technique of preparing imprint smear# comparision with frozen sections# application and its role in thyroid ,paathyroid,breast,skin,head and neck and mucinous tumors# advantages and limitations

1. IMPRINT CYTOLOGY
Dr Y L S

2. INTRODUCTION
◦ Imprint cytology simple method for preparing surgical specimens for pathological
investigations
◦ Fresh surgical specimen sent to pathology lab and will be immediately processed
◦ Cellular morphology ,tissue disease and resected margins can be made out by this procedure

3. ◦ This technique was reported by Dudgeon Patrick (1927) and Bamforth and Osborn (1958) .
◦ Imprint cytology are rapid diagnostic tool intraoperatively .
◦ Imprint cytology is simple ,rapid, inexpensive, will have excellent preservation of cellular
details, and gives information regarding surgical margins

4. DUGESON PATRICK

5. INTRODUCTION
◦ Imprint is a touch preparation in which tissue is touched on the slide and it leaves behind its
imprint in the form of cells on glass slide.
◦ studies are made after proper staining .
◦ A correct diagnosis helps in starting the specific therapy in time, thus reducing morbidity and
mortality.

6. ◦ The intraoperative diagnostic accuracy of a tumor is an essential part in patients’ work-up.
◦ Intraoperative diagnosis of surgically removed specimens can be achieved with the help of
frozen sections & or cytologic examinations.
◦ Various cytologic techniques including imprint, squash smears and scrape cytology may be used
for intraoperative evaluation of tumors & surgical margins

7. ◦ In benign conditions the cells appeared in clusters but were readily identifiable and diagnosed
correctly.
◦ Imprint from malignant lesions required less pressure and smears were hypercellular than
benign lesions.
◦ Mitotic Figures though less in number in imprint and scrape smear as compared to
corresponding paraffin section malignant lesions because cells in mitosis tend to rupture during
imprinting

8. ◦ Considering the accuracy observed by different scientists, imprint and scrape smear are
employed as adjuvant to histopathological study.
◦ It will be extremely useful in arriving the correct diagnosis.
◦ When patient is under anasthesia it can give accurate results in few minutes ,pathologist views
arrive at diagnosis and surgeon modifies the plan and treatment.

9. LITERATURE REVIEW
◦ Kamatchi et al 2015 said imprint cytology gives valuable morphological details of the cell.
◦ Though it has some pitfalls it is still considered as one of the best methods as it provides
excellent cytology clarity in fresh specimens.
◦ Dugeson and Patrick et al reported technique for examination of imprint of fresh surgical
specimens .
◦ It serves the surgeon in identifying lesion whether it is malignant or not.

10. ◦ Sometimes the first imprint contained excess tissue fluid and blood and it was found that
subsequent imprints gave better cytological results and third smear was found to be the best

11. Technique for imprint smear
◦ The imprints were prepared according to technique described by Tribe (1973).
◦ Slides properly labelled by glass marking pencil.
◦ After sectioning, the areas suggestive of disease were gently touched with dry gauze to remove
blood on the surface.
◦ Slide were then gently touched on the freshly cut surface of the specimen, avoiding a gliding
movement.
◦ Pressure applied for imprinting varied with the consistency of the specimen.

12. ◦ The tissue surface to be imprinted should be flat and there should be no portion of fat
protruding from the edges as these tend to smudge the imprints.
◦ Smears were quickly fixed in 95% alcohol in order to avoid air drying artefact stained with
◦ Papanicolaou’s-stain.
◦ Rapid haematoxylin and eosin.
◦ Depending on one's preference, a rapid polychrome dye, such as toluidine blue, can also be
used on heat-fixed slides.

13. ◦ This would further shorten the preparation time.
◦ But the differential colour of the preparation is not as good as that of a slide stained with
haematoxylin and eosin.
◦ The accuracy of the imprint method was assessed by comparing the imprint diagnosis with the
corresponding paraffin section diagnosis.

14. ◦ The case with which any tumor gets imprinted varies considerably.
◦ In order to obtain imprint nearest to one cell thickness, the amount of pressure applied at the
time of imprinting therefore varied.
◦ Benign looking lesions usually required more pressure in order to obtain sufficient cells for
diagnosis while malignant tumors get imprinted more easily.

16. Thyroid lesions
◦ Anila, K R; Krishna, G et al
◦ Imprint cytology has high sensitivity and specificity in diagnosing lesions of the thyroid.
◦ A correct intra-operative diagnosis helps eliminate the need for second surgery.
◦ Study was done on 84 patients of thyroidectomy pts
◦ The intraoperative imprint cytology smears were stained by Pap method.
◦ The imprint cytology interpretation was later compared with the paraffin section diagnosis.

17. ◦ Sensitivity 85%, specificity is 100% with PPV of 100% for detecting malignant lesions.
◦ It is simple reliable in thyroid cases and in spite of the advent of newer diagnostic modalities like
frozen sections still holds unique position In current perspect.
◦ The problems faced were in diagnosing follicular carcinomas and differentiating low grade
lymphoma from lymphocytic thyroiditis

19. Skin lesions
◦ Ramakrishnaiah, Vishnu Prasad Nelamangala; Babu, Ravindra; Pai, Dinker; Verma, Surendra
Kumar e al
◦ Imprint Cytology in the diagnosis of ulcerative skin neoplasms
◦ role of imprint/exfoliative cytology in the diagnosis of ulcerated skin neoplasm To check the
adequacy of resected margins intra operatively.

20. ◦ Imprints are taken from 107 pts
◦ A wedge biopsy obtained from the ulcer and imprint smears were taken and specimen sent for
HPE
◦ Comparision of results of imprint smears and HPE was done and showed Showing sensitivity of
94.3, specificity is 100% with PPV of 90.3%.
◦ Out of 59 cases of malignancy one case was not picked by imprint smears

22. TRANSRECTAL PROSTATE NEDDLE
BIOPSY
◦ Sayar, Hamide; Bulut, Burak Besir; Bahar, Abdulkadir Yasir; Bahar, Mustafa Remzi; Seringec,
Nurten; Resim, Sefa, Harun
◦ Patients with abnormal BRE and PSA >2.5 ng/ml are taken .
◦ Biopsy specimen were taken from 100 patients
◦ Samples with positive imprint cytology but negative initial histologic exam underwent repeat
sectioning and histological examination.
◦ Comparision of cytology with HPE after smear sectioning showed sensitivity of 98%, specificity is
96% with PPV of 98%.

23. ◦ Imprint cytology is valuable tool for evaluating TRUS-guided core needle biopsy specimens
from the prostate.
◦ Use of imprint cytology in combination with histopathology increases diagnostic accuracy when
compared with histopathologic assessment alone.

25. VABB(vaccum assisted breast biopsy)
◦ otou, Maria; Oikonomou, Vassiliki; Zagouri, Flora; Sergentanis, Theodoros N; Nonni, Afroditi;
Athanassiadou, George C et al
◦ Total of 93 women with micro calcifications BI-RADS 3 and 4 underwent VABB
and imprint samples were examined.
◦ The cores with micro calcifications confirmed by mammogram were gently rolled against glass
microscope slides and smears were made.
◦ Out of which 73 cases were benign and 15 were malignant and 5 were pre curser lesions
◦ sensitivity of 100%, specificity of 100% in detecting malignant cases was observed

27. Ovarian neoplasms
◦ Dey, Soumit; Misra, Vatsala; Singh, P A; Mishra, Sanjay; Sharma, Nishant et al
◦ Imprint cytology can be used as an adjunct to histopathology for rapid and early diagnosis in
the operation theatre, thus helping better management of patients.
◦ Helps better in differentiating benign and malignant lesions.
◦ A prospective investigation was performed on 30 cases of suspected ovarian neoplasms

28. ◦ Imprint smears were made intra operatively from fresh samples from representative areas, and
stained with
◦ Leishman Giemsa for air-dried smears
◦ Hematoxylin and eosin and Pap stain in fixed smears
◦ In prospective cases which were done for 30 cases in suspected ovarian neoplasms sensitivity of
96.2%, specificity is 86% with PPV of 96.3%.
◦ Charecterstic cytological patterns were noted in epithelial and germ cell tumors

30. Serous ca

31. Sentinel LN biopsy in CA breast
◦ Shiver, Stephen A; Creager, Andrew J; Geisinger, Kim; Perrier, Nancy D; Shen, Perry; Levine,
Edward A et al
◦ Axillary lymph node dissection can be performed during the initial surgery if the SLN is positive.
◦ Both frozen sectioning and imprint cytology are used for rapid intraoperative SLN evaluation.
◦ A retrospective review of the intraoperative imprint cytology results of 133 SLN mapping
procedures from 132 breast carcinoma patients was performed.
◦ SLN were evaluated intraoperatively by bisecting the lymph node and making imprints of each
cut surface.

32. ◦ Imprints were stained with (H&E) .
◦ Imprint cytology results were compared with final histologic results.
◦ Sensitivity and specificity of imprint cytology were 56% and 100%, respectively, producing a
100% ,PPV and 88% .
◦ Imprint cytology was significantly more sensitive for macro metastasis than micro metastasis
87% versus 22%.
◦ Of 13 total false negatives, 11 were found to be due to sampling error and 2 due to errors in
intraoperative interpretation

33. ◦ Both intraoperative interpretation errors involved a diagnosis of lobular breast carcinoma.
◦ The sensitivity and specificity of imprint cytology are similar to that of frozen section
evaluation.
◦ Imprint cytology is therefore a viable alternative to frozen sectioning when intraoperative
evaluation is required.
◦ If SLN micro metastasis is used to determine the need for further lymphadenectomy
◦ more sensitive intraoperative methods will be needed to avoid a second operation.

35. Head and neck Malignancies
◦ Naveed, Hania; Abid, Mariam; Hashmi, Atif Ali; Edhi, Muhammad Muzammamil; Sheikh,
Ahmareen Khalid; Mudassir, Ghazala; Khan, Amir et al
◦ Although frozen section analysis is a preferred method of intra-operative consultation, however
in resource limited countries , this facility is not available in most institute
◦ study involved 70 cases of UAT lesions operated during the study period

36. ◦ The slides of both touch Imprint cytology and histopathology were examined by two consultant
histopathologists
◦ The result of touch imprint cytology showed that touch imprint cytology was diagnostic in 68
cases (97.1%),
◦ 55 (78.6%) being malignant
◦ 2 cases (2.9%) were suspicious for malignancy
◦ 11 cases (15.7%) were negative for malignancy
◦ while 2 cases (2.9%) were false negative.

37. ◦ Amongst the 70 cases
◦ 55 cases (78.6%) were malignant
◦ Squamous cell carcinoma in 49 cases (70%)
◦ Adenoid cystic carcinoma in 2 cases (2.9%)
◦ Non-Hodgkin lymphoma 2 cases (2.9%)
◦ Muco epidermoid carcinoma 1 case (1.4%)
◦ Spindle cell sarcoma in 1 case (1.4%)
◦ Two cases (2.9%) were suspicious of malignancy showing atypical squamoid cells on
touch imprint cytology
◦ while 13 cases (18.6%) were negative for malignancy

38. ◦ The overall diagnostic accuracy of touch imprint cytology came out to be 96.7% with a
sensitivity and specificity of 96 and 100%,
◦ while PPV and NPV of touch imprint cytology was found to be 100 and 84%, respectively.

39. Mucoepidermoid carcinoma

40. Adenoid cystic carcinoma

41. Cytology of cardiac myxomas-detecting
UEA lectin by IHC
◦ Iwa, N; Yutani, C et al
◦ Cytological findings are presented of seven cases of cardiac myxomas.
◦ Avidin-biotin-peroxidase complex (ABC) method was employed to demonstrate Ulex europaeus
agglutinin-I (UEA-I) lectin in imprint smears as well as in tissue sections.
◦ The cytology was characterized by tumor cells with polyhedral or stellate and mucinous
background with lymphocytes, neutrophils, and hemosiderin-laden macrophages.

42. ◦ In smears as well as tissue sections, UEA-I lectin was detected throughout the cytoplasm of
myxoma cells.
◦
◦ This study established the applicability of the immune peroxidase staining for cardiac myxoma
as an aid in cyto pathological diagnosis.

43. PARATHYROID LESIONS
◦ The identification of parathyroid gland tissue and its distinction from adjacent structures such as
◦ Thyroid gland
◦ Lymphoid
◦ fibro adipose tissue
◦ Thymic tissues
◦ on frozen section (FS) may be challenging owing to freezing artifact.
◦ Intraoperative cytology (IC) provides valuable complementary morphologic details.

44. ◦ They evaluated 72 specimens with IC alone (group 1), followed by interpretation with FS to
reach a final interpretation using IC and FS together (group 2).
◦ An additional 105 specimens were evaluated by FS alone (group 3
◦ Permanent section diagnosis was used as the “gold standard.”
◦ Sensitivity and specificity were 100% for group 2 compared with group 1 and 3

45. ◦ IC is a valuable adjunct to FS during intraoperative consultation for evaluation of tissue in
parathyroid
◦ High diagnostic accuracy with imprint smear cytology for interpreting different tissues in a
parathyroid location

46. Uses
◦ Useful in determining the surgical resected margins
◦ Extensively used to diagnose benign or malignant lesions
◦ Imprint cytology provides good results without any difficulties in basal carcinomas of the skin.
◦ Sarcoma occurring in the alveolar soft part also imprint cytology has been useful.
◦ An accurate diagnosis is provided in the diagnosis of metastatic tumors.

47. ◦ Imprint cytology is used as a diagnostic tool in the study for assessing the salivary gland tumors
such as mixed parotid tumors, pleomorphic adenoma and mucoepidermoid carcinoma.
◦ In determining the parathyroid tissue
◦ Sentinal lymph nodes
◦ Adenomatous goiter

48. ◦ In tumors such as meningiomas , gliomas imprint cytology plays a major role.
◦ Imprint cytology provides good results without any difficulties in basal carcinomas of the skin.
◦ In the diagnosis of ovarian cancers, imprint cytology provides valuable details regarding the
lesion, for further investigative procedure

49. Imprint cytology Frozen section
Simple ,rapid, and takes
time for slide preparation
Takes atleast 20-30min
Extremely small samples
be processsed
Larger sections needed
Cost effective High expenditure
Less skilled technician,
inunderdeveloped
infrastructure
High skilled technician
needed.highly equipped
labs needed
TEMPERATURE- need not
be maintained
Has to be maintained

50. ADVANTAGES
◦ The procedure of imprint cytology can be done even in underdeveloped infrastructure and
deficient trained technicians.
◦ Analysis of individual cell is performed by imprint cytology.
◦ It provides immediate results with minimal artifacts.
◦ It is rapid, cheaper and hence most commonly used.
◦ A precise diagnosis is received through this technique.

51. DISADVANTAGE
◦ The depth of invasion cannot be assessed with imprint cytology
◦ Tumor and well differentiated tumors with dense fibrous stroma cannot be interpreted
through this method
◦ Insufficient cells: There is a dense fibrous stroma in some tumors, such as the linitis plastica
type of gastric carcinoma, markedly scirrhous carcinoma.

52. ◦ Breast tumors
◦ Krukenberg tumour
◦ Brenner tumour
◦ granulosa-theca cell tumour
◦ some fibrous soft-tissue tumours
◦ some skin tumours.
◦ In these cases the number of neoplastic cells transferred to the slide is insufficient to enable the
observer to make a correct diagnosis

53. CONCLUSION
◦ Imprint cytology plays a significant role in quick diagnosis of lesion
◦ It provides crisp cytological details
◦ Cost effectiveness rapid results and simplicity are the further criteria promoting it to be best
option
◦ It is better compared to frozen sections

54. REFERENCES
◦ 1. Dudgeon LS, Patrick CV. A new method for the rapid microscopical diagnosis of tumours, with
an account of 200 cases so examined. Br J Surg. 1927;15:250–61.
◦ 2. Silverberg S, Nochomovitz L, Jannotta SF, Schwartz A. 1st ed. Washington DC: ASCP; 1989.
Intraoperative Consultation. A Guide to Smears, Imprints and Frozen Sections.

55. ◦ Kim K, Phillips ER, Paolino M. Intraoperative imprint cytology: Its significance as a diagnostic
adjunct. Diagn Cytopathol. 1990;6:304–7.
◦ 4. Manafis K. An intraoperative consultation. Usefulness, reason and accuracy of the
method. Arch Hell Pathol. 1997;11:472–7.
◦ 5. Khalid A, Ul Haque A. International touch impression cytology versus frozen section as
intraoperative consultation diagnosis