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Gastrointestinal Cytology

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Abstract

Cytology of the gastrointestinal (GI) tract, with a relatively timid start, continues to develop due to the use of flexible endoscopy. Cytology specimens can be obtained as exfoliative cytology from the oral cavity to the stomach and also from the anorectal area, using brushes, abrasive balloons, and lavage. Fine-needle aspiration (FNA) specimens obtained with flexible endoscopes, aided by high-resolution ultrasound probe, allow for real-time visualization and sampling of lesions of the four layers of the GI tract. As in most areas, cytology specimens and biopsy specimens are complementary and increase sensitivity and specificity in diagnosing GI lesions. Although GI cytology/endoscopy is not yet used for mass screening, one can foresee a time when this is going to change, similar to existing screening programs for pulmonary and airway lesions. Currently, only screening for anorectal squamous intraepithelial lesions is ongoing, with well-determined reporting criteria. GI cytology can be used to diagnose infectious processes and malignancy in immunocompromised patients, and it could be used in surveillance of patients with Barrett’s esophagus or with inflammatory bowel diseases. Being acquainted with the type of cells that normally line the GI tract—basically squamous and glandular cells—and with its wide possible pathology, the cytopathologist is an essential player in the clinical management team. In addition, tissue obtained by FNA as fresh specimens or cell blocks will surely be used for additional molecular studies in the era of molecular testing and personalized medicine.

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References

  1. Chhieng DC, Stelow EB. Pancreatic cytopathology. New York: Springer; 2007.

    Book  Google Scholar 

  2. DeMay RM. The art and science of cytopathology. Exfoliative cytology, vol. I. 2nd ed. Chicago: American Society for Clinical Pathology Press; 2012.

    Google Scholar 

  3. Geisinger KR. Endoscopic biopsies and cytologic brushings of the esophagus are diagnostically complementary. Am J Clin Pathol. 1995;103:295–9.

    Article  CAS  PubMed  Google Scholar 

  4. Babshet M, Nandimath K, Pervatikar S, Naikmasur V. Efficacy of oral brush cytology in the evaluation of the oral premalignant and malignant lesions. J Cytol. 2011;28:165–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Yang H, Berner A, Mei Q, Giercksky KE, Warloe T, Yang G, et al. Cytologic screening for esophageal cancer in a high-risk population in Anyang County, China. Acta Cytol. 2002;46:445–52.

    Article  PubMed  Google Scholar 

  6. Patel AA, Strome M, Blitzer A. Directed balloon cytology of the esophagus: a novel device for obtaining circumferential cytologic sampling. Laryngoscope. 2017;127(5):1032.

    Article  PubMed  Google Scholar 

  7. Graham DY, Spjut HJ. Salvage cytology: a new alternative fiberoptic technique. Gastrointest Endosc. 1979;25:137–9.

    Article  CAS  PubMed  Google Scholar 

  8. Caos A, Olson N, Willman C, Gogel HK. Endoscopic “salvage” cytology in neoplasms metastatic to the upper gastrointestinal tract. Acta Cytol. 1986;30:32–4.

    PubMed  CAS  Google Scholar 

  9. Jhala NC, Jhala DN, Chhieng DC, Eloubeidi MA, Eltoum IA. Endoscopic ultrasound-guided fine-needle aspiration. A cytopathologist’s perspective. Am J Clin Pathol. 2003;120:351–67.

    Article  PubMed  Google Scholar 

  10. Kreimer AR, Clifford GM, Boyle P, Franceschi S. Human papillomavirus types in head and neck squamous cell carcinomas worldwide: a systematic review. Cancer Epidemiol Biomark Prev. 2005;14:467–75.

    Article  CAS  Google Scholar 

  11. D’Souza G, Fakhry C, Sugar EA, Seaberg EC, Weber K, Minkoff HL, et al. Six-month natural history of oral versus cervical human papillomavirus infection. Int J Cancer. 2007;121:143–50.

    Article  CAS  PubMed  Google Scholar 

  12. Näsman A, Attner P, Hammarstedt L, Du J, Eriksson M, Giraud G, et al. Incidence of human papillomavirus (HPV) positive tonsillar carcinoma in Stockholm, Sweden: an epidemic of viral-induced carcinoma? Int J Cancer. 2009;125:362–6.

    Article  CAS  PubMed  Google Scholar 

  13. Afrogheh A, Wright CA, Sellars SL, Wetter J, Pelser A, Schubert PT, Hille J. An evaluation of the Shandon Papspin liquid-based oral test using a novel cytologic scoring system. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113:799–807.

    Article  PubMed  Google Scholar 

  14. Navone R, Burlo P, Pich A, Pentenero M, Broccoletti R, Marsico A, Gandolfo S. The impact of liquid-based oral cytology on the diagnosis of oral squamous dysplasia and carcinoma. Cytopathology. 2007;18:356–60.

    Article  CAS  PubMed  Google Scholar 

  15. Glennie HR, Gilbert JG, Melcher DH, Linehan J, Wadsworth PV. The place of cytology in laryngeal diagnosis. Clin Otolaryngol. 1976;1:131–6.

    Article  CAS  PubMed  Google Scholar 

  16. Loss R, Sandrin R, França BH, de Azevedo-Alanis LR, Grégio AM, Machado MÂ, de Lima AA. Cytological analysis of the epithelial cells in patients with oral candidiasis. Mycoses. 2011;54:e130–5.

    Article  PubMed  Google Scholar 

  17. Barrett AP, Buckley DJ, Greenberg ML, Earl MJ. The value of exfoliative cytology in the diagnosis of oral herpes simplex infection in immunosuppressed patients. Oral Surg Oral Med Oral Pathol. 1986;62:175–8.

    Article  CAS  PubMed  Google Scholar 

  18. Napier SS, Speight PM. Natural history of potentially malignant oral lesions and conditions: an overview of the literature. J Oral Pathol Med. 2008;37:1–10.

    Article  PubMed  Google Scholar 

  19. Warnakulasuriya S, Johnson NW, van der Waal I. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med. 2007;36:575–80.

    Article  CAS  PubMed  Google Scholar 

  20. Izumo T. Oral premalignant lesions: from the pathological viewpoint. Int J Clin Oncol. 2011;16:15–26.

    Article  PubMed  Google Scholar 

  21. Gnepp DR. Diagnostic surgical pathology of the head and neck. 2nd ed. Philadelphia: W.B. Saunders; 2009.

    Google Scholar 

  22. Namala S, Guduru VS, Ananthaneni A, Devi S, Kuberappa PH, Udayashankar U. Cytological grading: an alternative to histological grading in oral squamous cell carcinoma. J Cytol. 2016;33:130–4.

    Article  PubMed  PubMed Central  Google Scholar 

  23. el-Naggar AK, Hurr K, Batsakis JG, Luna MA, Goepfert H, Huff V. Sequential loss of heterozygosity at microsatellite motifs in preinvasive and invasive head and neck squamous carcinoma. Cancer Res. 1995;55:2656–9.

    PubMed  CAS  Google Scholar 

  24. Graveland AP, Bremmer JF, de Maaker M, Brink A, Cobussen P, Zwart M, et al. Molecular screening of oral precancer. Oral Oncol. 2013;49:1129–35.

    Article  CAS  PubMed  Google Scholar 

  25. Vulliamy TJ, Marrone A, Knight SW, Walne A, Mason PJ, Dokal I. Mutations in dyskeratosis congenita: their impact on telomere length and the diversity of clinical presentation. Blood. 2006;107:2680–5.

    Article  CAS  PubMed  Google Scholar 

  26. Lin BP, Harmata PA. Gastric and esophageal brush cytology. Pathology. 1983;15:393–7.

    Article  CAS  PubMed  Google Scholar 

  27. Grossi L, Ciccaglione AF, Marzio L. Esophagitis and its causes: who is “guilty” when acid is found “not guilty”? World J Gastroenterol. 2017;23:3011–6.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Buss DH, Scharyj MS. Herpesvirus infection of the esophagus and other visceral organs in adults. Am J Med. 1979;66:457–62.

    Article  CAS  PubMed  Google Scholar 

  29. Eymard D, Martin L, Doummar G, Piché J. Herpes simplex esophagitis in immunocompetent hosts. Can J Infect Dis. 1997;8:351–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Wang HW, Kuo CJ, Lin WR, Hsu CM, Ho YP, Lin CJ, et al. The clinical characteristics and manifestations of cytomegalovirus esophagitis. Dis Esophagus. 2016;29:392–9.

    Article  PubMed  Google Scholar 

  31. Shaheen NJ, Falk GW, Iyer PG, Gerson LB, American College of Gastroenterology. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol. 2016;111:30–50.

    Article  CAS  PubMed  Google Scholar 

  32. Anderson LA, Watson RG, Murphy SJ, Johnston BT, Comber H, McGuigan J, et al. Risk factors for Barrett’s oesophagus and oesophageal adenocarcinoma: results from the FINBAR study. World J Gastroenterol. 2007;13:1585–94.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Falk GW. Risk factors for esophageal cancer development. Surg Oncol Clin N Am. 2009;18:469–85.

    Article  PubMed  Google Scholar 

  34. Wani S, Falk G, Hall M, Gaddam S, Wang A, Gupta N, et al. Patients with nondysplastic Barrett’s esophagus have low risks for developing dysplasia or esophageal adenocarcinoma. Clin Gastroenterol Hepatol. 2011;9:220–7.

    Article  PubMed  Google Scholar 

  35. Sikkema M, Looman CW, Steyerberg EW, Kerkhof M, Kastelein F, van Dekken H, et al. Predictors for neoplastic progression in patients with Barrett’s esophagus: a prospective cohort study. Am J Gastroenterol. 2011;106:1231–8.

    Article  CAS  PubMed  Google Scholar 

  36. Kestens C, Offerhaus GJ, van Baal JW, Siersema PD. Patients with Barrett’s esophagus and persistent low-grade dysplasia have an increased risk for high-grade dysplasia and cancer. Clin Gastroenterol Hepatol. 2016;14:956–62.

    Article  PubMed  Google Scholar 

  37. Verbeek RE, Leenders M, Ten Kate FJ, van Hillegersberg R, Vleggaar FP, van Baal JW, et al. Surveillance of Barrett’s esophagus and mortality from esophageal adenocarcinoma: a population-based cohort study. Am J Gastroenterol. 2014;109:1215–22.

    Article  PubMed  Google Scholar 

  38. Kastelein F, van Olphen SH, Steyerberg EW, Spaander MC, Bruno MJ, ProBar-Study Group, Impact of surveillance for Barrett’s oesophagus on tumour stage and survival of patients with neoplastic progression. Gut. 2016;65:548–54.

    Article  CAS  PubMed  Google Scholar 

  39. Schlemper RJ, Riddell RH, Kato Y, Borchard F, Cooper HS, Dawsey SM, et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut. 2000;47:251–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Montgomery E, Bronner MP, Goldblum JR, Greenson JK, Haber MM, Hart J, et al. Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation. Hum Pathol. 2001;32:368–78.

    Article  CAS  PubMed  Google Scholar 

  41. Falk GW. Cytology in Barrett’s esophagus. Gastrointest Endosc Clin N Am. 2003;13:335–48.

    Article  PubMed  Google Scholar 

  42. Dar M, Gramlich T, Falk G. Endoscopic brush cytology in Barrett’s esophagus: highly specific but less sensitive than previously reported [abstract]. Gastrointest Endosc. 2002;55:AB200.

    Google Scholar 

  43. Kumaravel A, Lopez R, Brainard J, Falk GW. Brush cytology vs. endoscopic biopsy for the surveillance of Barrett’s esophagus. Endoscopy. 2010;42:800–5.

    Article  CAS  PubMed  Google Scholar 

  44. Ilhan M, Erbaydar T, Akdeniz N, Arslan S. Palmoplantar keratoderma is associated with esophagus squamous cell cancer in Van region of Turkey: a case control study. BMC Cancer. 2005;5:90.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Chang F, Syrjänen S, Shen Q, Cintorino M, Santopietro R, Tosi P, Syrjänen K. Human papillomavirus involvement in esophageal carcinogenesis in the high-incidence area of China. A study of 700 cases by screening and type-specific in situ hybridization. Scand J Gastroenterol. 2000;35:123–30.

    Article  CAS  PubMed  Google Scholar 

  46. Cummings LC, Cooper GS. Descriptive epidemiology of esophageal carcinoma in the Ohio Cancer Registry. Cancer Detect Prev. 2008;32:87–92.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Ashktorab H, Nouri Z, Nouraie M, Razjouyan H, Lee EE, Dowlati E, et al. Esophageal carcinoma in African Americans: a five-decade experience. Dig Dis Sci. 2011;56:3577–82.

    Article  PubMed  PubMed Central  Google Scholar 

  48. The Cancer Genome Atlas Research Network. Integrated genomic characterization of oesophageal carcinoma. Nature. 2017;541:169–75.

    Article  CAS  PubMed Central  Google Scholar 

  49. Lin DC, Hao JJ, Nagata Y, Xu L, Shang L, Meng X, et al. Genomic and molecular characterization of esophageal squamous cell carcinoma. Nat Genet. 2014;46:467–73.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Bree RL, McGough MF, Schwab RE. CT or US-guided fine needle aspiration biopsy in gastric neoplasms. J Comput Assist Tomogr. 1991;15:565–9.

    Article  CAS  PubMed  Google Scholar 

  51. Allen DC, Irwin ST. Fine needle aspiration cytology of gastric carcinoma. Ulster Med J. 1997;66:111–4.

    PubMed  PubMed Central  CAS  Google Scholar 

  52. Hashemi MR, Rahnavardi M, Bikdeli B, Dehghani Zahedani M, Iranmanesh F. Touch cytology in diagnosing Helicobacter pylori: comparison of four staining methods. Cytopathology. 2008;19:179–84.

    Article  CAS  PubMed  Google Scholar 

  53. The Cancer Genome Atlas Research Network. Comprehensive molecular characterization of gastric adenocarcinoma. Nature. 2014;513:202–9.

    Article  CAS  Google Scholar 

  54. Borch K, Ahren B, Ahlman H, Falkmer S, Granerus G, Grimelius L. Gastric carcinoids: biologic behavior and prognosis after differentiated treatment in relation to type. Ann Surg. 2005;242:64–73.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Bosman FT, Carneiro F, Hruban RH, Theise ND, editors. WHO classification of tumours of the digestive system. Geneva: WHO Press; 2010.

    Google Scholar 

  56. Chiu BC, Weisenburger DD. An update of the epidemiology of non-Hodgkin’s lymphoma. Clin Lymphoma. 2003;4:161–8.

    Article  PubMed  Google Scholar 

  57. Herrmann R, Panahon AM, Barcos MP, Walsh D, Stutzman L. Gastrointestinal involvement in non-Hodgkin’s lymphoma. Cancer. 1980;46:215–22.

    Article  CAS  PubMed  Google Scholar 

  58. Koch P, del Valle F, Berdel WE, Willich NA, Reers B, Hiddemann W, et al.; German Multicenter Study Group. Primary gastrointestinal non-Hodgkin’s lymphoma: I. Anatomic and histologic distribution, clinical features, and survival data of 371 patients registered in the German Multicenter Study GIT NHL 01/92. J Clin Oncol. 2001;19:3861–73.

    Article  CAS  PubMed  Google Scholar 

  59. Ferrucci PF, Zucca E. Primary gastric lymphoma pathogenesis and treatment: what has changed over the past 10 years? Br J Haematol. 2007;136:521–38.

    Article  CAS  PubMed  Google Scholar 

  60. Cavalli F, Isaacson PG, Gascoyne RD, Zucca E. MALT lymphomas. Hematology Am Soc Hematol Educ Program. 2001:241–58.

    Article  Google Scholar 

  61. Zucca E, Bertoni F. Another piece of the MALT lymphomas jigsaw. J Clin Oncol. 2005;23:4832–4.

    Article  PubMed  Google Scholar 

  62. Rollinson S, Levene AP, Mensah FK, Roddam PL, Allan JM, Diss TC, et al. Gastric marginal zone lymphoma is associated with polymorphisms in genes involved in inflammatory response and antioxidative capacity. Blood. 2003;102:1007–11.

    Article  CAS  PubMed  Google Scholar 

  63. Eck M, Schmausser B, Haas R, Greiner A, Czub S, Muller-Hermelink HK. MALT-type lymphoma of the stomach is associated with Helicobacter pylori strains expressing the CagA protein. Gastroenterology. 1997;112:1482–6.

    Article  CAS  PubMed  Google Scholar 

  64. Hans CP, Weisenburger DD, Greiner TC, Gascoyne RD, Delabie J, Ott G, et al. Confirmation of the molecular classification of diffuse large B-cell lymphoma by immunohistochemistry using a tissue microarray. Blood. 2004;103:275–82.

    Article  CAS  PubMed  Google Scholar 

  65. Offit K, Lococo F, Louie DC. Rearrangement of the bcl-6 gene as prognostic marker in diffuse large cell lymphoma. N Engl J Med. 1994;331:74–80.

    Article  CAS  PubMed  Google Scholar 

  66. Chung KM, Chang ST, Huang WT, Lu CL, Wu HC, Hwang WS, et al. Bcl-6 expression and lactate dehydrogenase level predict prognosis of primary gastric diffuse large B-cell lymphoma. J Formos Med Assoc. 2013;112:382–9.

    Article  CAS  PubMed  Google Scholar 

  67. Starostik P, Greiner A, Schwarz S, Patzner J, Schultz A, Müller-Hermelink HK. The role of microsatellite instability in gastric low- and high-grade lymphoma development. Am J Pathol. 2000;157:1129–36.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Hossain FS, Koak Y, Khan FH. Primary gastric Hodgkin’s lymphoma. World J Surg Oncol. 2007;5:119.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Carney JA, Stratakis CA. Familial paraganglioma and gastric stromal sarcoma: a new syndrome distinct from the carney triad. Am J Med Genet. 2002;108:132–9.

    Article  PubMed  Google Scholar 

  70. Vij M, Agrawal V, Kumar A, Pandey R. Cytomorphology of gastrointestinal stromal tumors and extra-gastrointestinal stromal tumors: a comprehensive morphologic study. J Cytol. 2013;30:8–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  71. Miettinen M, Wang ZF, Sarlomo-Rikala M, Osuch C, Rutkowski P, Lasota J. Succinate dehydrogenase-deficient GISTs: a clinicopathologic, immunohistochemical, and molecular genetic study of 66 gastric GISTs with predilection to young age. Am J Surg Pathol. 2011;35:1712–21.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Conrad R, Castelino-Prabhu S, Cobb C, Raza A. Role of cytopathology in the diagnosis and management of gastrointestinal tract cancers. J Gastrointest Oncol. 2012;3:285–98.

    PubMed  PubMed Central  Google Scholar 

  73. Logrono R, Kurtycz DF, Molina CP, Trivedi VA, Wong JY, Block KP. Analysis of false negative diagnoses on endoscopic brush cytology of biliary and pancreatic duct strictures: the experience at 2 university hospitals. Arch Pathol Lab Med. 2000;124:387–92.

    PubMed  CAS  Google Scholar 

  74. Howlader N, Noone AM, Krapcho M, Miller D, Bishop K, Kosary CL, et al., editors. SEER 18 2010–2014, all races, both sexes SEER cancer statistics review, 1975–2014. Bethesda, MD: National Cancer Institute. http://seer.cancer.gov/csr/1975_2014/, based on November 2016 SEER data submission, posted to the SEER web site, April 2017.

  75. Centers for Disease Control and Prevention (CDC). Human papillomavirus-associated cancers—United States, 2004-2008. MMWR Morb Mortal Wkly Rep. 2012;61:258–61.

    Google Scholar 

  76. Silverberg MJ, Lau B, Justice AC, Engels E, Gill MJ, Goedert JJ, et al.; North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of IeDEA. Risk of anal cancer in HIV-infected and HIV-uninfected individuals in North America. Clin Infect Dis. 2012;54:1026–34.

    Article  PubMed  PubMed Central  Google Scholar 

  77. Park IU, Palefsky JM. Evaluation and management of anal intraepithelial neoplasia in HIV-negative and HIV-positive men who have sex with men. Curr Infect Dis Rep. 2010;12:126–33.

    Article  PubMed  PubMed Central  Google Scholar 

  78. Zhao C, Domfeh AB, Austin RM. Histopathologic outcomes and clinical correlations for high-risk patients screened with anal cytology. Acta Cytol. 2012;56:62–7.

    Article  PubMed  Google Scholar 

  79. Darragh TM, Winkler B, Souers RJ, Laucirica R, Zhao C, Moriarty AT, College of American Pathologists Cytopathology Committee. Room for improvement: initial experience with anal cytology: observations from the College of American Pathologists interlaboratory comparison program in nongynecologic cytology. Arch Pathol Lab Med. 2013;137:1550–4.

    Article  PubMed  Google Scholar 

  80. Daragh TM, Palfsky JM. Anal cytology. In: Nayar R, Wilbur D, editors. The Bethesda system for reporting cervical cytology. Cham: Springer; 2015. p. 263–85.

    Google Scholar 

  81. Centers for Disease Control and Prevention. Stool specimens–intestinal parasites: comparative morphology tables. http://www.cdc.gov/dpdx/diagnosticProcedures/stool/morphcomp.html. Accessed 13 Jan 2018.

  82. Wentzensen N, Follansbee S, Borgonovo S, Tokugawa D, Sahasrabuddhe VV, Chen J, et al. Analytic and clinical performance of cobas HPV testing in anal specimens from HIV-positive men who have sex with men. J Clin Microbiol. 2014;52:2892–7.

    Article  PubMed  PubMed Central  Google Scholar 

  83. Stier EA, Chigurupati NL, Fung L. Prophylactic HPV vaccination and anal cancer. Hum Vaccin Immunother. 2016;12:1348–51.

    Article  PubMed  PubMed Central  Google Scholar 

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Oprea-Ilies, G., Siddiqui, M.T. (2018). Gastrointestinal Cytology. In: Jing, X., Siddiqui, M., Li, Q. (eds) Atlas of Non-Gynecologic Cytology . Atlas of Anatomic Pathology. Springer, Cham. https://doi.org/10.1007/978-3-319-89674-8_5

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