Original Article Pathology & Laboratory icine Vol (9) No (2) July-December 2018 Effectiveness of cell block technique in diagnostic pathology. Dr. Meena Gopalbhai Aghara*, Dr. Neeru Dave** Abstract : Background : One of the constraints of the conventional Fine Needle Aspiration smear is the limited material available for adjuvant diagnostic investigations, This employs the retrieval of small tissue fragments from the FNAC specimen and correlates cytological and histological findings. The ability to obtain multiple tissue sections allows multiple immunostains and other studies to be performed on it. We can also prepare cell block from tissue bits of biopsy material in histopathological specimen. This study is catvied out to establish and implement the cell block technique into the routine diagnostic setting, and to determine the effectiveness of cell block technique in various samples. Total 70 cases were studied. Cell block is very useful in histapathological specimen having scanty tissue bit. This study concludes that direct FNAC smear and cell block complement each other .Our results indicate that both are needed in diagnostic workup. Key words : Cellblock, diagnostic, effectiveness, FNAC Introduction : Surgical biopsies have always been the mainstay for a precise diagnosis however fine needle aspiration is used as a safe, reliable and an alternative adjunct because of their minimally invasive technique and cost effectiveness. One of the constraints of the conventional Fine Needle Aspiration (FNA) smear is the limited material available for adjuvant diagnostic investigation, Smears prepared from these aspirates, may at times be inconclusive and difficult to interpret. Hence to make the best possibie use of aspirate, smear should be combined with cell block preparation that in turn gives a better morphological and histological detail thus refining the diagnosis. Despite the advantages of FNA, this technique also presents itself with certain inevitable disadvantages like the material that is aspirated might not be sufficient to make a diagnosis and there is always a risk of false diagnosis or intermediate diagnosis which requires the use of experience and expertise for confident diagnosis using FNA, ‘The cell block technique employs the retrieval of small tissue fragments from a FNA specimen which are * Thin Year Pathology Resident, % Assoriate Profesor, Department of Pathology, -M.PShah Government Medel College, Jamnagar Corresponding author: Dr Meena Gopaltha: Agbara Soham’, Sshrami society, Near Swami Narayan Gar Dhebar road, Rel 360001 EMAIL: meena oghare1990@¢ma com processed to form a paraffin block. During microscopic examination as well, cell block technique poses less difficulty for observation as lesser dispersal of the cells occurs with this technique. Also like the conventional slides the sections prepared from the cell block can be stored for a longer period of time for retrospective studies as well." Cell block technique helps in analysis of liquid content as well as microscopic tissue fragments Cell block can be prepared from various material like FNAC material , from fluid, bronchial ‘washings/peritoneal washings, broncho alveolar lavage and from scanty tissue fragments(mini biopsies).” Materials and methods : ‘The present study was carried at the department of pathology with collaboration of the departments of TB & Chest Disease, Medicine, Surgery, ENT and Radiotherapy in our hospital. Total 70 cases were studied from September 2014 to September 2016. Cases included in this study are of Routine cytological ENAC cases, Radiological (CT scan & USG) guided ENAC cases of clinically suspected lung carcinoma / breast carcinoma / thyroid / liver lesion, body fluids including pleural, peritoneal fluid etc. Tissue bits of biopsy from lung lesions, and small biopsy from oral cavity lesion, scanty dilatation and curettage material, bronchial washings and broncho-alveolar lavage etc. And from these materials we prepared cytology smears as well as cell blocks which were studied in cytopathology and histopathology laboratory. CellCell block techniques blocks are prepared by two methods, histogel method and plasma thrombin method. Cytology smears and cell blocks were stained with routinely used H&E and Papanicolaou (PAP) stain." Results: Total 70 cases were studied, which includes Fine Needle Aspiration (FNA) material, specimen having multiple tissue bits (crush material from lung ),scanty tissue in biopsy material, effusion fluid (pleural peritoneal).various washing and lavage (mainly bronchial). Amongst total cytological specimens(41) ENAC cases were (22), Fluid (pleural and peritoneal effusion) were (16) while of bronchial /peritoneal washing and lavages were (03). Total cases of biopsy from lung and various other organs having scanty tissue bits were (29), Table : Age Distribution of cases (n=70) ‘Age group, No. of cases Percentage (%) 20-29 05 714% 30:39 03. 4.29% 40-49 10, 14.29% 5059 16. 22. 86% 60-69. 24 34.26% 70-79 12 17.14%, Table :2 Site Wise Distribution of cases (n=70) Cell block specimen source. Number of Specimen Peritoneal eflusion/ascitic uid oo Pleural eflusion 07 Broncho alveolar lavage 02 Bronchial washing /perifoneal washings OL Thyroid FNAC 08 Breast FNAC 06. Liver FNAC 02 Lung FNAC 06 Lung biops 18 Breast biopsy O1 Dilatation and curettage material 02 Very Small biopsies (from intestinal growth, 08 growth at base of tongue, post cricoid growth etc.) Total 70 In the present study the age of patients varied from 20 years to 80 years. Mean age being 55.2. years (Table no.1) ‘As shown in Table no.2, maximum no. of specimens ‘were of lung biopsy (with very scanty tissue bits), followed by ascitic fluid cases Table : 3 Diagnostic/non Diagnostic yield of Cell block (n=70) Yield of sample_| No. of cases (%) Diagnostic 53 (75.719) Non Diagnostic [17 (24.29%) Total 70,Pathology & Laboratory Medicine Vol (9) No (2) July-December 2018 Table : 4 Comparison of yield of cytological specimens by various methods (n=41) Yield of Conventional | (%) | Cell block | (%) sample method method Diagnostic 36 87.80% 37 Non diagnostic 05 12.20% 04 Total 41 100% 41 Table : 5 Morphological preservation in cytological specimens (n=41) Morphological Grade ‘Smear |] Cell Block Preservation Poorly preserved 0 oF 5 ‘Well preserved Ts 37 36 Table : 6 Comparison of various Cell Block Methods (n=70) Method No. of Cases] Diagnostic | Non Diagnostic Material Material Plasma Thrombin _| 23 21 91.31%) [02 6.69) HISTOGEL [47 ‘32 (68.08%) | 15 (31.92%) Table : 7 Comparison of sensitivity of smear and cell block method. ‘Author ‘Specimen ‘Smear method | Cell block method Nathan et al™™(2000) | Total Cases Fluid +FNAQ) [88.0% 78.2% Th present study Total Cases Fluid sFNAG) | 87.80% 90.25 Table : 8 Comparison of diagnostic yield material by plasma thrombin method as well histogel method of cell block preparation. ‘St No. | Author Histogel method _] Plasma thrombin method 1_ | Kshatriya AS (2016) 93.55% 81.58% 2 __| Present study(2016) 68.08% 91.30% Table : 9 Comparison of diagnostic yield by various methods. ‘St | Method used Liu et altady™] Nathan et al] Kehatriya AS™] Present study(2016) 1_ | FNAC smear 94% 30% 87.8% 2 | Cell block, 57% 58.6296 3 | FNAC smear + cell - 89% 90.25% block ‘Table : 10 Comparison of diagnostic yield material by plasma thrombin method of cell block preparation. ‘Sr No. | Author Plasma thrombin method T Yang et al™(2012) 88.80%) z Present study(2016) 91.30% 1Cell block techniques Figure 1: Showing cell pellet after solidification of histogel Figure 2: Smear made after centrifugation of ascitic fluid showing scanty cellularity (H & E stain x 40X) Figute 3: Cell block from same ascitic fluid as fig 2 (histogel method) : showing good cellularity in small concentrated area (H &E stain x 10X) Figure 4: Cell block from ascitic fluid (histogel method): showing sae ice (H&E stain x 100X) Figure 5: Cell block from scanty biopsy fom hung mass (histogel method): shows pleomorphic squamous cells along with dysplastic lining epithelium suggestive of Squamous cell carcinoma (poorly differentiated) (H & E stain x 40X) Table no. 3 shows that among 70 cases 53 cases (75.72%) had diagnostic yield while 17 cases (24.29%) had non diagnostic veld. As shown in table no.4, yield of sample by cell block method is more (90.25%) as compared to conventional smear method (87.80%), Cellularity and arrangement of cells were well preserved while morphological architecture was less preserved in cell block technique as compared to conventional cytological smear method, (Tableno.5) Inthe present study diagnostic vield was more in plasma: thrombin. method (91.30%) as compared to histogel method (68.08%) In present study in cell block technique sensitivity was 90.25% which is more than Nathan et al"study, while smear methoditis comparable. In present study we had also performed Histogel method for cell block preparation. Diagnostic yield by Histogel method was 68.08% which is slightly lower than Kshattiya AS" study while diagnostic yield by plasma thrombin method was 91.30% which is more than Kshatriya AS" In present study only FNAC smear gave 87.8% of accuracy while only cell block gave 58.62% of accuracy {in small and scanty tissue bits) while FNAC and cell block both combined gave 90.25% of diagnostic accuracy. In present study diagnostic yield by plasma thrombin method was 91.3% which is comparable with the Yung et al!™'study,Pathology & Laboratory Medicine Vol (9) No (2) July-December 2018 Discussion FAC is a simple, safe and reliable procedure for diagnosis of various lesions, although diagnostic failure rate can be as high as 45%, " An inconclusive diagnosis fon FNAC may be due to poor spreading, air drying artifact and presence of thick tissue fragments despite aspiration of adequate material. *”"" We performed cell block method of tissue processing along with the conventional methods in cytopathology laboratory. We applied this method in very smal/tiny biopsy material as well which were received in histopathology laboratory Wide range of histological fixatives have been used for cell blocks, primarily buffered formalin, neutral buffered formaldehyde solution, Bouin’s solution etc."*"" In the present study we used 10% buffered formalin as a fixative for the cell block material. The observations of the present study and their comtelation with other studies are discussed in following paragraphs. Conclusion : ENAC technique is useful in detecting lesions of various solid organs Fluid cytology ~peritoneal and pleural is also useful for differentiating between reactive and ‘malignant etiology. Scanty biopsy (mini biopsy) is also useful in diagnosing many lesions and guiding surgeon for further approach. But if all these FNAC /Fuuid/Scanty biopsy are processed by only routine methods definitive diagnosis is not possible in all cases. Coli block technique is simple and reproducible, reliable technique which uses routine safe laboratory chemicals and that s suitable for all type of cytological specimen as well tiny biopsies. Cell block technique retrieves even the scanty material which is generally lost in Conventional methods of processing. Therefore cell block technique is required for better and definitive diagnosis of various lesions. Cell block can be applied to fluid cytology material, FNAC material as well mini biopsy material. Cytological material is processed as Histopathological section which can be used for special stain and immuno-histochemistry marker study .Cell block can also be used for molecular analysis in biomarker based targeted therapy. Direct FNAC smear and cell blocks complement each other and both are needed in diagnostic work up of patient. Role of cell block preparation in diagnostic pathology is without out of immense significance as it allows for multiple special investigations and consequently more refined diagnosis. References : 1. DohimaS Hegde Pand Shetty Pel Blocka Forgoten Too Jot MolPathEpemol 2015:1:2 2. Koss LG; Diagnose Ciolgy ands Hiopahoogt Bas Fith Edition vl Iwel2. Phibdelphia, J Lipinca, 199% 3. Banaoft J, Gamble M Theory and practze of Histoogeal techniques. lb Ba Eddugh: Churchil Liangsone, 1996100 02,186.89, 4. Lee R, Foster RS, Ppl JL. 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