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Table of Content-Volume 12 Issue 2 - November 2019


 

 


Evaluation of spectrum of various disorders diagnosed on conventional cytological smear examination of ascitic fluid at a tertiary care hospital in Konkan region of Maharashtra, India

 

Shweta Joshi-Warpe1, Bhushan M. Warpe2*, Suvarna N. Patil3, Riddhi R. Gurav4, Sujata Pawar5

 

1Assistant Professor (Pathology), 2*Associate Professor (Pathology), 3Medical Director, 4PG-DMLT (Technician),  5Associate Professor (Paediatric Nursing)  at Department of Pathology, B.K.L. Walawalkar Rural Medical College, Shree-Kshetra Dervan, Taluka– Chiplun, District- Ratnagiri- 415606, State- Maharashtra, INDIA.

Email:shwetajoshi4422@yahoo.com,bhushan.warpe@gmail.com

 

Abstract               Background: The findings of Serous fluid cytology, especially ascitic fluid vary in different regions of the country. The aims and objectives were: To study the spectrum of various disorders diagnosed on conventional cytological smears in ascitic fluid’s centrifuged deposits in Konkan belt and determine their analytical number. Methods: Inclusion Criteria: All cases of ascitic/peritoneal fluid coming for conventional cytological examination in our cytopathology section were evaluated over two years by this prospective, observational study. Exclusion Criteria: Fluids other than ascitic effusions like CSF, Pericardial effusion, Pleural effusion, Synovial fluid, Fluids from cystic lesions, Pus, Broncho-alveolar lavage (BAL) were excluded from this study. After registration of the sample it was grossly examined for quantity, colour, appearance, deposit, coagulum, presence of blood. Sample was taken in a test tube and centrifuged at 2000 rpm for 15 mins. Supernatant was discarded and sediment was used for smear preparation. Smeared slides were wet fixed with methanol in Coplin jar and stained with PAP, H & E stains, while air dried smears were stained with Giemsa (MGG), AFB, Gram stain. After proper staining, the slides were duly labelled and submitted for cytopathological opinion. Results: Total number of cases that came to cytology section for ascitic fluid conventional smear examination was 204 in two year duration in present study. Maximum number of cases who came for ascitic fluid cytological evaluation was in an age group of 51-60 years of age. More female patients with 59.80% were observed with M:F ratio as 0.67:1. Cases which came for ascitic fluid conventional smear evaluation in present study were predominantly cases of different malignancies (64.21%), followed by abdominal TB (6.86%) and alcoholic liver disease (5.39%). Amongst the clinical diagnosis of malignancy cases, ovarian carcinomas were predominant (15.68%) followed by HCC (14.50%), Ca-breast and Ca-cervix with 12.97% cases each. Amongst the cytological impression reported for ascitic fluid, most cases (65.35%) were reported as negative for malignant/metastatic cells in known cases of malignancy. 25.98% cases were positive for malignancy and 8.66% cases were suspicious of malignancy. Amongst inflammatory smears, maximum number of cases turned out to be chronic inflammatory smears (46.75%) followed by acute inflammatory smears (36.36%), out of total 77 cases. Conclusion: Malignancy cases predominantly came for ascitic fluid conventional smears in our tertiary care hospital. Ovarian malignancies were more in number, out of all cases of malignancy in our hospital. Hence, cytological evaluation was the easy way to detect the presence of malignancy in body cavity fluids and cytological study of the same provided a complete modality for diagnosis. Body fluid analyses provide etiology of effusions and differential diagnosis which helps clinicians in therapy and prognosis.

Key Words: Ascitic fluid, effusions, cytopathology

 

INTRODUCTION

The serous body cavities are mesothelial-lined potential spaces that surround the lungs (pleura), heart (pericardium), and the abdomen and pelvis (peritoneum). Tapping and analysing body fluids in terms of biochemical parameters and cytology not only serves in therapeutic and diagnostic intervention but also aids in disease monitoring, prognosis, staging of tumours and treatment outcome.1

Diagnostic cytology is the science of interpretation of cells that are exfoliated from the epithelial surfaces or removed from various tissues. The advantages are it is non-invasive, simple and helps in faster reporting and is relatively inexpensive. Cytopathology is an imperative branch that provides key information in a wide spectrum of infective, inflammatory and neoplastic conditions.1

Cytological examination of serous fluids is one of the commonly performed investigation.2Cytological study of body fluids is a complete diagnostic modality.3Cytological evaluation is the best way to detect the presence of malignancy/ metastasis in body cavity fluids.2

Ascites refers to an increased volume of fluid collecting within the peritoneal cavity.5 Patients suffering from ascites routinely undergo paracentesis at presentation and in some cases, for diagnostic or therapeutic purposes thereafter.6Ascitic fluid analysis consists of microscopic, chemical and cytological evaluation to help differentiate between infectious, inflammatory and malignancy induced ascites formation.7

Ascitic fluid has been traditionally classified into a transudate or exudate depending on the protein content of the fluid.5 Transudates make up 90% of ascitic fluids and they are caused by conditions of non-malignant etiology. This fluid is clear, with a small number of cells and low level of albumin. An exudate is usually malignant, cloudy, with a greater number of cells and a higher level of proteins than transudate.8

Ascites is the most common complaint of patients with ovarian carcinoma. In patients with peritoneal carcinomatosis, ascites is the first detectable sign of malignancy.9 The most common occult primary tumour presenting with malignant effusions are intestinal and pancreatic adenocarcinoma in men and ovarian cancer in women.10Lucke and Klebs first demonstrated atypical cells in ascitic fluid in 1867.10

The causes of intra-abdominal fluid production are many: cirrhosis, congestive heart failure, nephrosis, pancreatitis, peritonitis, primary malignancy or hepatic metastases.11Tuberculosis remains the most common cause of reactive effusion.4

Reactive mesothelial cells, abundance of inflammatory cells and paucity of representative cells contribute to considerable difficulties in making conclusive diagnosis on conventional smears.1 We prospectively evaluated ascitic fluid smears for cytological interpretation at our Konkan set-up over two years.

 

AIMS AND OBJECTIVES

To study the spectrum of various disorders diagnosed on ‘ascitic’ fluid ‘cytological examination’ at our set-up of Konkan belt.

 

MATERIALS AND METHODS

The present study was hospital based, prospective study of two years duration from 1st July 2017 to 31st June 2019. The total number of cytological cases obtained in present study was 204.

Inclusion criteria: All cases of ascitic/peritoneal fluid coming for conventional cytological examination at our institute in our cytopathology section were evaluated over two years by this prospective observational study.

Exclusion criteria: Fluids other than ascitic effusions like CSF, Pericardial effusion, Pleural effusion, Synovial fluid, Fluids from cystic lesions, Pus, Broncho-alveolar lavage (BAL) were excluded from this study.

Serous fluid sample was received in Central clinical laboratory (CCL) from different Indoor patient department sections. As soon as fluid sample was received, it was labelled by comparing the sample with requisition from for patient identification number, Name, Age, Sex, Lab number. After registration of sample, it was send to clinical pathology section, where it was grossly examined for quantity/volume, colour, appearance, deposit, coagulum, presence of blood. Volume:1 to 2 mL of serous fluid was collected in Lavender-top (EDTA) tube or green-top (heparin) tube. Fluid was examined within 2 hours of collection. If there was any delay, fluid was refrigerated at 2°C to 8°C; as it remains stable for 48 hours.5

Sample was taken in a test tube and centrifuged at 2000 rpm for 15 mins. Supernatant was discarded and sediment was used for smear preparation. Smeared slides were wet fixed with methanol in Coplin jar and stained with PAP, HandE stains while air dried smears were stained with Giemsa (MGG), AFB, Gram stain. After proper staining, slides were mounted with DPX after Xylene dip. The slides were duly labelled and submitted for cytopathological opinion.


 

OBSERVATIONS AND RESULTS

Total cases of ascitic effusions for cytopathology observed during the study period were 204. The maximum cases were seen in 51-60 years of age distribution (26.47%).

Table 1: Age wise distribution of ascitic fluid cytology examination

Age Group (years)

Cases of Ascitic fluid cytology examination

Percentage (%)

11 – 20

0

0%

21 – 30

17

8.33%

31 – 40

25

12.25%

41 – 50

47

23.03%

51 – 60

54

26.47%

61 – 70

47

23.03%

71 – 80

12

5.88%

81 – 90

2

0.98%

Total

204

100%

 

1

Pie-chart 1: The gender-wise distribution of the cases revealed males as 82 cases (40.19%) with maximum 122 female cases (59.80%).              Male : Female ratio was 0.67:1

The following Table 2 shows that malignancy/ metastasis (64.21% cases) was the most common diagnosis on clinical impression of ascites in our Konkan region, unlike other studies. This was followed by cases that came for ascitic fluid conventional smear evaluation with abdominal TB (6.86%) and Alcoholic liver disease (5.39%).

 

Table 2: Clinical diagnosis of cases with ascitic fluid for cytology examination

Clinical diagnosis

Total no. of cases

Percentage %

Malignancy/ metastasis

131

64.21%

Alcoholic liver disease

11

5.39%

Liver Cirrhosis

10

4.90%

CRF

6

2.94%

CCF

5

2.45%

Pancreatitis

5

2.45%

Abdominal TB

14

6.86%

Perforated appendicitis

4

1.96%

Intestinal obstruction

4

1.96%

Ascites under evaluation

8

3.92%

Endometrial hyperplasia, leiomyoma

3

1.47%

Others (COPD,PID,Ovarian cyst)

3

1.47%

Total

204

100%

The following Table 3 shows that 131 cases out of 204 cases showed history of some malignancy that led to ascites. It majorly showed Carcinoma cases of ovary (32 cases with 15.68%), followed by Hepatocellular carcinoma cases (19 cases with 14.5%). Amongst the clinical diagnosis of malignancy cases, this was followed by Ca breast and Ca cervix with 17 cases (12.97%) each in present study.

Table 3: Cases of malignancy with ascitic fluid for cytological examination

Malignancy

Total no. of cases

Percentage

Ca. Buccal mucosa

2

1.52%

Ca. Oesopagus

2

1.52%

Ca. lung

2

1.52%

Ca. breast

17

12.97%

Ca. stomach

7

5.34%

Ca. colon

15

11.45%

Ca. rectum

6

4.58%

Ca. pancreas

2

1.52%

Ca. endometrium

7

5.34%

Ca. ovary

32

15.68%

Ca. Cx

17

12.97%

NHL

2

1.52%

HCC

19

14.50%

Others (Carcinoma of unknown origin)

1

0.76%

Total

131

100%

The following Table 4 shows 77 cases out of 204 cases as inflammatory cases on cytology, while malignant / metastasis cases comprised 127 cases (maximum) out of 204 cases.

Malignancy cases with ascites were detected in this study. Malignancy cases without metastatic cells in ascitic fluid cytology were 65.35% in this study, reported as negative for malignant cells/metastasis. 25.98% cases were positive for malignancy/metastasis and 11 cases with 8.66% were suspicious of malignancy/metastasis.

Amongst inflammatory smears, maximum number of cases turned out as chronic inflammatory smears (36 cases with 46.75%) followed by acute inflammatory smears (28 cases with 36.36%) out of total 77 cases.

Table 4: Cytological impression of ascitic fluid examination

Cytological impression

Total no. of cases

Percentage %

Inflammatory smears

Acute

28

36.36%

Chronic

36

46.75%

Mixed

13

16.88%

Total

77

100%

Malignancy/ metastasis

Suspicious of malignancy/ metastasis

11

8.66%

Negative for malignancy/ metastasis

83

65.35%

Positive for malignancy/ metastasis

 

33

25.98%

Total

127

100%

 


DISCUSSION

Normally, movement of these organs is facilitated by a small amount of fluid, an ultra-filtrate of plasma. When production and resorption of this plasma ultra-filtrate are not properly balanced, fluid may accumulate within one or more serous cavities, resulting in a true fluid-filled cavity (effusion).6 Serous fluids include pleural, pericardial and peritoneal fluids.7

Normally, there is just enough fluid between the two membranes to provide lubrication. The normal adult has less than 50 mL of peritoneal fluid.7

Effusions may be classified as transudates, exudates, chylous, or pseudochylous.6Ascites is defined as pathological fluid accumulation within the abdominal cavity The word ascites is derived from the Greek word ‘askos’, which means a bag or sack. Ascites usually carries an unfavourable prognosis.8Because many diseases can cause ascites, in particular cirrhosis, samples of ascitic fluid are commonly analysed in order to develop a differential diagnosis.8 Clinically, ascites is a consequence or complication of a number of diseases, including hepatic, cardiac, and renal diseases, infection, and malignancy.8

Mixed ascites occurs when cirrhosis is combined with a malignant or infectious process, which occurs in 5% of patients with ascites. Peritoneal carcinomatosis with or without liver metastases and tuberculous peritonitis are the most common causes of mixed ascites.6

Cardiac-related ascites, for example, is a transudative process with a total protein level typically in the exudate range. The raised serum ascites–albumin gradient (SAAG), determined as the serum albumin concentration minus the ascitic fluid albumin concentration, is a more physiologically appropriate test.6

Gross examination can play a vital role in determining the pathogenesis of the effusion. Transudates are usually clear and pale yellow and do not clot.9,10 Cloudy or purulent fluid is most often associated with an inflammatory process. Hemorrhagic fluid might indicate a traumatic tap, malignant neoplasm, infarction, or trauma. A chylous fluid will appear turbid or milky, even after centrifugation. Pseudo-chylous effusions may be milky or greenish and have a sparkly sheen from the accumulation of cholesterol crystals6 when the fluid is clear to straw-coloured, further workup is unnecessary unless chemical examinations indicate an exudative process.6

Cytological examination of serous fluids is one of the commonly performed investigations as it reveals information about inflammatory and malignant lesions of serous membranes.11-12 Serous fluid examination with correlation of various parameters like clinical history and examination, different serum marker levels, primary malignancy if present and previous cytological diagnosis are very useful for the final diagnosis.13 Cytological examination of serous effusions is of paramount importance in the diagnostic algorithm and has therapeutic as well as prognostic implications.1

 The first line of investigation of a suspected neoplastic lesion is often the cytological examination of fluid tapped from pleural, peritoneal and pericardial cavity. A positive diagnosis is often considered as definitive diagnosis and obviates exploratory surgery.14

The differential diagnosis of ascites remains a problem in clinical practice. 90% of ascitic fluids are transudates resulting from non-malignant conditions, such as congestive heart failure or liver cirrhosis. Causes of non-malignant ascites are: liver diseases (cirrhosis), congestive heart failure, and occlusion of the inferior vena cava or the hepatic vein occlusion, as well as benign tumours of the genital tract (ovarian fibromas).7

Malignant ascites indicates the presence of malignant cells in the peritoneal cavity and is a grave prognostic sign as it increases the stage of the associated tumour signifying the spread of disease beyond the organ of origin.11 Malignant ascites is a sign of peritoneal carcinomatosis. It is believed that the pathogenesis of malignant ascites is multifactorial and that the most important pathogenic mechanisms include increased vascular permeability, lymphatic drainage obstruction, increased difference in hydrostatic pressure and reduced difference in oncotic pressure.11,16

The quality of fluid in patients with malignancy related ascites due to peritoneal carcinomatosis is distinctive, with positive cytology, high ascitic fluid protein concentrations and low serum-ascites albumin gradient.11Malignant ascites accounts for about 10% of all cases of ascites. Malignant ascites are most commonly found with gynaecological neoplasms (primarily ovarian and endometrial cancer), gastrointestinal malignancies, and breast cancer. In 15–30% of cases, the ascites is associated with carcinomatosis of the endometrium.15

Adenocarcinomas are the most common neoplasm. The most common occult primary tumor presenting with malignant effusion are intestinal and pancreatic adenocarcinoma in men and ovarian cancer in women.17 Accurate identification of the exact nature of cells (benign / malignant / reactive) is often a practical problem in conventional cytology smears (CS), due to overcrowding of cells, cell loss and different laboratory processing methods.18 Tumor and biochemical markers along with the morphological features of the cytological smear, immuno-histochemical staining and clinical history are important in determining both the presence of malignancy related ascites and the primary sites of metastatic carcinomas.11

The disease recurrence is almost always associated with the development of ascites. The ascites indirectly affects a malignant disease prognosis, both by forming a specific microenvironment promoting tumour growth and by developing chemo-resistance.19

  • In present study, maximum number of cases was from the age group of 51-60 years.
  • Similar results were observed in study done by Sarkar S, et al (2017)10 in their study named Immuno-histochemical study on cell block of ascitic fluid to ascertain the etiology.
  • Same findings were observed in study of Gandhi B, et al20 in their study named the diagnostic utility of cell block as an adjunct to cytological smears.
  • Similar observations were seen in study :Ascitic fluid cytology in suspected malignant effusions with special emphasis on cell block preparation by  Pal S, et al14.
  • In present study, maximum female patients were observed.
  • Similar results were observed in study by Sarkar S, et al (2017)10.
  • Similar findings were observed in study by Bista P (2013) in Nepal.1
  • Similar observation of female prepronderance was seen in study of ROC Karoo,et al (2003)5in UK.
  • In present study, malignancies/metastasis followed by Abdominal TB, Alcoholic liver disease, Liver cirrhosis, CRF, CCF, pancreatitis, peritonitis were the clinical diagnosis of cases which were referred for ascitic fluid cytological conventional smears examination.
  • Similar findings were observed in study done by Suma L Sangisetty, et al (2012)11 in study named Malignant ascites: A review of prognostic factors, pathophysiology and therapeutic measures.
  • In present study, ovarian malignancies were predominant cases.
  • Similar observations were found in study by Gandhi B, et al in study named the diagnostic utility of cell block as an adjunct to cytological smears in Andhra Pradesh (2014).20
  • Similar findings were observed in study of Karoo ROC, et al5 in study named How valuable is ascitic cytology in the detection and management of malignancy in 2003.
  • Similar study was found by Bhanvadia VM, et al.3
  • In present study, amongst inflammatory smears, chronic inflammatory smears were observed more in number.
  • Similar findings were seen in study by Matreja SS, et al in their study titled Comparison of efficacy of cell block versus conventional smears study in exudative fluids at Madhya Pradesh in 2019.12
  • In present study, amongst malignancy cases, ascitic fluid report with Negative for malignant/metastatic cells were predominantly seen.
  • Similar observations were found in study done by Pal S, et al in their study named Ascitic fluid cytology in suspected malignant effusions with special emphasis on cell block preparation in 2015.14
  • Similar findings were observed by Matreja SS, et al in the study named Comparison of efficacy in cell block versus conventional smear study in exudative fluid in M.P (2019).12
  • Nair GG, et al also observed similar findings in their study named Comparative study of cell blocks and routine cytological smears of pleural and peritoneal fluids in suspected cases of malignancy in Kerala.4
  • Bhanvadia VM, et al also showed similar observations in their study.3
  • Similar findings were also observed in study done by Bhade SD, et al in 2019 in their study named Cyto-morphologic analysis of body fluids at Nashik, Maharashtra.21

 

CONCLUSION

  • Malignancy cases predominantly came for ascitic fluid conventional smear evaluation in our tertiary care hospital in Konkan region.
  • Ovarian malignancies were more in number, out of all cases of malignancy in our tertiary care hospital.
  • Hence, cytological evaluation is the easiest, cost-effective and instant way to detect the presence of malignancy/metastasis in body cavity fluids. The cytological study of body fluids provided a complete modality for diagnosis and treatment.
  • Body fluid analyses provide etiology of effusion and differential diagnosis which helps clinicians in therapy and prognosis.

 

ACKNOWLEDEMENT

Dr. R.H. Deshpande (Professor, Pathology)

Dr. V.D. Dombale (Professor, Pathology)

 

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