*Corresponding author:Parveen Malhotra, Department of Medical Gastroenterology, PGIMS, Rohtak-124001, Haryana, India
How to cite this article:Parveen M, Ritesh K, Sonia C, Vani M, Yogesh S, et al. Brush Cytology- Alternative to Endoscopic Biopsy in Diagnosing
Malignancy. Adv Res Gastroentero Hepatol, 2020;15(3): 555914. DOI: 10.19080/ARGH.2020.15.555915.
Introduction: Upper gastrointestinal tract lesions are the leading cause of morbidity and mortality worldwide. Upper gastrointestinal symptoms include dysphagia, vomiting, anorexia, retrosternal pain, weight loss and mass abdomen and patients may present with visible red and white mucosal lesions, ulcers, polypoidal or ulcerative growth in upper gastrointestinal tract (GIT)
Observation: Fifty patients suspected of having upper gastrointestinal malignancies, from the gastroenterology ward/OPD were included in the study.
Results: In our study, maximum number of cases were in the age group of 41-60 years with the mean age being 58 years. Male to female ratio was approximately 2:1. Maximum number of patients (42 cases) presented with dysphagia
Conclusion:Although endoscopic biopsies are an established gold standard for diagnosing gastrointestinal malignancies but brush cytology can be used as an accurate diagnostic adjunct to biopsy in diagnosis of cancer and an important screening technique for detecting upper gastrointestinal malignancy in high risk population and in cases where difficulty is encountered in obtaining adequate tissue for histopathological examination
Upper gastrointestinal tract lesions are the leading cause of morbidity and mortality worldwide. Upper gastrointestinal symptoms include dysphagia, vomiting, anorexia, retrosternal pain, weight loss and mass abdomen and patients may present with visible red and white mucosal lesions, ulcers, polypoidal or ulcerative growth in upper gastrointestinal tract (GIT) . The pattern of primary cancers differ in different regions of the world depending upon the genetic, cultural, dietary and socioeconomic factor . Upper gastrointestinal tract is a common site for malignant tumours among which gastric adenocarcinoma is most common [3,4]. Worldwide gastric adenocarcinoma is the second most common cancer and carcinoma esophagus is sixth leading cause of death . The prevalence of oesophageal cancer has increased six times in the recent three decades, which is the most rapid increase amongst major malignancies . In India, according to National Cancer Registery, oesophageal and gastric cancers are the most common cancers found in men while oesophageal cancer ranks third among women after carcinoma of breast and cervix . Colo-rectal cancer is the third most common malignant diseases and the second most common frequent cause of cancer
death in the United States . Worldwide colorectal cancer is the third most commonly diagnosed malignant disease . An early detection of oesophageal cancers gives five year survival rate of 83.5% and that of gastric cancer gives more than 90% five year survival rate .
The advent of endoscopy and endoscopic biopsy has greatly facilitated the detection and diagnosis of gastrointestinal neoplasms . GIT lesions can be detected in many ways such as endoscopic guided balloon abrasive technique, lavage, or fine needle aspiration performed under either endoscopic guidance, or computed tomographic guidance . However, the diagnostic value of cytology has been less recognized in the evaluation of these lesions. The use of cytology in addition to biopsy still remains controversial, as it appears to duplicate biopsy .
In 1964, Kobayashi S et al introduced brushing cytology under direct vision using fiberoptic gastroscope . Brush cytology often complements and increases the sensitivity and specificity of detection of GIT lesions in many ways6. Brushing can yield near-tissue equivalent diagnostic material that can form the basis for therapeutic decisions. Minimal morbidity, low cost, and a rapid turn around time that reduces patient anxiety make
adjuvant brush cytology along with biopsy, a preferred method
in the evaluation of gastrointestinal malignancy . It is useful
in narrow, strictured lesions where access to the tumor by the
biopsy forceps is limited and broader surface area can be accessed
as compared to biopsy .
The highest incidence of malignancy is in the esophagus,
stomach and colorectal regions. In fact, esophagogastric and
colorectal malignancies are amongst the commonest cancers
in humans . Over the last years the use of gastrointestinal
cytology has declined due to preference for tissue biopsies
 however, cytologic evaluation is often complementary to
histologic diagnosis and is quite accurate and safe in expert
hands . Cytological smears show numerous small clusters and
glandular groups with overlapping and loss of polarity. Loosely
cohesive cells and scattered single cells may be seen in a necrotic
background. The cytoplasm is variable in amount, delicate, finely
granular and may show vacuolation. The tumor cell nuclei are
enlarged, pleomorphic, have irregular nuclear membranes and
show prominent nucleoli .
Vidyavathi K et al,  did a study to find correlation of
endoscopic brush cytology with endoscopic biopsy in diagnosis
of upper gastrointestinal neoplasms. Seventy five patients with
upper gastrointestinal symptoms such as dysphagia, vomiting,
retrosternal pain, anorexia, loss of weight and mass abdomen
were subjected to endoscopy over a period of 2 years. Patients
with visible mucosal lesions such as ulcer, polypoid or ulcerative
growth in the upper GIT were included in the study. After visual
examination of the lesion, cytology is performed using a small
brush which is introduced through a separate channel in the
endoscope. Six smears were made by directly smearing the brush
onto a slide. Four slides were fixed with a spray fixative containing
95% ethyl alcohol in carbowax and were stained by haematoxylin
and eosin and Papanicolaou stain. Two slides were air-dried
and stained with May-Grunwald-Giemsa stain. After brushing,
multiple biopsies were taken from the surface and margins of
the suspicious lesion. The tissue fragments were fixed in 10%
buffered formalin and processed routinely. Histological sections
were routinely stained by haematoxylin and eosin method.
Histopathological and cytological findings were compared. Out
of 75 cases, brush cytology was positive for malignancy in 65
cases (86.66%) and biopsy was positive in 58 cases (77.33%);
thereby suggesting brush cytology as a useful adjunct to biopsy
in the diagnosis of upper gastrointestinal tract malignancy. The
study concluded that though biopsy is used as a routine procedure
in diagnosis of gastrointestinal tract lesions, cytology is useful
because it is inexpensive, gives a rapid diagnosis and offers
minimal discomfort to the patient .
The present prospective study was conducted in the
Department of Pathology in collaboration with Department of
Gastroenterology at Pt. B.D. Sharma PGIMS, Rohtak. A total of fifty
patients suspected of having upper gastrointestinal malignancies
formed the study group. After taking the detailed history, patients
were subjected to endoscopy using flexible video endoscope.
After visual examination of the lesion, a cytological brush made
up of small nylon bristles at the tip was introduced through a
separate channel in the endoscope. The brush was advanced up to
the lesions so that the bristles touched the mucosa or suspected
lesion, by up and down or rotary motions. The trapped exfoliated
cells were smeared on minimum of two glass slides. Half of the
slides were air dried and others were fixed in 95% alcohol. Air
dried slides were stained with Romanowsky stain and alcohol fixed
slides were stained with Haematoxylin and Eosin/Papanicolaou
stain. After brushing, biopsies were taken from the lesions and
preserved in 10% formalin. Biopsies were processed by routine
histopathological technique and paraffin sections obtained were
stained with Haematoxylin and Eosin (H&E) stains. Smears and
sections were interpreted as negative, suspicious of malignancy
and positive for malignancy.
The data was subsequently analysed using SPSS software
(Version 21.0). Chi-square test and other relevant statistics
(including sensitivity, specificity, positive predictive value and
negative predictive value) were used. P-value less than 0.05 was
accepted as statistically significant.
Fifty patients suspected of having upper gastrointestinal
malignancies, from the gastroenterology ward/OPD were
included in the study (Figure 1-12).
Thus, brush cytology and histopathological findings on biopsy
were compared and the accuracy of brush cytology for detection
of malignant lesions was evaluated taking histopathology as
the reference standard test. The results were interpreted in the
form of sensitivity (likelihood that patient with the disease has
positive test results), specificity (likelihood that patient without
the disease has negative test results), positive predictive value
(the probability that patients with a positive screening test truly
have the disease), negative predictive value (the probability that
patients with a negative screening test truly do not have the
The sensitivity and positive predictive value in our study is
84.4% and 97.4% respectively while the specificity and negative
predictive value is 100% and 50% respectively which means in
an adequate brush cytology smear, malignancy was never over
diagnosed. These findings substantiate the value of brush cytology
in diagnosing upper gastrointestinal malignancies.
Gastrointestinal malignancies are a leading cause of morbidity
and mortality worldwide. In India, according to National cancer
registery, oesophageal and gastric cancers are the most common
cancers found in men, while oesophageal cancer ranks third
among women after the carcinoma of breast and cervix . Early
lesions are asymptomatic and highly curable, but unfortunately
most of them are diagnosed in advanced stages of disease. The
introduction of flexible fibre optic endoscope has greatly expanded
the usefulness and precision of gastrointestinal tract cytology .
So direct vision brush cytology of upper GIT mucosa with flexible
endoscope is now a standard method of diagnosis independently
or as an adjunct to tissue biopsy. Its reliability has been reported to
range from 75% to 90% in various studies . The primary role of
gastrointestinal cytology is in cancer detection. Endoscopy allows
the visualization of mucosal lesions and at same time permits the
sampling of cytology and biopsy for a definitive diagnosis. It is an
outpatient procedure and is considered minimally invasive and
does not require any significant recovery after the procedure .
During our study period, 50 cases suspected of upper
gastrointestinal malignancies were included in which brush
cytology followed by biopsy were performed. Patients were
divided into various age groups ranging from 0-20, 21-40, 41-60,
61-80 and 81-100 years. In our study, majority of patients were
in the age group of 41-60 years with the mean age being 58 years.
The mean age is comparable to studies conducted by Vidyavathi &
Kaur et al. [5,11].
In our study, the total male count diagnosed with upper
gastrointestinal cancer was 33 and the female count was 17 with
male to female ratio almost 2:1. This ratio is in conformity with
findings of Vidyavathi & Kaur et al. [5,11] who reported a male:
female ratio of 2.5:1 and 1.7:1 respectively. In all the studies, males
were found to be affected more commonly as compared to females.
The reason for this finding is that males are comparatively more
exposed to environmental pollutants as compared to females and
are more indulged in habits of smoking and tobacco consumption
as compared to females.
In our study, dysphagia was most common clinical complaint
found in 42 patients (84%) followed by dysphagia with epigastric
pain in 4 patients (8%) and dysphagia with vomiting in 4 cases
(8%). This is in accordance with the study of Karmarkar et al.
 who also reported dysphagia to be the most common clinical
complaint in patients of upper gastrointestinal malignancies.
Vidyavathi et al,  however reported abdominal pain to be the
most common symptom (38.66%) followed by dysphagia in
34.61% patients because maximum cases in his study were of
gastric lesions (64%) followed by oesophageal lesions (30.66%).
Esophagus was the most common site of involvement
accounting for 49 out of 50 cases in this study. One case was
reported to be of gastric malignancy. This is in accordance
with Karmarkar et al.  whose study showed 94% cases of
oesophageal lesions, 5% gastric lesions and 1% duodenal lesion.
Vidyavathi et al,  however reported predominance of gastric
lesions in her study (64%) followed by oesophageal (30.66%) and
duodenal (5.33%) lesions. This difference is attributed to various
studies being carried in different geographical areas with wide
difference in habits of the people living in these areas.
The lesion was located in upper 1/3rd of the esophagus in
11 patients, middle 1/3rd in 23 patients and lower 1/3rd in 15
patients. This finding was in accordance with the Vidyavathi et al,
 whose study also showed middle 1/3rd as the predominant site
Kaur et al, .
In our study, out of 45 cases positive for malignancy on biopsy
in upper GIT, 36 (80%) cases were squamous cell carcinoma (SCC),
7 (16%) cases were adenocarcinoma, 1 was of neuroendocrine
tumour (2%) and 1 case was of poorly differentiated carcinoma
(2%). Out of 39 cases positive for malignancy on cytology
 (51%) cases were squamous cell carcinoma, 3 (8%) were
adenocarcinoma, 1(3%) was of small cell carcinoma, 4 (10%)
cases were poorly differentiated carcinoma and 11(28%) were
unspecified carcinoma. Studies by Kaur & Vidyavathi et al, [5,11]
also showed squamous cell carcinoma being the most common
malignancy in upper GIT.
Statistical analysis revealed the overall sensitivity of brush
cytology in this study to be 84.4% which emphasizes the usefulness
of brush cytology as a screening procedure. The sensitivity of
this study is comparable to studies of Kaur et al,  having the
diagnostic sensitivity of 80.95% & Vidyavathi et al,  having
98%. Many factors influence the diagnostic accuracy of brush
cytology. In order to improve the positive rate of brush cytology
examination, some technical considerations should be noted such
as appropriate selection of the site for the specimen, avoiding areas
covered by thick slough or necrotic material and the procedure
should be performed by a technically trained person. It should be
performed at the margin of the lesion and the entire head of nylon
brush should be used over a wide area with appropriate force. After
brushing is completed, the head of brush should be withdrawn to
the tip to prevent the loss of specimen. During smearing of the
slides, filter paper should be used to absorb excess mucus or clot
adherent to the head of the brush . Considering these points,
endoscopic brush cytology can emerge as an effective method for
evaluating and screening upper gastrointestinal lesions and can
be used as an alternative to biopsy, that is an invasive technique,
for rapid diagnosis with minimal discomfort to patients though it
is not able to differentiate characteristically between dysplasia, in
situ and invasive malignancy.
In our study, maximum number of cases were in the age
group of 41-60 years with the mean age being 58 years. Male
to female ratio was approximately 2:1. Maximum number of
patients (42 cases) presented with dysphagia. Dysphagia with
epigastric pain was seen in 4 cases and the rest presented with
dysphagia with vomiting. Esophagus was the most common site
of involvement accounting for 49 out of 50 cases and a single
case was of gastric lesion. Maximum number of oesophageal
malignancies (23 cases) were located in middle 1/3rd followed
by lower 1/3rd in 15 cases and upper 1/3rd in 11 cases. Out of
39 cases positive for malignancy on brush cytology, 51% were
squamous cell carcinoma, 8% were adenocarcinoma, 3% were
small cell carcinoma, 10% were poorly differentiated carcinoma
and 28% cases were diagnosed as carcinoma (unspecified).
Out of 45 cases positive for malignancy on biopsy, 80% were
squamous cell carcinoma, 16% were adenocarcinoma, 2%
neuroendocrine tumor and 2% poorly differentiated carcinoma.
The overall sensitivity of brush cytology in our study was 84.4%
which emphasizes the usefulness of brush cytology as a screening
procedure. The overall specificity of brush cytology in our study
was 100%, meaning by that the patients without disease have
negative test results. The positive predictive value of cytology in
our study was 97.4% which signifies that in an adequate brush
cytology smear, malignancy was never over diagnosed. The
negative predictive value in our study was 50%. To conclude,
brush cytology is a reliable, simple, safe, rapid, non-invasive yet
effective, inexpensive method of detecting malignancy of upper
gastrointestinal tract. A large surface area can be sampled and the
technique has high specificity and good sensitivity. With increased
experience, meticulous care in technique and adherence to strict
criteria for malignancy and by identifying a suspicious category,
malignancy can be effectively detected and treated and it can
drastically alter the outcome in terms of morbidity and mortality.
Although endoscopic biopsies are an established gold standard for
diagnosing gastrointestinal malignancies but brush cytology can
be used as an accurate diagnostic adjunct to biopsy in diagnosis of
cancer and an important screening technique for detecting upper
gastrointestinal malignancy in high risk population and in cases
where difficulty is encountered in obtaining adequate tissue for
Brush cytology can be used as an independent technique
for screening and early detection of oesophageal malignancy
among high risk population and in high risk patients with
known premalignant conditions like Barrett’s esophagus, cardiac
achalasia etc. and for clinical follow up. With increased expertise in
procedure and reporting, it can emerge as an effective diagnostic
modality in mass screening projects..
Karmarkar P, Wilkinson A, Manohar T, Joshi A, Mahore S (2013) Diagnostic utility of endoscopic brush cytology in upper gastrointestinal lesions and its correlation with biopsy. IOSR J Dental Med Sci 5(2): 32-36.
Al Diab J, Sahib FA, Strak SK (2005) Endoscopic biopsy versus brush cytology in the diagnosis of various gastrointestinal diseases with special reference to gastrointestinal tumors. Bas J Surg 11(2): 15-18.
(1973) The Coordinating Group for the Research of Esophageal carcinoma. Chinese Academy of Medical Sciences and Honan Province. The early detection of carcinoma of the esophagus. Scientia Sinica 16: 457-463.