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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
Original article / research
Full Version
Formalin Sediment Cytology of Small Biopsy Samples: An Adjunct to Histopathology
Correspondence Address :
Dr, B Deepak Kumar,
Professor, Department of Pathology, ESIC Medical College and PGIMSR and Model Hospital, Rajajinagar, Bengaluru- 560010, Karnataka, India.
E-mail: dkgajare@gmail.com
Introduction: Cytological evaluation of malignant neoplasms forms an integral part of diagnostic work-up in any malignant disorders. Sediment cytology or more aptly called as biopsy sediment cytology is a technique that involves study of smears prepared from sediment of biopsy specimen fixatives. The preliminary diagnosis on sediment cytology helps in planning and early initiation of treatment.
Aim: To evaluate the cytomorphological features of sediment cytology of small biopsy samples and compare the same with histopathological diagnosis.
Materials and Methods: A cross-sectional study was conducted over a period of two months from July 2021 to August 2021 at ESIC Medical College and PGIMSR, Bengaluru, Karnataka, India. A total of 51 samples were included for the study. The sediments of biopsy specimens were collected in a test tube, centrifuged at 2500 rpm for 10 minutes and smears were prepared. Stained smears were evaluated for presence and morphology of cells. The morphology was compared with histopathological diagnosis of biopsy specimens. The concordance rate was assessed by Pearson’s correlation coefficient in non neoplastic/benign lesions and malignant lesions separately. A p value of <0.05 was taken to be statistically significant.
Results: Biopsies from gastrointestinal system accounted for the maximum number of cases (16 cases, 31.4%), followed by biopsies from oral cavity (15 cases, 29.4%) and female genital tract (11 cases, 21.5%). Sediment cytology yielded diagnostic material in 46 cases (90.2%). The diagnostic yield was 90.2% with an overall concordance of 60.8%. The sensitivity, specificity and diagnostic accuracy was 65.12%, 100% and 60.8% respectively. The concordance rate in non neoplastic/benign lesions was r=0.99, with p=0.0001, whereas with respect to malignant lesions, concordance rate was r=0.86 with p=0.0003.
Conclusion: Cytological evaluation plays an important role in early and effective planning of appropriate treatment. Biopsy sediment cytology although an adjunct to histopathology has practical utility and fulfills the desired role of any cytological sample in providing a provisional diagnosis.
Cytomorphological evaluation, Diagnostic yield, Exfoliated cells, Malignant neoplasms, Preliminary diagnosis, Technique
Cytological evaluation of malignant neoplasms forms an integral part of diagnostic work-up in any malignant disorder. Fine Needle Aspiration Cytology (FNAC), fluid cytology, cervical smear cytology, lavage, imprint smears are some of the domains where a rapid cytological diagnosis is possible (1),(2). Sediment cytology or more aptly called as biopsy sediment cytology is a technique that involves study of smears prepared from sediment of biopsy specimen fixatives (3),(4). The fixative in which the biopsy is received contains exfoliated cells from the cut surface of the biopsy specimens. The cytological examination of fixative fluid has distinct advantages, as it is a rich source for cytological material and a preliminary diagnosis can probably be established by the time the final histopathological diagnosis is formulated. Studies have shown that sediment cytology is a good complementary method to histopathology in biopsy material in various lesions of gastrointestinal, breast, cervix, bone, urinary bladder, ovarian neoplasms and oral cavity neoplasms (1),(5),(6),(7),(8),(9). Diagnosis on sediment cytology acts as an ancillary presumptive diagnostic test which helps in the formulation of final diagnosis on histopathology. With this background, this study was conducted with an objective to evaluate the cytomorphological features of sediment cytology of small biopsy samples and compare the same with histopathological diagnosis. Hitherto, only a few studies were conducted and that too on specific organ systems, however the present study includes biopsy samples from various organ systems which adds novelty to this study.
This was a cross-sectional study conducted in the Department of Pathology, ESIC Medical College and PGIMSR, Bengaluru, Karnataka, India. Ethical clearance was obtained from Institutional Ethical Committee (IEC) vide no: 532/L/11/12/Ethics/ESICMC&PGIMSR/EsttVol.IV dated 22.06.2021. Since this study was done on routine samples, prior informed consent taken at the time of surgical procedure was deemed to be sufficient. The study was conducted over a period of two months from July 2021 to August 2021.
Sample size calculation: Based on the laboratory data of the proportion of small biopsy samples in institution, the sample size was calculated with a relative precision of 13%, 95% confidence interval and 80% power. The minimum sample size was found to be 48 for this study. As all the consecutive small biopsy samples received during the study period at the laboratory were included for the study, the final sample size was 51.
Inclusion criteria: As the study involved purposive sampling all small biopsy specimens received in the Department of Pathology were included in the study.
Exclusion criteria: Small biopsy samples sent without formalin fixative and without clinical details were excluded from the study.
Procedure: Upon receipt of the sample in the container with the fixative, the sample was gently shaken to loosen the cells. The sediment was collected in a test tube, centrifuged at 2500 rpm for 10 minutes and smears were prepared. Smears were stained with Leishman stain and Haematoxylin- Eosin (H&E) stain. Fresh formalin was put in the biopsy container and the biopsy was kept for fixation and further processing as per standard operating protocol of histopathology. Stained smears were evaluated for presence and morphology of cells. Based on the presence of cellular material, cases were categorised as those with diagnostic yield and those with no diagnostic yield. Further based on cellular morphology, the lesions were categorised as non neoplastic/benign and malignant. The morphology of sediment cytology slides was seen by two pathologists who were blinded to clinical details and specimen type (tissue/organ). The morphology was compared with histopathological diagnosis and histopathological diagnosis was considered as gold standard.
Statistical Analysis
Data was entered in Microsoft excel and tabulated. Percentages for each variables were calculated. The diagnostic yield for each of the biopsies of various organs was calculated. Cohen’s kappa was used to assess the agreement between the two pathologists with respect to the diagnostic yield and categorisation of cases into benign/non neoplastic and malignant. The Cohen’s kappa value with respect to diagnostic yield was k=0.85 (% of agreement=96%); whereas with respect to categorisation of cases into non neoplastic/benign and malignant was k=1 (% of agreement=100%) and k=0.89 (% of agreement=95.8%) respectively. The concordance of findings on sediment cytology with histopathology was calculated organ wise. The concordance rate was assessed by Pearson’s Correlation coefficient in non neoplastic/benign lesions and malignant lesions separately. The 2 tailed p-value was used to test if the correlation obtained was significant or not. Statplus statistical analysis software for Mac (version 8.0) was used for computation of correlation coefficient and p-value. A p-value of <0.05 was taken to be statistically significant.
This study was conducted on a total of 51 small biopsy specimens. The biopsy samples received from various organs/tissues is detailed in (Table/Fig 1). Biopsies from gastrointestinal system accounted for the maximum number of cases (16 cases, 31.4%), followed by biopsies from oral cavity (15 cases, 29.4%) and female genital tract (11 cases, 21.5%).
Sediment cytology yielded diagnostic material in 46 cases (90.2%) (Table/Fig 2). In the samples which did not yield diagnostic material on sediment cytology, two were from oral cavity and one each were from stomach, skin and oesophagus.
With respect to 16 cases from gastrointestinal tract, 14 (87.5%) cases had diagnostic yield. Among them, biopsy samples from duodenum, colon and rectum yielded 100% diagnostic yield whereas biopsy samples from oesophagus and stomach had a diagnostic yield of 50% and 66.7% respectively. Seven out of eight non neoplastic lesions/benign lesions (87.5%) showed concordance with histopathology. Out of these 7 cases, all 3 cases (100%) of duodenal biopsies and 4 out of 5 cases (80%) of colon biopsies showed concordance with histopathology. (Table/Fig 3) shows one of the non neoplastic lesions from biopsy of colon showing concordance between sediment cytology and histopathology. Among the 6 malignant lesions of GIT, only two (one each from duodenum and rectum) (33%) showed concordance with histopathology. (Table/Fig 4) shows biopsy of malignant rectal lesion showing concordance between sediment cytology and histopathology. Sediment cytology samples from malignant lesions of stomach, oesophagus and colon did not yield the desired cells. (Table/Fig 5) shows biopsy from gastric junction. There was a disconcordance between sediment cytology and histopathology.
Biopsies from the oral cavity yielded diagnostic material in 13 (86.6%) out of 15 cases on sediment cytology. All three (100%) non neoplastic/benign lesions showed concordance with histopathology. Only 4 out of 10 biopsies (40%) with a diagnosis of malignancy showed concordance with histopathology.
All 11 cases (100%) pertaining to female genital tract (09 from cervix and 02 from endometrium) showed diagnostic yield. All the 09 (100%) non neoplastic/benign conditions on sediment cytology showed concordance with histopathology. (Table/Fig 6) shows biopsy from cervix of a non neoplastic lesion showing concordance between sediment cytology and histopathology. The concordance with histopathology with respect to malignant lesions was 50%.
All 4 (100%) breast lesions did not have any diagnostic yield on cytology but were malignant on histopathology. Biopsies from skin yielded diagnostic material in 2 (66.7%) out of three cases. One non neoplastic/benign lesion showed concordance with histopathological examination whereas one malignant case did not yield malignant cells on sediment cytology.
One case each of bone and prostate biopsy included in the study yielded diagnostic material. The sediment cytology sample from bone biopsy showed concordance with histopathology, whereas the sediment cytology sample of prostate biopsy did not show malignant cells, thereby having a discordance with histopathology.
With an overall diagnostic yield of 90.2% and diagnostic accuracy of 60.8%, the sensitivity was 65.12% and specificity was 100%. The concordance rate assessed by Pearson’s correlation coefficient in non neoplastic/benign lesions was r=0.99, with 2-tailed p=0.0001, whereas with respect to malignant lesions, concordance rate was r=0.86 with 2-tailed p=0.0003. In both these categories, sediment cytology findings showed a significant positive correlation with histopathology.
Cytological examination and interpretation of exfoliated cells has been a part of diagnostic evaluation since several decades. The variety and type of samples that can be subjected for cytological evaluation have been explored extensively. The common cytological samples that are utilised for cytomorphological evaluation are direct smears on a glass slides, study of centrifuged/cytocentrifuged samples or preparation of cell block from sediment samples (10),(11),(12),(13). Sediment cytology where in the centrifuged sediment deposit is used for cytological evaluation is a well-known cytological evaluation technique in body fluid evaluation and evaluation of fluid filled cystic lesions. The same principle was explored by few authors and sediment from formalin fixative of tissue biopsies was utilised to study the morphology of cells. The present study also explored the utility of this technique - the biopsy fluid cytology, which probably is a rich source for cytological material and offers a distinct advantage, where in a rapid diagnosis can be formulated based on the cytoanalysis of the formalin sediment in both non neoplastic/benign and malignant lesions. The concordance of the same with histopathological diagnosis was evaluated separately in both non neoplastic/benign and malignant lesions. Very few studies have been done to determine the role of sediment cytology as an adjunct to histopathology.
Studies conducted by Nayak R et al., (14), Chaudhari VV et al., (4) Shah S et al., (7) and Shahid M et al., (5) have documented a good over all diagnostic yield using this technique. The present study also showed a good diagnostic yield (90.2%), which in itself signifies the utility of this technique. As per the sparse available literature, authors have studied the utility of formalin sediment with a sample size of as low as 20, as in a study by Chaudhari VV et al., (4), to an average sample size of 50 to 60 as studied by Nayak R et al., (14), Shah S et al., (7) and Shahid M et al., (5). The proportion of benign cases in studies conducted by Nayak R et al., (14), Chaudhari VV et al., (4), Shah S et al., (7) and Shahid M et al., (5) were in the range of 41-63%. In the present study, the percentage of benign cases were 43%. The proportion of malignant cases in studies conducted by Chaudhari VV et al .,(4), Shah S et al., (7) and Shahid M et al., (5) were in the range of 45-48% whereas the proportion of malignant cases in study conducted by Nayak R et al., (14) was 20%. In the present study the proportion of malignant cases were 47%.
The proportion of sediment cytology cases which were inconclusive have been less in all the studies as documented in the literature, ranging from 11-16%. In the present study about 10% of cases were found to be inconclusive/inadequate for opinion. (Table/Fig 7) shows comparison of various studies (4),(5),(7),(14).
Studies conducted by Nayak R et al., (14), Chaudhari VV et al., (4), Shah S et al., (7) and Shahid M et al., (5) had a concordance rate with histopathological diagnosis ranging from 81-89% of cases. In the present study, although the diagnostic yield was high (90.2%), the concordance rate was 60.8%, which was lower compared to studies done by Nayak R et al., (14), Chaudhari VV et al., (4), Shah S et al., (7) and Shahid M et al., (5). Among the two categories of lesions i,e non neoplastic/benign versus malignant, benign lesions showed a concordance of 95.5% with a r value of 0.99. Malignant lesions showed a concordance of 29.1%, with a r value of 0.86. Both the r values were statistically significant. The low sediment cytology-histopathology concordance in malignant lesions (29.1%) compared to non neoplastic/benign lesions can be attributed to the sites of the biopsy (oral cavity and breast) and the nature and amount of desmoplastic stroma and presence of inflammatory infiltrate. In these cases, histopathological sections revealed low cellularity and high desmoplastic response.
Aishwarya KP et al., in their study highlighted the utility of sediment cytology and opined that biopsy sediment cytology is a simple and rapid tool for early diagnosis of bone lesions and also acts as a good complementary test to histopathology (6). Shah S et al., in their study on sediment cytology of bone biopsy specimens concluded that in biopsy specimens like bone, where decalcification is a time-consuming process and often delays the diagnosis, studying sediment cytology is a rapid and effective tool for early diagnosis (7). Similarly a study by Shahid M et al., on the role of sediment cytology in gastrointestinal lesions, obtained a sensitivity, specificity and diagnostic accuracy of 91.6%, 100% and 88.8% respectively (5). The current study showed the sensitivity, specificity and diagnostic accuracy of 65.12%, 100% and 60.8% respectively.
Diagnostic yield was 90.2%, which was on higher side, compared to other studies. The reason for good diagnostic yield can be attributed to the technical aspects like gentle shaking of biopsy specimens prior to subjecting the formalin to centrifugation and sectioning of biopsy specimens wherever possible. The time interval between the surgery and receipt of specimen in lab along with prompt initiation of the process of sedimentation was found to be an important factor as more the delay in receipt of specimen in the lab would lead to fixing of cells and thereby causing low diagnostic yield.
Limitation(s)
The significant limitation of the study was sample size. A higher sample size representing all the organ systems/tissues would have probably resulted in an increase in the diagnostic accuracy in the present study.
In the current era where rapid diagnosis is facilitated by various techniques and with aid of various instruments, cytological evaluation plays an important role in effective planning of appropriate treatment. Biopsy sediment cytology although an adjunct to histopathology has practical utility and fulfills the desired role of any cytological sample in providing a provisional diagnosis. Hence it is advisable to subject formalin sediment from small biopsy specimens for cyto-analysis before heading forth for routine histopathological processing.
DOI: 10.7860/JCDR/2022/57944.16834
Date of Submission: May 22, 2022
Date of Peer Review: Jun 22, 2022
Date of Acceptance: Aug 13, 2022
Date of Publishing: Sep 01, 2022
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. NA
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