.2-0.8% of all malignant neoplasms and 3% of those occurring in the head and neck.  Fine needle aspiration (FNA) of paranasal sinus lesions is difficult due to closed architecture, and only one study has been documented in the literature.  The present study was taken to find the efficacy of intra-operative cytology and frozen section taking paraffin-embedded histology as gold standard for frequently encountered tumor and tumor-like lesions of the nose and paranasal sinuses.
| Materials and Methods|| |
Thirty cases of tumor and tumor-like lesions of nose and paranasal sinuses were included in the study. Of these,20 were non-neoplastic and 10 were neoplastic. Out of neoplastic lesions,6 were benign and 4 were malignant. There were 20 males and 10 females with male: female ratio of 2:1. Age ranged from 8 to 65 years. The most common age group both in males and females involved was 20-30 years with the mean age of presentation being 30.5 years.
All patients were clinically evaluated by history, examination, hematological and radiological investigations. The material for cytologic examination and frozen sections were taken per operatively. Cytological smears were prepared by imprint/squash methods from the representative tissue pieces and stained with Giemsa and Papanicolaou stain. Frozen sections and paraffin-embedded sections were stained with hematoxylin and eosin stain. A rapid opinion regarding the benign or malignant nature of the lesion and the type of tumor was given. The findings were compared with the histological observations of paraffin-embedded sections.
Imprint smears were prepared from the material obtained by blotting the specimen by a filter paper and lightly touching and rolling it on a clean, grease-free glass slide.
For squash smear, small fragments of tissue were kept between two slides, which were then pulled apart gently. In nose and paranasal sinuses lesion, squash smear preparation was little difficult because of presence of mucus, which made the tissue slippery. The smears thus prepared were immediately fixed in 95% ethyl alcohol for 30 seconds and stained with Papanicolaou stain. Air-dried smears were stained with Giemsa stain. The entire procedure usually took 10 to 12 minutes.
A small piece of the tissue was processed by frozen section. Multiple sections of the tissue were cut at 4 microns.
| Results|| |
Thirty cases of tumor and tumor-like lesions of nose and paranasal sinuses were included in the study. Of these, 20 were non-neoplastic and 10 were neoplastic. Out of neoplastic lesions,6 were benign and 4 were malignant.
Most common site of involvement was left nasal cavity (50%) followed by right nasal cavity (40%) and paranasal sinuses (10%). Non-neoplastic lesions mainly included polyps (allergic and inflammatory). Benign lesions included nasopharyngeal angiofibroma, and malignant lesions included 4 cases of squamous cell carcinoma. Two malignant lesions were seen in maxillary sinuses and 2 in nose.
Cytomorphological features on imprint smears, squash smears, and frozen section
Non-neoplastic lesions were seen in 12 males and 8 females in age group of 11-50 years. All cases were described as non-neoplastic lesion on imprint [Figure 1]a and squash cytological smear technique using Giemsa stain. In imprint smears, one case had markedly increased cellularity of pseudo stratified epithelial cells suggestive of epithelial hyperplasia and in 4 cases along with columnar cells, clusters of squamous epithelial cells were also seen, which was suggestive of squamous metaplasia. One case showed few large hyperchromatic atypical cells, leading to suspicion of neoplastic lesion in squash smear.
On frozen section, in 2 cases, morphological details of cells were not clear and one case showed only degenerative tissue. This may be due to improper technique. In one case, underlying glands showed multilayered glandular lining with cellular change that gave rise to suspicion of neoplastic lesion. One case showed focal area of epithelial hyperplasia, which corresponded to increased cellularity seen in imprint smear.
|Figure 1: (a) Imprint from a nasal polyp showing clusters of columnar epithelial cells (Giemsa, × 400), (b) Polyp with pseudo stratified squamous epithelial lining with edematous stroma (Paraffin block; H and E, × 100); (c) Imprint from angiofibroma showing columnar epithelial cells, endothelial cells and fibroblasts (Giemsa, × 400); (d) Numerous thin walled blood vessels with fibrous stroma (Frozen section; H and E, × 100)|
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On histological examination, 6 cases showed mild to moderate squamous metaplasia. Cases with degenerative tissue on frozen section showed areas of squamous metaplasia with focal areas of degeneration on histological examination. No malignant cells were seen. Case with increased cellularity on imprint smear and focal areas of hyperplasia on frozen section showed no area of hyperplasia on histological examination [Figure 1]b.
Nasopharyngeal angiofibroma was seen in 6 cases in males of age group of 11-20 years. All cases were described as benign lesions on imprint [Figure 1]c and squash cytological smear technique.
On frozen section [Figure 1]d, all the cases were described as benign lesions that correlated well with diagnosis by H and E section. On histological examination, all cases were diagnosed as nasopharyngeal angiofibroma.
Squamous cell carcinoma
Squamous cell carcinoma was seen in 4 cases; 2 in male and 2 in female of age group of 40-50 years. All cases were diagnosed by imprint and squash cytological smear technique as malignant lesions. On frozen section, all cases were described as malignant lesions correlated well with histological diagnosis of non-keratinizing squamous cell carcinoma on paraffin-embedded blocks [Figure 2]a-d.
|Figure 2: (a) Clusters of pleomorphic hyperchromatic squamous cells (Imprint; Giemsa, × 400); (b) Clusters of pleomorphic hyperchromatic cells with high nuclear: cytoplasmic ratio. (Squash smear; Giemsa, × 400); (c) Frozen section suggestive of malignant lesion probably squamous cell carcinoma (H and E, × 100); (d) Section from paraffin block suggestive of Non keratinizing squamous cell carcinoma (H and E, × 100)|
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Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of imprint smears, squash smears, and frozen section were calculated taking histology as gold standard.
The sensitivity, specificity, positive predictive value, and negative predictive value, of imprint cytology, squash cytology, and frozen section were 100%, 100%, 100%, and 100%; 100%, 96.15%, 80.0%, and 100%; and 100%, 96.15%, 80.0%, and 100%, respectively. Overall diagnostic accuracy of imprint smears, squash smears, and frozen section were 100%, 96.7%, and 96.7%, respectively. Out of the two cytological technique imprint smears had better specificity as cells morphology could be more accurately appreciated as compared to squash smears [Table 1].
|Table 1: Comparison of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy on imprint, squash smears, and frozen section|
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| Discussion|| |
In last decade, cytodiagnosis has gained importance due to rapid results. Cytologic specimens can be collected by 3 ways.  Exfoliative cytology is based on spontaneous shedding of cells derived from the lining of an organ into a body cavity; hence, they can be removed by non-abrasive means. Organs usually applied for exfoliative cytology are female genital tract, respiratory tract, urinary tract, effusions.
Abrasive cytology is based on purpose to enrich the sample with cells obtained directly from the surface of the target organ. Various instruments like cervical scraper or spatula, gastric balloon, esophageal balloons, and number of brushing instruments with or without fiberoptic guidance are used in abrasive cytology.
Fine needle aspiration cytology is a method where a fine needle is used to remove a sample of cells from a suspicious mass for diagnostic purposes. The material obtained is made into a cytological sample suitable for microscopic examination. FNAC is regarded as minimally invasive, cost-effective technique with diagnostic accuracy in the range of 90-99%. Because of early and rapid diagnosis, high sensitivity, specificity, and cost-effectiveness, the use of intra-operative cytology and frozen section is rapidly increasing.
There are 3 principal reasons for operating room consultations.  These are, to provide rapid gross or microscopic diagnosis for intra- or peri-operative patient management, to optimally process tissue for special studies to be used for diagnosis, treatment, or research, and to confirm lesional tissue is present for diagnosis. Combinations of frozen sections and cytological imprint preparation, squash, or crush preparation are often used in intra-operative diagnosis.
The nasal cavity and paranasal sinuses are exposed to a variety of infections, chemically irritating and antigenically stimulating, mechanical, and traumatic influences. As a consequence of these exposures, there are formations of tumor-like and truly neoplastic conditions. The nose and paranasal sinuses accounts for less than 1% of all malignant tumors in the general and not more than 3% of the head and neck region malignancies.
Initially, most of the cytological studies in nose and paranasal sinuses were done by collection of secretion / exfoliated cells.
Belic et al., evaluated the cytologic examination of secretions of nose and maxillary sinuses in patients with naso-sinusal disorders. They concluded that cytological examination of secretions of the nose and maxillary sinuses can diagnose chronic bacterial inflammation with great accuracy as compared to the allergic process, but for documentation of malignancy, cytology is not a reliable diagnostic method. They further observed that cytologic examination of secretions of the nose and maxillary sinuses may be used as an additional method to indicate possible etiologic factors and to direct further diagnostic steps.
Bogaerts et al.  and Voss et al., studied patients of chronic sinusitis and the patients who had an increase d incidence of carcinoma, respectively, by exfoliative cytology. They concluded that exfoliative cytology was found to be a reliable means of detecting the differential diagnosis of exudative rhinopathy and preneoplastic changes in the nasal mucosa of individuals in selected risk groups.
Maru et al., studied the 151 patients of various inflammatory, benign, and malignant conditions in rhinological problems and compared brush cytology with histo-pathological examination. They found that brush cytology method can be used as an adjuvant to clinical diagnosis and histo-pathological diagnosis.
Gupta et al., retrospectively studied the fine needle aspiration of sinonasal region. They concluded that variety of non-neoplastic and neoplastic conditions can involve the sinonasal region. FNAC is a reliable diagnostic procedure in a good number of cases.
To the best of our knowledge, there is no well-documented study in literature searched, describing the efficacy of intra-operative cytology in the lesions of nose and paranasal sinuses.
The utility of intra-operative cytology and frozen section of various neoplastic and non-neoplastic lesion of the body for assisting the operating surgeon by providing an accurate and rapid diagnosis and intra-operative cytology has gained popularity in the last two decades. Intra-operative cytologic evaluation has emerged as an accurate, simple, and rapid diagnostic tool in the interpretation of neoplastic and non-neoplastic conditions. Well-prepared cytologic preparation may eliminate the need for frozen section or at least influence its interpretation. Kim et al., evaluated 664 specimens retrospectively by intra-operative imprint cytology to find its significance as a diagnostic adjunct. They concluded that the use of intra-operative cytology demonstrated the technique to be of value in providing abbreviated preparation time (3-5 min), supportive diagnostic information when frozen section was equivocal or when frozen-section evaluation could not be done (e.g., excessively small sample). It further adds contributory information for final diagnosis on difficult cases and was found to be excellent teaching material for cytopathology. A frozen section is an important intra-operative consultation for rapid diagnosis of specimens while a patient is undergoing surgery, usually under general anesthesia. 
Liu et al., had investigated the utility of intra-operative touch preparation with comparison of frozen section in 122 cases taken from various sites. The rate of correct diagnosis for touch preparation was 88.5% as compared to 86.1% for frozen section. Scucchi et al., studied the 2250 intra-operative cytology with frozen section with the final diagnosis on paraffin-embedded sections. The sensitivity and specificity combined intra-operative cytology and frozen sections were respectively 98.2% and 100%. For frozen section, the sensitivity was 89.9% and specificity was 97.9% as compared to the touch cytology, which had a sensitivity of 94.9% and specificity of 96.8%. The combined diagnostic accuracy of intra-operative cytology and frozen section to distinguish benign from malignant lesions was 99.2%. The diagnostic accuracy of each technique alone was 94.9%.Guarda LA  also compared the results of intra-operative cytology and frozen section taken from various organs of body and found that the accuracy of cytology and frozen section were 98.4% and 99.2%, respectively.
In some of the earlier studies from our center, the diagnostic accuracy of imprint cytology was found to be 98%, 98.5%, and 83.3% for neoplastic lesions of esophagus, colo-rectum, and ovary, respectively. ,
In another study, diagnostic accuracy of imprint and squash cytology for diagnosing CNS malignancy was found to be 92.0% and 89.3%, respectively. The combined efficacy was 94.6%. 
In our study, the sensitivity, specificity, and positive predictive value of imprint cytology, squash cytology, and frozen section were 100%, 100%, and 100%; 100%, 96.15%, and 80.0%; and 100%, 96.15%, and 80.0%, respectively. Overall diagnostic accuracy of imprint smears, squash smears, and frozen section were 100%, 96.7%, and 96.7%, respectively. Imprint smears had better specificity as cells morphology could be more accurately appreciated and provide better cellular details and fewer artefacts in comparisons of squash smears and frozen section. The main disadvantage of squash cytology was loss of cellular and architectural details. In nose and paranasal sinuses lesion, squash smear preparation are little difficult because of presence of mucus, which make the tissue slippery.
| Conclusions|| |
The main drawback of this study was smaller number of cases, but still by this preliminary study, it can be concluded that intra-operative cytology and frozen section examinations of lesions of nose and paranasal sinuses are useful, quick, and reliable diagnostic technique for rapid and early diagnosis in the operation theatre and can be used as an adjunct to histopathology for better management of patients. Another study with larger number of cases may further help to deciding its efficacy and use in day-to-day practice.
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J S Nigam
Department of Pathology, M.L.N. Medical College, Allahabad, Uttar Pradesh
[Figure 1], [Figure 2]