Journal of Cytology
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   Table of Contents - Current issue
Coverpage
January-March 2020
Volume 37 | Issue 1
Page Nos. 1-66

Online since Monday, December 23, 2019

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INVITED REVIEW ARTICLE  

Indian academy of cytologists guidelines for collection, preparation, interpretation, and reporting of serous effusion fluid samples Highly accessed article p. 1
Radhika Srinivasan, Bharat Rekhi, Arvind Rajwanshi, Saleem Pathuthara, Sandeep Mathur, Deepali Jain, Nalini Gupta, Upasana Gautam, Naresh Rai, Vijay Shrawan Nijhawan, Venkat Iyer, Pranab Dey, Prabal Deb, Dev Prasoon
DOI:10.4103/JOC.JOC_157_19  
Cytological examination plays an important role in the initial work-up of the serous cavity effusion fluids to find out the possible etiology as benign or malignant. Among malignant effusions, cytology is helpful in determining the exact type, site, and stage of the tumor. However, for reporting effusion cytology specimens, there is no consistent and reproducible reporting system. Aims: The aim of these guidelines is to provide a standardized format for effusion cytopathology right from sample receipt to its ultimate report sign-out for implementation in all cytopathology laboratories. The Indian Academy of Cytologists in consultation with experts across the country has prepared guidelines pertaining to collection, preparation, and diagnostic categories of effusion specimens to reduce reporting variability. The guidelines are made keeping in mind the different areas of practices in India, especially low- and medium-resource settings. The guidelines are broadly divided into essential, optimal, and optional categories for best usage and appropriate allocation of the precious specimens. In referral centers or well-established setups, essential ancillary techniques can be done for accurate and final diagnosis. By adhering to and implementing these uniform guidelines, it is hoped that clinical patient care and management in India will improve and be of uniformly good quality by enabling and facilitating good laboratory practices.
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ORIGINAL ARTICLES Top

Fine-needle aspiration cytology of salivary gland lesions: A revised classification based on “Milan system”—4years experience of tertiary care cancer center of South India p. 12
Malathi Mukundapai, Neelam Sharma, Akkamahadevi Patil, Champaka Gopal
DOI:10.4103/JOC.JOC_68_18  
Background: Fine-needle aspiration cytology plays role in preoperative diagnosis of any salivary gland mass lesions. Because of heterogeneity of salivary gland lesions and cytomorphology overlap, a uniform 6-tier Milan classification proposed which could be helpful in better communication of reports for patient's management. Methods: Study included 4 years (2011–2015) retrospective data retrieval from cytology department of our Institute, which is a tertiary care cancer center of South India. Histopathology correlation was done wherever possible. Result: Total 253 cases were studied. Histopathological follow-up was available in 115 cases. Cases were categorized as nondiagnostic (1.58%), nonneoplastic (13.43%), benign (30%), atypia (0.8%), and suspicious for malignancy and malignant cytology (51.8%). The risk for malignancy was high for suspicious for malignancy and malignant cytological categories ranged from 96–100%. The sensitivity, specificity, and accuracy for diagnosing malignancy varied from 86.76%, 93.75%, and 89%, respectively. Conclusion: Risk stratification approach in classifying salivary gland cytology aspirate as per Milan system provides a standardized reporting and better communication to clinician.
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Evaluation of accuracy of milan system for reporting salivary gland cytology: Review of morphology and diagnostic challenges in each category p. 18
K Amita, HB Rakshitha, Avinash Singh, S Vijay Shankar
DOI:10.4103/JOC.JOC_191_18  
Background: Fine-needle aspiration cytology (FNAC) in salivary gland lesions is challenging for the cytopathologists due to diverse morphological pattern and overlapping morphologic features which are responsible for the pitfalls. The present study was conducted to evaluate the efficacy of the Milan system in the diagnosis of salivary gland lesions and to discuss and review the morphology and diagnostic challenges in individual Milan categories. Materials and Methods: The study was a retrospective diagnostic analytical study in the department of pathology at a tertiary care hospital attached to medical college over a duration of 2 years. All the salivary gland FNAC cases were reviewed and divided into six categories as per the proposed Milan system for reporting salivary gland cytopathology. Histopathology correlation was performed wherever possible. Results: A total of 131 cases formed the study group. The number of cases in each category were: nondiagnostic 4.5%, nonneoplastic 51.9%, atypical lesions 0.76%, neoplastic category benign neoplasm 21.37%, salivary lesion of uncertain malignant potential 1.52%, suspicious category 2.29%, and malignant category 17.5%. The risk of malignancy for each categories were 6.25% (nonneoplastic), 100% (atypical), 3.3% (neoplastic), 0% (benign), 25% (salivary neoplasm of uncertain neoplastic potential), 100% (suspicious for malignancy), and 100% (malignant) categories. Sensitivity, specificity, positive predictive value, and negative predictive value of FNAC with application of Milan system was 89.4%, 100%, 100%, and 95.74%, respectively. Conclusion: The high efficacy of FNAC obtained in the present study, when Milan system was applied, confirms the usefulness of this scheme in reporting salivary gland lesions.
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“Agar Cell-Suspension”: A novel technique for processing clear specimens p. 26
Swati B Dighe, Irene C Ruben, Chirag B Waghela
DOI:10.4103/JOC.JOC_199_18  
Context: Clear cytology specimens are processed by cytocentrifugation which is preferred over membrane filters (MF). Although both techniques are expensive, cytocentrifugation is less tedious and may cause cellular distortion. Aim: To standardize “Agar cell-suspension” (ACS) an innovative, simple, cost-effective technique to process clear specimens. Methods and Materials: About 93 clear specimens (65 urine, 15 effusion, 12 CSF, and 1 bronchial lavage) were processed by both cytocentrifugation and ACS. The sample was centrifuged in two tubes; one was used for ACS and other for cytocentrifugation. ACS smears were prepared by mixing one drop of 0.5% agar solution with the last drop of the centrifugate. Smears were fixed in methanol and stained by Papanicolaou staining method. ACS smears were compared with cytocentrifuged smears (CS) and evaluated for cellularity, cytomorphology preservation, staining quality, time, and cost. Results: As compared to CS smears, ACS smears showed better cellularity in 16.1%, comparable in 53.7%, and less in 30.1%. All ACS smears (100%) showed well-preserved cytomorphology as compared to 96.7% CS. Staining quality was optimal in 96.7% ACS smears against 91.3% CS. Both techniques took equal time. The additional cost of ACS was only 0.03 INR compared to 12.50 INR for CS. Conclusions: ACS is an innovative, simple, easy, and cost-effective technique for processing clear specimens. It gives equally good results comparable to cytocentrifugation in terms of cellularity and staining quality. ACS does not cause cell distortion or air-drying as seen in some CS. Thus, ACS is a superior alternative to cytocentrifugation.
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Decoy cells versus plasma real-time polymerase chain reaction for the detection of polyomaviruses in renal transplant patients: A single institutional experience p. 30
Nasar Y Alwahaibi, Thuraya M Al Maskari, Najat Aldairi
DOI:10.4103/JOC.JOC_167_18  
Background and Aims: Microscopic detection of decoy cells is routinely performed in urine samples from renal transplant patients for the evaluation of polyomaviruses. However, they are scanty papers evaluated the diagnostic accuracy of decoy cells in urine samples. The aim of this study is to evaluate the diagnostic accuracy of decoy cells in urine samples and compare with plasma real-time polymerase chain reaction (RT-PCR) as a gold standard method. In addition, to compare the findings of this study with other similar studies. Methods: A retrospective study over a period of four years from January 2014 to December 2017 was performed. A total of 89 urine samples from renal transplant patients were assessed for the presence of polyomaviruses and compared with plasma RT-PCR. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were measured. Results: There were 29 males and 18 females. The mean patient age was 40.3 years. The sensitivity, specificity, accuracy, PPV and NPV were 86.6%, 67.5%, 70.7%, 35.1% and 96.1%, respectively. Other similar studies reported a sensitivity of 41.9-84.6%, specificity of 65.8-100% and accuracy of 69.9-82%. Conclusion: The findings of this study show that the detection of decoy cells in urine samples is a sensitive screening method for polyomaviruses. The findings of this study are compatible with other similar studies.
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FNAC of breast lesions with special reference to IAC standardized reporting and comparative study of cytohistological grading of breast carcinoma p. 34
Hemlata Panwar, Pooja Ingle, Tummidi Santosh, Vandita Singh, Amit Bugalia, Nighat Hussain
DOI:10.4103/JOC.JOC_132_18  
Background: International Academy of Cytology (IAC) has established a process to produce comprehensive and standardized approach to fine-needle aspiration cytology (FNAC) reporting. They have categorized the breast lesions in C1 to C5. (C1-Insufficient material, C2-Benign, C3- Atypical, C4-Suspicious & C5-Malignant). Aims and Objectives: The aim of study is to classify various breast lesions (C1 to C5) and to grade breast carcinoma on FNAC using Robinson's grading system which is then correlated with modified Bloom–Richardson grading. Materials and Methods: All routine FNAC for breast lump were included in the study during the period from Jan 2016 to Jan 2017. The study was conducted in the Department of pathology and lab medicine of a tertiary care hospital in central India. Results: A total 225 female patients were included in the study, with an age group ranging from 15 - 79 years, with lesions in breast were taken. C1 lesions were found in 3 cases, C2 in 186 cases, C3 in 13 cases, C4 in 4 cases, and C5 in 19 cases. Correlation of cytohistological grading was obtained in 108 cases. Conclusion: Cytological categorization based on IAC structured reporting will enhance the reproducibility of reports among pathologist & clinicians. With the comparison between cytohistological nuclear grading, the cytoprognostic scores will help in evaluating the aggressiveness of tumor, predicts histological grade and prognosis. It could be a useful parameter for selecting neo-adjuvant chemotherapy.
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The incidence of free peritoneal tumor cells before and after neoadjuvant chemotherapy in gastroesophageal junction cancer p. 40
Rune B Strandby, Lars B Svendsen, Rikard Ambrus, Andreas A Rostved, Jane P Hasselby, Michael P Achiam
DOI:10.4103/JOC.JOC_164_18  
Context: The utility of peritoneal washing cytology in patients with gastroesophageal junction cancer has not been thoroughly evaluated. Aims: The study aimed to determine the incidence of free peritoneal tumor cells by peritoneal washing cytology before and after neoadjuvant chemotherapy using conventional cytopathological methods and immunohistochemical staining for the analysis of peritoneal washings. Settings and Design: A prospective study conducted at a single tertiary referral hospital. Materials and Methods: Patients with gastroesophageal junction cancer and without suspicion of intra- or extraabdominal metastases before the staging laparoscopy were prospectively and consecutively enrolled. Peritoneal washing cytology was performed at staging laparoscopy (primary cytology) and after neoadjuvant chemotherapy during robot-assisted or open resection (secondary cytology). Peritoneal fluid samples were analyzed by conventional cytology and an immunohistochemical panel. Results: Overall, 81 patients met the primary inclusion criteria. During primary cytology, positive cytology without overt metastases (C1M0) was detected in three patients (3.8%) while five patients (6.3%) had overt intra-abdominal metastases but negative cytology (C0M1). None of the patients with C1M0 underwent surgery due to extra-abdominal (n = 1) or intra-abdominal metastases (n = 2), and the overall survival was 4, 7, and 14 months. During secondary cytology, no patients with free peritoneal tumor cells were identified, but seven patients were classified as C0M1 (10.9%). Conclusions: The incidence of C1M0 was 3.8% and 0% before and after neoadjuvant chemotherapy, respectively in patients with gastroesophageal junction cancer. Free peritoneal tumor cells were not identified in several patients with intra-abdominal metastases suggesting that peritoneal washing cytology with conventional cytology and immunohistochemical staining lack sensitivity.
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Cytological diagnosis of Rosai–Dorfman disease: A study of twelve cases with emphasis on diagnostic challenges p. 46
Rallapalli Rajyalakshmi, Mohammad Akhtar, Yarlagadda Swathi, Ranjani Chakravarthi, Jeeru Bhaskara Reddy, Maddirala Beulah Priscilla
DOI:10.4103/JOC.JOC_4_19  
Context: Rosai–Dorfman disease, also known as Sinus histiocytosis with massive lymphadenopathy, is a benign proliferative disorder of histiocytes. It typically affects lymph nodes; however, extranodal disease is being increasingly reported. The latter entity poses exceptional diagnostic challenge clinico-radiologically by forming mass lesions. Fine needle aspiration cytology (FNAC) is the investigation of choice to avoid unnecessary surgery as the majority are self-limiting. Aims: The objective is to assess the utility of FNAC in the diagnosis of Rosai–Dorfman disease and to highlight the diagnostic difficulties. Material and Methods: The cytology features of 12 cases of Rosai–Dorfman disease were analyzed and correlated with histopathology and immunohistochemistry. Results: The present study included six nodal and six extranodal Rosai–Dorfman disease. The cytology smears showed a variable number of large histiocytes exhibiting characteristic emperipolesis. Ten cases diagnosed as Rosai–Dorfman disease on cytology were confirmed on histopathology. The presence of granulomas, atypical histiocytes, insignificant emperipolesis, and eosinophil infiltration were the challenges we faced. Conclusions: FNAC, a simple and cost-effective method with its unique cytology features is the first line of investigation in the diagnosis of Rosai–Dorfman disease.
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Utility of fine needle aspiration in diagnosis of intraoral minor salivary gland tumors p. 53
Meeta Singh, Nishant Sagar, Surekha Yadav, Radhika Aggarwal, Shramana Mandal, Nita Khurana, Shyama Jain, Ravi Meher
DOI:10.4103/JOC.JOC_62_19  
Objective: To evaluate the utility of intraoral fine-needle aspiration cytology (FNAC) in diagnosis of minor salivary gland neoplasms (MSGN) with application of Milan system of reporting salivary gland cytopathology; keeping histopathology as gold standard and to detail the cytological findings of MSGNs. Method: Retrospective study between Jan 2008 and June 2017 (appro × 10 years) on the cytology of the minor salivary gland tumor along with the histopathological correlation. The relevant clinical data was collected from the medical record. Result: Sixty-four cases of MSGNs were included in the study. The histodiagnosis of the 41 were available. Twenty-one cases were diagnosed as malignant, while rest 20 cases were reported as benign. The most common tumor diagnosed was pleomorphic adenoma (PA) (50% cases), followed by mucoepidermoid carcinoma (14%) and adenoid cystic carcinoma (12.5%). The most common site of MSGT was found to be hard palate (44%), followed by soft palate (23%), floor of the mouth (12%), lip (11%), buccal mucosa (5%), and tongue (5%) with no gender predilection. Sensitivity of FNAC for detection of malignancy was 81% while specificity 95%. For malignancies, positive predictive value for malignancies was 17/18 (94.4%) and negative predictive value was 19/23 (82.3%). According to Milan system out of 21 cases in category IV B, 4 cases were found malignant (Category VI), while 1/18 case in category VI turned out to be nonneoplastic lesion (Category II). Conclusion: FNAC is imperative in early diagnosis and subsequent management of MSGNs
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Micronucleus and its significance in effusion fluids p. 58
Dravya Jayakumar, Kalpana Kumari Kasturi
DOI:10.4103/JOC.JOC_42_19  
Background: Micronucleus (MN) is an extranuclear body within the cell formed due to failure of incorporation of whole chromosomes or their fragments during cell division. MN scoring can be done to identify malignant effusions. Aims: This study aimed to score micronuclei to distinguish malignant effusion from benign effusions and to correlate MN score with type of malignant effusion. Methods and Materials: A retrospective study was conducted on 30 malignant and 30 benign effusions. The number of micronucleated cells per 1,000 cells was counted in effusion smears stained with Papanicolaou stain under oil immersion (1,000×). Results: The mean MN score in malignant effusions was 3.77 with standard deviation (SD) of 2.13. The mean MN score in benign effusions was 0.50 with SD of 0.57. The difference in MN score between malignant and benign effusions is statistically significant (P < 0.001). A cut-off MN score of 6.5 was seen to distinguish malignant and benign effusions with 100% specificity and 100% sensitivity in this study. Conclusions: MN score is higher in malignant effusions when compared with benign effusions. This can be used to differentiate malignant effusions from benign effusions in low resource setting.
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LETTERS TO EDITOR Top

Pilomatricoma simulating metastatic pancreatic carcinoma: A diagnostic pitfall p. 62
Gaurav Shelgaonkar, Anupama Arya, Bhavna Bansal, Dilip Kumar, Poonam Das
DOI:10.4103/JOC.JOC_104_19  
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Secretory carcinoma breast – the characteristic cytological features in diagnosis of this rare carcinoma p. 63
Surbhi Gupta, Puneet Gupta
DOI:10.4103/JOC.JOC_72_19  
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Incidental finding of microfilaria in cervicovaginal liquid-based cytology smear p. 65
Swasti Jain, Prajwala Gupta, Minakshi Bhardwaj
DOI:10.4103/JOC.JOC_81_19  
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