HOW TO DO IT
A Simple Technique for Obtaining Pap Smears of the Esophagus P. Lo Gerfo, M.D., C. W. Findley, M.D., J. Hill, M.S., and R. Crawford, M.D. ABSTRACT A simple method for obtaining Papanicolaou smears of the esophagus is described. The procedure is easy to perform, does not require specialized equipment, and is a useful adjuvant to direct esophageal biopsy.
Most surgeons treating carcinoma of the esophagus have occasionally experienced difficulty in obtaining satisfactory tissue for pathological evaluation. This is usually associated with the biopsy of necrotic tumor or of the inflammatory mass surrounding the tumor. In order to circumvent this problem, we have routinely been obtaining Papanicolaou smears of the esophagus using a modified nasogastric tube. This simple procedure has led to a decreased number of repeat endoscopies. A description of the method and results obtained are the basis of this report.
Materials, Technique, and Results Twenty-seven patients with esophageal carcinoma were evaluated with esophageal Pap smears over a three-year period from 1969 to 1972. After initial studies, a Pap smear of the esophagus was obtained and esophagoscopy was carried out. Forthe Pap smear, a 0 silk suture was wrapped around the tip of a standard nasogastric tube as illustrated in the Figure, A. The tube was then passed through the nose or mouth, using water as a lubricant. Every effort was made to advance the tube beyond the lesion so that cells would be scraped off as the tube was removed. A Pap smear was then prepared by unwrapping the suture and smearing it on a glass slide (Figure, B); smears obtained directly from the nasogasFrom the Department of Surgery, Columbia University, College of Physicians and Surgeons, New York, NY. Accepted for publication Aug 8, 1975. Address reprint requests to Dr. Lo Gerfo, Room 215-R, Institute for Cancer Research, 99 Fort Washington Ave, New York, NY 10032.
449
tric tube were unsatisfactory, and it is important that the suture be unwound and smeared directly on the slide. The slide was sprayed with Cytospray and sent to the pathology department for staining. The distribution of these lesions in the esophagus is shown in the Table. Of the 27 patients with carcinoma, 21 had lesions that could be diagnosed with a Pap smear. Thirteen of the 27 patients had both a positive Pap smear and a positive esophagoscopy. There were 8 patients in whom the esophageal biopsy was not satisfactory, and their definitive preoperative diagnosis was based on the results of the Pap smear; these 8 patients would have required repeat esophagoscopy if the diagnosis had not been established with the smear. There were 6 patients in whom Pap smears were nondiagnostic. The reason for this in 4 patients appears related to our inability to advance the nasogastric tube past their lesion. One patient with adenocarcinoma of the fundus of the stomach and 1 with lymphoma of the stomach had lesions that were passable with the nasogastric tube, and their Pap smears were nondiagnostic. Fifteen (70%) of the 21 patients with positive Pap smears required more than one attempt to get smears that could be unequivocally interpreted as carcinoma.
Comment The results of this study indicate that nasogastric tube scrapings of the esophagus are a useful adjunct to esophagoscopy in diagnosing carcinoma. The method is particularly useful for lesions that incompletely obstruct the esophagus and for patients in whom esophageal biopsies are insufficient for a definitive pathological diagnosis. More recently we have been obtaining Pap smears using the same technique at the time of esophagoscopy. This makes it easier to get the nasogastric tube past some lesions that are almost totally obstructive and increases the yield of positive results. We
450 The Annals of Thoracic Surgery Vol 21 No 5 May 1976
1
( A )Nasogastric tube wound with a heavy silksuture to provide an abrasive surface for obtainingcells for Pap smears. (B)Preparation of the Pap smear. It is important that the smear be obtained directly from the silk suture, as illustrated.
have not had enough experience with esophageal brushing to compare our results using the two methods. When the procedure was carried out in the patient’s room, it was necessary to repeat the examination in 70% of the cases to get a definitive diagnosis. The procedure, however, was
easily repeated and well tolerated by the patient. Repeat examination procedures were markedly decreased when attempted by someone experienced with the technique. No erroneous diagnoses were made in patients who had a positive Pap smear, but theoretically such errors might occur in someone with other types of head or neck cancer or in patients with lung carcinoma who were swallowing their secretions. Several negative Pap smears in a patient with a benign stricture provided some assurance that carcinoma was not present.
Distribution of Esophageal Neoplasms and Results Obtained with Pap Smears and Esophageal Biopsy No. of Patients
Location of Lesion Upper third Middle third Lower third Total
Carcinoma
of Esophagus
Positive Diagnosis by Pap Smear
Positive Pap Smear, Positive Esoph Biopsy
4
3
10
11 6
6 4
27
2l a
13
4 13
=Fifteendiagnoses (70%) required two or three attempts to obtain satisfactory Pap smears. bAll diagnoses were confirmed at operation or at postmortem examination.
Positive Pap Smear, Negative Esoph Biopsy
1 5 2
A Simple Technique for Obtaining Pap Smears of the Esophagus P. Lo Gerfo, M.D., C. W. Findley, M.D., J. Hill, M.S., and R. Crawford, M.D. ABSTRACT A simple method for obtaining Papanicolaou smears of the esophagus is described. The procedure is easy to perform, does not require specialized equipment, and is a useful adjuvant to direct esophageal biopsy.
Most surgeons treating carcinoma of the esophagus have occasionally experienced difficulty in obtaining satisfactory tissue for pathological evaluation. This is usually associated with the biopsy of necrotic tumor or of the inflammatory mass surrounding the tumor. In order to circumvent this problem, we have routinely been obtaining Papanicolaou smears of the esophagus using a modified nasogastric tube. This simple procedure has led to a decreased number of repeat endoscopies. A description of the method and results obtained are the basis of this report.
Materials, Technique, and Results Twenty-seven patients with esophageal carcinoma were evaluated with esophageal Pap smears over a three-year period from 1969 to 1972. After initial studies, a Pap smear of the esophagus was obtained and esophagoscopy was carried out. Forthe Pap smear, a 0 silk suture was wrapped around the tip of a standard nasogastric tube as illustrated in the Figure, A. The tube was then passed through the nose or mouth, using water as a lubricant. Every effort was made to advance the tube beyond the lesion so that cells would be scraped off as the tube was removed. A Pap smear was then prepared by unwrapping the suture and smearing it on a glass slide (Figure, B); smears obtained directly from the nasogasFrom the Department of Surgery, Columbia University, College of Physicians and Surgeons, New York, NY. Accepted for publication Aug 8, 1975. Address reprint requests to Dr. Lo Gerfo, Room 215-R, Institute for Cancer Research, 99 Fort Washington Ave, New York, NY 10032.
449
tric tube were unsatisfactory, and it is important that the suture be unwound and smeared directly on the slide. The slide was sprayed with Cytospray and sent to the pathology department for staining. The distribution of these lesions in the esophagus is shown in the Table. Of the 27 patients with carcinoma, 21 had lesions that could be diagnosed with a Pap smear. Thirteen of the 27 patients had both a positive Pap smear and a positive esophagoscopy. There were 8 patients in whom the esophageal biopsy was not satisfactory, and their definitive preoperative diagnosis was based on the results of the Pap smear; these 8 patients would have required repeat esophagoscopy if the diagnosis had not been established with the smear. There were 6 patients in whom Pap smears were nondiagnostic. The reason for this in 4 patients appears related to our inability to advance the nasogastric tube past their lesion. One patient with adenocarcinoma of the fundus of the stomach and 1 with lymphoma of the stomach had lesions that were passable with the nasogastric tube, and their Pap smears were nondiagnostic. Fifteen (70%) of the 21 patients with positive Pap smears required more than one attempt to get smears that could be unequivocally interpreted as carcinoma.
Comment The results of this study indicate that nasogastric tube scrapings of the esophagus are a useful adjunct to esophagoscopy in diagnosing carcinoma. The method is particularly useful for lesions that incompletely obstruct the esophagus and for patients in whom esophageal biopsies are insufficient for a definitive pathological diagnosis. More recently we have been obtaining Pap smears using the same technique at the time of esophagoscopy. This makes it easier to get the nasogastric tube past some lesions that are almost totally obstructive and increases the yield of positive results. We
450 The Annals of Thoracic Surgery Vol 21 No 5 May 1976
1
( A )Nasogastric tube wound with a heavy silksuture to provide an abrasive surface for obtainingcells for Pap smears. (B)Preparation of the Pap smear. It is important that the smear be obtained directly from the silk suture, as illustrated.
have not had enough experience with esophageal brushing to compare our results using the two methods. When the procedure was carried out in the patient’s room, it was necessary to repeat the examination in 70% of the cases to get a definitive diagnosis. The procedure, however, was
easily repeated and well tolerated by the patient. Repeat examination procedures were markedly decreased when attempted by someone experienced with the technique. No erroneous diagnoses were made in patients who had a positive Pap smear, but theoretically such errors might occur in someone with other types of head or neck cancer or in patients with lung carcinoma who were swallowing their secretions. Several negative Pap smears in a patient with a benign stricture provided some assurance that carcinoma was not present.
Distribution of Esophageal Neoplasms and Results Obtained with Pap Smears and Esophageal Biopsy No. of Patients
Location of Lesion Upper third Middle third Lower third Total
Carcinoma
of Esophagus
Positive Diagnosis by Pap Smear
Positive Pap Smear, Positive Esoph Biopsy
4
3
10
11 6
6 4
27
2l a
13
4 13
=Fifteendiagnoses (70%) required two or three attempts to obtain satisfactory Pap smears. bAll diagnoses were confirmed at operation or at postmortem examination.
Positive Pap Smear, Negative Esoph Biopsy
1 5 2
