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Peritoneal lavage and filtration for cytology
Peritoneal lavage and filtration WILLIAM
S. FLOYD,
CHARLES PAUL
R.
GERALD T. Detroit,
N.
M.D.
BOYCE,
GOODMAN,
M.D. M.D.
MANDELL, EVANS,
for cytology
M.D.
M.D.
Michigan
A technique for cul-de-sac peritoneal lavage and filtration is described. Preliminary experience with this procedure suggests its mass application may result in earlier cytologic diagnosis and increased salvage of patients with clinically occult intra-abdominal malignant disease.
of ascitic fluid C Y T o L o G I c examination aspirated from the peritoneal cavity may lead to the diagnosis of cancer. However, ascites is usually associated with an advanced and incurable neoplasm. Attempts to diagnose cancer cytologically before ascites develops often have been unsuccessful because an inadequate specimen was obtained. Graham, Graham, and Schueller’,” detected several early ovarian neoplasms by recovering small quantities of peritoneal fluid after altering the patient’s position. Thirty per cent of their attempts were unsatisfactory because of vaginal and/or bowel contamination or absence of cells in the aspirated fluid. The cellular pattern of cul-desac fluid reflects the tissue pattern of the organs exfoliating into the peritoneal cavity.3 Abdominal peritoneal lavage may produce cytologic evidence of breast, gastrointestinal, uterine, and Fallopian tube carcinomas4, ’ In 1935, an excellent correlation was established between ascitic fluid cytology and the findings at operation and necropsy.’ Earlier attempts to detect ovarian cancer before ascites develops by cul-de-sac aspira-
From
the Departments
and Obstetrics State
University
tion after injecting saline solution have been described.?? 8 This method was abandoned because of the lack of positive findings. Specimens obtained were often inadequate and altered by autolysis and blood contamination. This report concerns a new technique which offers pro’mise of increasing the accuracy of early cytodiagnosis of intra-abdominal tumors by examination of fluid obtained by cul-de-sac lavage. Methods
Following pelvic examination of 2 18 women, a No. 20 gauge needle was inserted through the posterior vaginal fornix into the cul-de-sac of Douglas after aseptic precautions. Twenty cubic centimeters of physiologic saline solution was injected and promptly aspirated. The aspirated fluid was injected through a Cytosieve” containing a cytology membrane, Metracel GA-1 (Fig. 1). The Cytosieve was constructed to distribute cells symmetrically over a 1 inch disk. Debris less than 5 p in diameter filters through. The membrane was fixed in 10 per cent formalin for at least 10 minutes, stained
of Gynecology Wayne of Medicine.
and Pathology, School
Ann
425
*Gelman Arbor,
Instrument Michigan
Company, 48106.
600 South
Wagner
Road,
426
Floyd et al.
1. co1 nponent
Fig. 2. Cluster
of mesothelial
parts
of the
cells
Cytosieve,
capsule,
pad,
and
1 inch
filter
and histiocytes.
by the Papanicolaou method, and cleared to transparency with mounting media. When aspirated fluid was cloudy, some was injected through the filter and the remainder passed through additional filters or centrifuged for preparation of cell blocks. A specimen was regarded as negative in the absence of malignant cells and when mesothelial cells were present, confirming peritoneal entry. Results
Interpretation ed there were
support
of 2 18 preparations suggest15 malignancies, 4 were sus-
Fig. 3. Cluster
of normal
mesothelial
cells.
picious, 28 unsatisfactory, and 17 1 negative. Four specimens contained fecal material, one with barium. However, no complications resulted from this procedure. The best preparations were obtained following immediate filtration and fixation. Prompt fixation should not represent a problem, since tile
Volume Number
103 3
Peritoneal
lavage
and
filtration
for
cytology
427
Fig. 4. Cluster of adenocarcinoma cells from case of bilateral ovarian serous cystadenocarcinoma.
Fig. 5. Histologic shown in Fig. 4.
Cytosieve is disposable and can be placed immediately into 10 per cent formalin. Most preparations were excellent, but a few were inadequate for diagnosis because of cellular autolysis resulting from delayed fixation. Overloading of the cytology membrane occurred occasionally. When there is increased resistance because of the amount of cellular debris, Cytosieve filtration should cease and the remaining aspirate should be processed into a cell block. Contamination with vaginal cells occurred when negative pressure was maintained as the needle was withdrawn. In one patient with cervical carcinoma in situ a positive squamous cell vaginal preparation was obtained. Forceful filtration with rupture of the cytology membrane, venipuncture, and penetration of the urinary bladder were other causes of unsatisfactory preparations. Acellularity of the fluid is usually due to failure to enter the peritoneal cavity. Success is related to the technical skill and experi-
ence of the one performing the cul-de-sac puncture. Most specimens were satisfactory. Mesothelial cells occur singly, in clusters, or in large sheets. Hyperchromatic artifacts occurred when mesothelial cells were dense. Vacuolization and multinucleation are frequent. Histiocytes and lymphocytes are found in lesser numbers. Ciliary columnar cells are occasionally seen.l, o-11 In 4 instances suspicious cells were not associated with malignancy (Figs. 2 and 31. Peritoneal giant cells were found in one with disseminated lupus erythematosus. The remaining 3 were misinterpretations of small papillary groups which we have subsequently learned to identify as benign.
section of the ovarian
lesion
Malignancies
The specimens diagnosed as malignant were associated with carcinoma of the ovary (Figs. 4 to 6)) pseudomyxoma peritoneii (Figs. 7 and 8)) pancreas (Fig. 9)) and the stomach (Fig. 10).
428
Floyd et al.
Fig. 6. Cluster of large adenocarcinoma cells from case of bilateral secondary ovarian carcinoma. The primary transverse colon carcinoma had been removed 4 months previously. Therr was no nscitrs.
Fig. 7. Syncytium of malignant pseudomyxoma peritoneii.
Fig. 8. myxoma
Fig. 9. Cluster of adenocarcinomr plastica of the stomach.
Histologic peritoneii
section of nodule shown in Fig. 7.
of
pscudo-
~-ells.
in
cells,
c.ue
linitis
01
Volume Number
103 3
Fig. 10. Cluster of adenocarcinoma cells case of adenocarcinoma of the pancreas.
Peritoneal
from
a
Comment Advantages of this technique are: ( 1) instillation of fluid insures a greater percentage
lavage
and
filtration
for
cytology
4’29
of successful taps; (2) all of the fluid aspirated can be filtered easily; (3) artifacts produced by centrifugation and sedimentation are eliminated; (4) the microporous membrane allows debris to pass through while the exfoliated cells are retained; (5) formalin fixation produces less precipitation of debris than ether-alcohol mixtures; (6) all of the cellular debris is concentrated on a 1 inch disk; and (7) collection and preparation of the specimens are performed easily and quickly. This limited experience suggests that mass application of this screening technique may result in earlier diagnosis and increased salvage of patients with heretofore occult intraperitoneal malignant disease. Cells may migrate through a single mesothelial layer which permits diagnosis of abdominal maiignancy before it is clinically evident.
REFERENCES
1. Graham, John B., Graham, Ruth M., and Schueller, Edmund F.: Cancer 17: 1414, 1964. 2. Graham, Ruth M., Schueller, Edmund F., and Graham, John B.: Ohst. & Gynec. 26: 151, 1965. 3. Floyd, William S., Boyce, Charles R., and Evans, T. N.: AM. J. OBST. & GYNEC. 97: 1150, 1967. 4. Marcus, Cyril C.: Obst. & Gynec. 20: 701, 1962. D. G., Moore, J. G., and Chany, N.: 5. Morton, AM. J. OBST. & GYNEC. 81: 1115, 1961. H.. and Abrahamsen, H.: Geburtsh. u. 6. Smolka, Frauenh. 15: 735, 1935.
7. Keettel, William C., and Elkins, H. B.: AM. J. OBST. & GYNEC. 71: 553, 1956. W. C., and Pixley, E.: Clin. Obst. & 8. Keettel, Gynec. 1: 592, 1958. D., Stienmier, R., and Lovell, D.: 9. Grillo, Obst. & Gynec. 28: 346, 1966. 10. McGowan, L., Stein, D. B., and Miller, W.: AM. J. OBST. & GYNEC. 96: 413, 1966. Breen, J. L., Peraglie, B. R., Calerine, H. R., Il. Miller, B. E., and Albano, E. H.: J. Newark City Hosp. 1: 106, 1964. 3800 Woodward Detroit, Michigan
Avenue 4820!
S. FLOYD,
CHARLES PAUL
R.
GERALD T. Detroit,
N.
M.D.
BOYCE,
GOODMAN,
M.D. M.D.
MANDELL, EVANS,
for cytology
M.D.
M.D.
Michigan
A technique for cul-de-sac peritoneal lavage and filtration is described. Preliminary experience with this procedure suggests its mass application may result in earlier cytologic diagnosis and increased salvage of patients with clinically occult intra-abdominal malignant disease.
of ascitic fluid C Y T o L o G I c examination aspirated from the peritoneal cavity may lead to the diagnosis of cancer. However, ascites is usually associated with an advanced and incurable neoplasm. Attempts to diagnose cancer cytologically before ascites develops often have been unsuccessful because an inadequate specimen was obtained. Graham, Graham, and Schueller’,” detected several early ovarian neoplasms by recovering small quantities of peritoneal fluid after altering the patient’s position. Thirty per cent of their attempts were unsatisfactory because of vaginal and/or bowel contamination or absence of cells in the aspirated fluid. The cellular pattern of cul-desac fluid reflects the tissue pattern of the organs exfoliating into the peritoneal cavity.3 Abdominal peritoneal lavage may produce cytologic evidence of breast, gastrointestinal, uterine, and Fallopian tube carcinomas4, ’ In 1935, an excellent correlation was established between ascitic fluid cytology and the findings at operation and necropsy.’ Earlier attempts to detect ovarian cancer before ascites develops by cul-de-sac aspira-
From
the Departments
and Obstetrics State
University
tion after injecting saline solution have been described.?? 8 This method was abandoned because of the lack of positive findings. Specimens obtained were often inadequate and altered by autolysis and blood contamination. This report concerns a new technique which offers pro’mise of increasing the accuracy of early cytodiagnosis of intra-abdominal tumors by examination of fluid obtained by cul-de-sac lavage. Methods
Following pelvic examination of 2 18 women, a No. 20 gauge needle was inserted through the posterior vaginal fornix into the cul-de-sac of Douglas after aseptic precautions. Twenty cubic centimeters of physiologic saline solution was injected and promptly aspirated. The aspirated fluid was injected through a Cytosieve” containing a cytology membrane, Metracel GA-1 (Fig. 1). The Cytosieve was constructed to distribute cells symmetrically over a 1 inch disk. Debris less than 5 p in diameter filters through. The membrane was fixed in 10 per cent formalin for at least 10 minutes, stained
of Gynecology Wayne of Medicine.
and Pathology, School
Ann
425
*Gelman Arbor,
Instrument Michigan
Company, 48106.
600 South
Wagner
Road,
426
Floyd et al.
1. co1 nponent
Fig. 2. Cluster
of mesothelial
parts
of the
cells
Cytosieve,
capsule,
pad,
and
1 inch
filter
and histiocytes.
by the Papanicolaou method, and cleared to transparency with mounting media. When aspirated fluid was cloudy, some was injected through the filter and the remainder passed through additional filters or centrifuged for preparation of cell blocks. A specimen was regarded as negative in the absence of malignant cells and when mesothelial cells were present, confirming peritoneal entry. Results
Interpretation ed there were
support
of 2 18 preparations suggest15 malignancies, 4 were sus-
Fig. 3. Cluster
of normal
mesothelial
cells.
picious, 28 unsatisfactory, and 17 1 negative. Four specimens contained fecal material, one with barium. However, no complications resulted from this procedure. The best preparations were obtained following immediate filtration and fixation. Prompt fixation should not represent a problem, since tile
Volume Number
103 3
Peritoneal
lavage
and
filtration
for
cytology
427
Fig. 4. Cluster of adenocarcinoma cells from case of bilateral ovarian serous cystadenocarcinoma.
Fig. 5. Histologic shown in Fig. 4.
Cytosieve is disposable and can be placed immediately into 10 per cent formalin. Most preparations were excellent, but a few were inadequate for diagnosis because of cellular autolysis resulting from delayed fixation. Overloading of the cytology membrane occurred occasionally. When there is increased resistance because of the amount of cellular debris, Cytosieve filtration should cease and the remaining aspirate should be processed into a cell block. Contamination with vaginal cells occurred when negative pressure was maintained as the needle was withdrawn. In one patient with cervical carcinoma in situ a positive squamous cell vaginal preparation was obtained. Forceful filtration with rupture of the cytology membrane, venipuncture, and penetration of the urinary bladder were other causes of unsatisfactory preparations. Acellularity of the fluid is usually due to failure to enter the peritoneal cavity. Success is related to the technical skill and experi-
ence of the one performing the cul-de-sac puncture. Most specimens were satisfactory. Mesothelial cells occur singly, in clusters, or in large sheets. Hyperchromatic artifacts occurred when mesothelial cells were dense. Vacuolization and multinucleation are frequent. Histiocytes and lymphocytes are found in lesser numbers. Ciliary columnar cells are occasionally seen.l, o-11 In 4 instances suspicious cells were not associated with malignancy (Figs. 2 and 31. Peritoneal giant cells were found in one with disseminated lupus erythematosus. The remaining 3 were misinterpretations of small papillary groups which we have subsequently learned to identify as benign.
section of the ovarian
lesion
Malignancies
The specimens diagnosed as malignant were associated with carcinoma of the ovary (Figs. 4 to 6)) pseudomyxoma peritoneii (Figs. 7 and 8)) pancreas (Fig. 9)) and the stomach (Fig. 10).
428
Floyd et al.
Fig. 6. Cluster of large adenocarcinoma cells from case of bilateral secondary ovarian carcinoma. The primary transverse colon carcinoma had been removed 4 months previously. Therr was no nscitrs.
Fig. 7. Syncytium of malignant pseudomyxoma peritoneii.
Fig. 8. myxoma
Fig. 9. Cluster of adenocarcinomr plastica of the stomach.
Histologic peritoneii
section of nodule shown in Fig. 7.
of
pscudo-
~-ells.
in
cells,
c.ue
linitis
01
Volume Number
103 3
Fig. 10. Cluster of adenocarcinoma cells case of adenocarcinoma of the pancreas.
Peritoneal
from
a
Comment Advantages of this technique are: ( 1) instillation of fluid insures a greater percentage
lavage
and
filtration
for
cytology
4’29
of successful taps; (2) all of the fluid aspirated can be filtered easily; (3) artifacts produced by centrifugation and sedimentation are eliminated; (4) the microporous membrane allows debris to pass through while the exfoliated cells are retained; (5) formalin fixation produces less precipitation of debris than ether-alcohol mixtures; (6) all of the cellular debris is concentrated on a 1 inch disk; and (7) collection and preparation of the specimens are performed easily and quickly. This limited experience suggests that mass application of this screening technique may result in earlier diagnosis and increased salvage of patients with heretofore occult intraperitoneal malignant disease. Cells may migrate through a single mesothelial layer which permits diagnosis of abdominal maiignancy before it is clinically evident.
REFERENCES
1. Graham, John B., Graham, Ruth M., and Schueller, Edmund F.: Cancer 17: 1414, 1964. 2. Graham, Ruth M., Schueller, Edmund F., and Graham, John B.: Ohst. & Gynec. 26: 151, 1965. 3. Floyd, William S., Boyce, Charles R., and Evans, T. N.: AM. J. OBST. & GYNEC. 97: 1150, 1967. 4. Marcus, Cyril C.: Obst. & Gynec. 20: 701, 1962. D. G., Moore, J. G., and Chany, N.: 5. Morton, AM. J. OBST. & GYNEC. 81: 1115, 1961. H.. and Abrahamsen, H.: Geburtsh. u. 6. Smolka, Frauenh. 15: 735, 1935.
7. Keettel, William C., and Elkins, H. B.: AM. J. OBST. & GYNEC. 71: 553, 1956. W. C., and Pixley, E.: Clin. Obst. & 8. Keettel, Gynec. 1: 592, 1958. D., Stienmier, R., and Lovell, D.: 9. Grillo, Obst. & Gynec. 28: 346, 1966. 10. McGowan, L., Stein, D. B., and Miller, W.: AM. J. OBST. & GYNEC. 96: 413, 1966. Breen, J. L., Peraglie, B. R., Calerine, H. R., Il. Miller, B. E., and Albano, E. H.: J. Newark City Hosp. 1: 106, 1964. 3800 Woodward Detroit, Michigan
Avenue 4820!