Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 81576

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : EC16 - EC20 Full Version

Role of Squash Cytology in Intraoperative Diagnosis of Meningioma


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/47878.15260
Gowri Prakasam, K Karkuzhali, Veeraraghavan Gurusamy

1. Assistant Professor, Department of Pathology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India. 2. Assistant Professor, Department of Pathology, Thanjavur Medical College, Thanjavur, Tamil Nadu, India. 3. Assistant Professor, Department of Pathology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Gowri Prakasam,
31, Chinna Mudali Street, Pudhupet, Gudiyatham, Vellore-632602, Tamil Nadu, India.
E-mail: gowriprakasam18@gmail.com

Abstract

Introduction: Primary Central Nervous System (CNS) tumours constitute less than 2% of overall cancers in adults and are the second most frequently encountered tumours in children. Meningiomas form 24-30% of primary intracranial tumours. Most intrinsic brain tumours are soft and gelatinous in consistency, smear preparation can readily made which gives excellent cytological details when compared to frozen section as the latter produces ice crystal artifacts.

Aim: To assess the diagnostic utility of squash cytological evaluation of meningiomas and its comparison with final histopathological diagnosis.

Materials and Methods: The cross-sectional study was done at Thanjavur Medical College, Thanjavur, Tamil Nadu, India for period of three years from January 2015 to December 2017. Total of 54 clinically diagnosed and radiologically suspected case of meningiomas were selected. Smears were prepared from the biopsy samples sent in normal saline and stained by Haematoxylin and Eosin (H&E) method. The cytological features were noted and matched with biopsy findings. Descriptive statistics were used to analyse the results.

Results: Total of 54 squash smears with male to female ratio was 1:1.5. Maximum number of cases were seen between 41-50 years followed by 51-60 years. Complete concordance was obtained in 51 cases (94.44%) and partial concordance was noted in a case due to underestimation of malignancy grade in squash cytology. Out of 54 cases, two cases were found to be discordant with final histopathological diagnosis.

Conclusion: Intraoperative squash cytology is easy, rapid, reliable and cost-effective technique for neurosurgical consultation with fairly high accuracy in diagnosing meningiomas.

Keywords

Central nervous system tumours, Cytological-histological comparison, Cytomorphological features, Squash smear cytology

Primary Central Nervous System (CNS) tumours constitute less than 2% of overall cancers in adults and are the second most frequently encountered tumours in children (1). It is estimated that annual incidence of CNS tumours ranges from 10-17 per 1,00,000 persons for intra-cranial tumours and 1-2 per 1,00,000 persons for intraspinal tumours (1). Meningiomas form 24-30% of primary intracranial tumours (2).

Most intrinsic brain tumours are soft and gelatinous in consistency, smear preparation can readily made which gives excellent cytological details when compared to frozen section as the latter produces ice crystal artifacts (3). Intraoperative squash cytology preparation was first introduced by Eisenhardt and Cushing in early 1930 and by Badt in 1937 (4),(5),(6),(7). This technique was furthered and documented by Russell et al., in 1937 (5). Recently, the role of intraoperative smear preparation technique has gained importance because of advent of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) guided stereotactic biopsies (5),(6).

The advantages of squash smear technology are: (1) simple and rapid technique; (2) no technical expertise is required for preparation of smear; (3) provides both cytological and architectural features of CNS tumours; (4) background matrix and necrosis are easy to appreciate; (5) rapid diagnosis aids the neurosurgeon to plan the extent of surgery (8).

Objectives

• To assess the utility of intraoperative squash smear cytology in diagnosing meningioma and its limitations.
• To study about cytomorphological features of different types of meningioma in squash preparation.

Material and Methods

This cross-sectional study was done in Thanjavur Medical College and Hospital, Thanjavur, Tamil Nadu, India, for a period of three years from January 2015 to December 2017. The study was conducted after obtaining approval from Institutional Ethical Committee, Thanjavur (IEC NO. 117/dated/10.04.2015). A total of 54 clinically diagnosed and radiologically suspected cases of meningiomas were included and other CNS tumours were excluded from the study.

Study Procedure

For all the 54 cases, unfixed fresh biopsy material sent in normal saline from operation theatre was obtained. Initially, gross examination of specimen was done to evaluate the nature of spread. Care was taken not to allow the tissue to dry out. To prepare squash smears, small pin head sized or 2-3 mm tissue was taken and placed on one end of the slide. Flat surface of another slide placed at right angle on the top of the specimen and advanced with uniform motion without exerting undue pressure on the tissue. Minimum of 4-6 smears were made depending on the amount and sample of the tissue received. All the smears were fixed in 99.9% isopropyl alcohol and stained with Harris haematoxylin and eosin stain and examined.

Remaining tissue was fixed in 10% neutral buffered formalin for histopathological examination. Intraoperative squash smear cytological diagnosis was then compared with histopathological findings. Histopathological diagnosis was considered as final gold standard diagnosis to estimate the accuracy of squash smear cytology. The diagnosis was made, based on World Health Organisation (WHO) 2007 classification of CNS neoplasm and graded accordingly (2). In all cases, relevant clinical data and radiological findings were obtained.

Cytology results were classified into the following categories (9):

Complete agreement- Cases with same diagnosis and grade on cytology and histopathology.
Partial agreement- Cases with same diagnosis, but the grade was misdiagnosed on cytology.
Disagreement- Cases where there is difference in the cell of origin.

The overall accuracy rate was calculated by including the cases which show complete concordance with final histopathological diagnosis.

Statistical Analysis

The data obtained were analysed using Statistical Package for the Social Sciences (SPSS) and then the parameters were evaluated and expressed in percentage.

Results

A total of 54 squash smears comprising 38 females and 26 males were included in the study. Male to female ratio was 1:1.5 irrespective of age group with female predilection. The age group ranged from 21 years to 80 years. Maximum number of cases was seen between 41-50 years followed by 51-60 years comprising 21 cases and 14 cases respectively (Table/Fig 1).

Meningiomas were encountered in the following sites like parasagittal region, sphenoid wing region, olfactory groove adjacent to cribriform plate, the tentorium, falx cerebri, free surfaces of cerebral convexities of frontal, temporal, parietal region followed by Cerebellopontine (CP) angle/posterior fossa location Convexities of cerebral hemispheres followed by Cerebellopontine angle. Most common site of presentation for meningiomas in the present study was angle/posterior fossa location (Table/Fig 2).

Out of 54 cases, 51 cases showed complete concordance with final histopathological findings and partial concordance was obtained in a case due to underestimation of grading of malignancy in squash cytology. Two cases were found to be discordant with final histopathological diagnosis. The overall diagnostic accuracy of squash cytology in diagnosing meningioma was 94.44% (Table/Fig 3), (Table/Fig 4).

Total of 44 cases of meningothelial and transitional meningioma showed plump to ovoid meningothelial cells arranged in syncytial pattern with characteristic whorled configuration and were unrelated to blood vessels as shown in (Table/Fig 5), (Table/Fig 6). Occasional concentric calcification termed as psammoma bodies which appear as round dark blue formations was noted in few cases as shown in (Table/Fig 7). Histopathological examination revealed lobules of meningothelial cells with indistinct cell borders having syncytial cytoplasm as shown in (Table/Fig 8). Nuclei are pale round to oval with marginated chromatin.

Four cases of psammomatous meningioma showed numerous psammoma bodies occupying more than half of the slide with very few tumour cells as shown in (Table/Fig 9).

Two cases of angiomatoid and a case of metaplastic meningioma were really very difficult to make smear and it showed occasional clusters of meningothelial cells in syncytial pattern, reported as grade I meningioma in smear cytology. Nuclei in maximum cases were round to ovoid with delicate nuclear chromatin and scant cytoplasm. Intranuclear inclusions were noted in few cases in the present study (Table/Fig 10).

Histopathological examination of angiomatoid meningioma revealed numerous small to large vascular spaces lined by flattened endothelial cells with thickened hyalinised vessel walls, and surrounding nests of meningothelial cells having syncytial cytoplasm as shown in (Table/Fig 11). Metaplastic meningioma showed syncytial nests of meningothelial cells admixed with lobules of mature adipocytes with eccentrically placed nuclei as shown in (Table/Fig 12).

A case of schwannoma in posterior fossa location was reported as fibrous meningioma, which lacks characteristic whorls in squash smear cytology (Table/Fig 13). As a result of non representative sampling, a case of anaplastic meningioma downgraded as grade I meningioma, and a case of anaplastic meningioma on squash cytology turned out to be glioblastoma (WHO Grade IV) on HPE.

Discussion

Meningiomas are benign slow growing neoplasm arising from meningothelial cells of arachnoid layer (10). It is the most frequently reported brain tumour accounting for 36% of all brain tumours (10). About 20-25% and 1-6% of meningiomas are WHO grade II and III, respectively (10). High water and fat content and innate fragility of brain tissue may give rise to freezing artifacts on frozen section studies (13). Neurosurgeons often depend upon rapid intraoperative diagnosis for immediate surgical management in Central Nervous System (CNS) lesions (6). Squash smear technique is frequently offered by neurosurgeons for rapid and reliable diagnosis and also helps to plan the extent of surgery intraoperatively and modify the treatment accordingly (6).

The current study was to assess the diagnostic accuracy of intraoperative squash smear cytology of meningiomas and to compare it with the final histopathological diagnosis. The overall diagnostic accuracy in the present study was 94.44%. Following studies have also reported higher degree of accuracy rate in diagnosing meningiomas on squash smear cytology Karanjekar SR and Parate SN, Gopal R and Lalitha, Rao S et al., Dumitrescu G et al., Shukla K et al., Roessler K et al., and Acharya S and Azad S, (11),(12),(13),(14),(15),(16),(17).

Clinically, most of the patients presented with headache, seizures and other pressure symptoms due to compression of underlying brain parenchyma. Radiological finding in most of the cases were, uniformly contrast enhancing circumscribed dural mass with well-defined brain tumour interface (Table/Fig 14). Higher diagnostic accuracy rate in squash smear cytology is achieved by correlating cytological features with clinical and radiological findings (16).

Out of 54 cases, 33 cases were reported as meningothelial meningioma, 11 cases of transitional meningioma, followed by four cases of psammomatous meningioma, two cases of angiomatous meningioma and one case of metaplastic meningioma. The tumours were classified and graded according to the World Health Organisation (WHO) classification of CNS neoplasms 2007. Characteristic type of each meningioma was finally confirmed in histopathological diagnosis mainly for transitional, metaplastic and angiomatous meningioma. Jha B et al., also stated that, it was not possible to provide clear cut differentiation between types of meningioma on cytology as in the present study (3).

Most of the cases of meningothelial and transitional meningioma showed the characteristic whorling pattern of meningothelial cells as stated by Karanjekar SR and Parate SN (11).

Krishna Prasad HV et al., stated that psammomatous meningiomas are invariably occurs in spinal canal, but in the present study most of the cases located in the supratentorial region as extradural space occupying lesion (4). Basically, meningiomas are easy to spread but in psammomatous meningioma and transitional type with high fibrous component were difficult to make a uniform smear (2),(18).

Exact subtyping of angiomatoid and metaplastic meningioma was found to be difficult due to loss of specific features in the tissue submitted for squash preparation (17). Each meningioma shows variable cellularity found to be high in meningothelial and transitional meningioma, low in fibrous meningioma (4). Metaplastic changes include xanthomatous, cartilaginous, osseous, myxoid changes (19),(20). Foci of meningothelial cells give a clue to the diagnosis.

Schwannoma and meningioma, particularly the fibrous type resist smearing (19),(20),(21),(22),(23),(24),(25),(26). Features such as whorling, psammoma bodies and plump to ovoid cells with syncytial cytoplasm are more in favour of meningioma.

Possible reasons for the discordance in a case of anaplastic meningioma diagnosed as glioblastoma were, one of the reasons was the exact tumour’s anatomic relationship with dura and brain was obscured on imaging. Another reason was found to be sampling error as the smear shows only varying amount of oval to spindle shaped cells with necrotic debris in the background. Hence, in a radiologically high grade tumour it is wise to get more representative sample, if needed multiple samples from various sites before coming to a definitive diagnosis. This needs proper communication with the neurosurgeon.

Due to the non representative sampling, a case of atypical meningioma was diagnosed as grade I meningioma in squash smear cytology. This situation signifies the importance of radiological finding and representative sampling in diagnosing CNS tumours using smear cytology (10),(15),(24).

Limitation(s)

Major limitation encountered was non representative sampling, in which necrotic areas misleads the final diagnosis in the present study. This could overcome by representative sampling.

Conclusion

This study shows a higher degree of cytological-histological matching in diagnosing meningiomas. It needs adequate clinical history, neuroimaging details and intraoperative impression of neurosurgeon in aiding the pathologists to improve the diagnostic accuracy. Squash smear cytology is fairly accurate, relatively safe, rapid, and simple tool to diagnose meningioma intraoperatively and helps the neurosurgeon to plan about the extent of surgery.

References

1.
Frosch MP, Anthony DC, De Girolami U. The Central Nervous System. In: Kumar AA, editor. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Philadelphia: Elseiver; 2014. p.1306.
2.
Louis DN, Ohgaki H, Weistler OD, Canvenee WK, editors. WHO Classification of Tumours of the Central Nervous System. 4th ed. Lyon, France: IARC Press; 2007.
3.
Jha B, Patel V, Patel K, Aggarwal A. Role of squash smear technique in intraoperative diagnosis of CNS tumors. Int J Med Sci Public Health. 2013;2:889-92. [crossref]
4.
Krishna Prasad HV, Fernandes H, Nayak TM. Role of crush cytology in the intraoperative diagnosis of meningioma. Int J Recent Trends Sci Technol. 2015;14:559-62.
5.
Pawar N, Deshpande K, Surase S, D’costa G, Balgi S, Goel S. Evaluation of the squash smear technique in the rapid diagnosis of central nervous system tumours: A cytomorphological study. Internet J Pathol. 2009;11. [crossref]
6.
Deshpande K, Surase S, Shedge R, D’costa G, Bharambe B. Accuracy and diagnostic yield of intraoperative squash smear technique in the rapid diagnosis of CNS lesions. Bombay Hosp J. 2010;52:153-60.
7.
Eisenhardt L, Cushing H. Diagnosis of intracranial tumours by supravital technique. Am J Pathol. 1930;6(5):541-52.
8.
Nigam K, Nigam N, Mishra A, Nigam N, Narang A. Diagnostic accuracy of squash smear technique in brain tumors. JARBS. 2013;5:186-90.
9.
Badiginchala S, Amitkumar C, Rukmangadha N, Prasad BCM, Arunakumari P. Utility of squash cytology in diagnosing CNS lesions. Int J of Sci Res. 2019;8(3):15-19.
10.
Louis DN, Wiestler OD, Cavenee WK. WHO Classification of Tumours of the Central Nervous System. Revised 4th ed. Lyon: International Agency for Research on Cancer; 2016:231-44.
11.
Karanjekar SR, Parate SN. Utility of squash smear cytology in intraoperative diagnosis of central nervous system lesions. Int J Recent Sci Res. 2018;9(11):29719-26.
12.
Gopal R, Lalitha. Diagnostic accuracy of squash cytology in meningioma. Indian J Appl Res. 2019;9(3): 45-46.
13.
Rao S, Rajkumar A, Ehtesham MD, Duvuru P. Challenges in neurosurgical intraoperative consultation. Neurol India. 2009;57:464-68. [crossref] [PubMed]
14.
Dumitrescu GF, Anca S, Ciobanu D, Gra???mada?? Fl, Turliuc D, Eva L, et al. Intracranial meningiomas: Correlations between intraoperative consultation and histopathological diagnosis. Romanian Neurosurgery. 2012; XIX(1).
15.
Shukla K, Parikh B, Shukla J, Trivedi P, Shah B. Accuracy of cytopathological diagnosis of central nervous system tumours in crush preparation. Indian J Pathol Microbiol. 2006;49:483-86.
16.
Roesller K, Dietrich W, Kitz K. High diagnostic accuracy of cytologic smears of central nervous system tumours. A 15-year experience based on 4,172 patients. Acta Cytol. 2002;46:667-74. [crossref] [PubMed]
17.
Acharya S, Azad S. Squash smear cytology, CNS lesions- Strengths and limitations. Natl J Lab Med. 2016;5:01-05.
18.
Kini JR, Jeyraj V, Jayaprakash CS, Indira S, Naik CN. Intraoperative consultation and smear cytology in the diagnosis of brain tumours. Kathmandu Univ Med J (KUMJ). 2008;6:453-57. [crossref] [PubMed]
19.
Silverberg SG, DeLellis RA, Frable WJ, LiVolsi VA, Wick MR. Silverberg’s principles and practice of surgical pathology and cytopathology. 4th ed. Philadelphia: Churchill Livingstone; 2006.
20.
Rosai J. Rosai and Ackerman’s Surgical Pathology, 10th ed. China: Elsevier; 2011.
21.
Nanarng V, Jacob S, Mahapatra D, Mathew JE. Intraoperative diagnosis of central nervous system lesions: Comparison of squash smear, touch imprint, and frozen section. J Cytol. 2015;32:153-58. [crossref] [PubMed]
22.
Rani H, Kulkarni P, Dinesh US, Rao RV, Melkundi S. Comparison of squash smears and frozen sections versus paraffin sections in the intraoperative diagnosis of central nervous system lesions. El Mednifico Journal. 2013;2(2). [crossref]
23.
Goel D, Sundaram C, Paul TR, Uppin SG, Prayaga AK, Panigrahi MK, et al. Intraoperative cytology (squash smear) in neurosurgical practice pitfalls in diagnosis experience based on 3057 samples from a single institution. Cytopathology. 2007;18:300-08. [crossref] [PubMed]
24.
Sanjeev K, Aparna B, Anuradha K, Brijesh T, Sanjay K, Neetika S. Intraoperative squash cytology of central nervous system and spinal cord lesions with histological correlation. Ann Pathol Lab Med. 2016;3:61-72.
25.
Sarkar S, Sengupta M, Datta Ch, Chatterjee U, Ghosh SN. Evaluation of intraoperative cytological smears for diagnosis of brain tumors with special reference to immunohistochemistry. Indian J Med Paediatr Oncol. 2017;38(3):296-301. [crossref] [PubMed]
26.
Meshram S, Parate S, Tathe S, Randale A. Utility of squash cytology in the intraoperative diagnosis of central nervous system lesions. J Med Sci Clin Res. 2018;6(12):286-90. [crossref]

DOI and Others

10.7860/JCDR/2021/47878.15260

Date of Submission: Nov 24, 2020
Date of Peer Review: Feb 03, 2021
Date of Acceptance: Jun 25, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Dec 02, 2020
• Manual Googling: Jun 11, 2021
• iThenticate Software: Jul 23, 2021 (17%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com