Squash Cytology vs Frozen section

in diagnosing CNS lesions

Dr. Mohammed Shahin,

JR (Academic), Dept. of Pathology and Lab Medicine,
AIIMS Bhubaneswar.

Moderator
Dr Suvendu Purkait,
Assistant Professor,
Department of Pathology and Lab Medicine,
AIIMS Bhubaneswar.
Objectives

• To have an understanding about squash cytology

• To have an understanding about frozen section
• To have an overview about the diagnosis of CNS
lesions
• To understand the role of squash cytology vs frozen
section in the diagnosis of various CNS lesions
Introduction

• CNS: one of the most challenging domains for the

neurosurgeon and pathologists
• Intraoperative pathological diagnosis: crucial in
neurosurgery
• CNS diagnosis: Clinical findings + Radiology +
Pathological diagnosis
• Cytological/Histopathological diagnosis: For
confirmation and proper management
Intraoperative pathological diagnosis in
CNS: methods

• Touch preparations
• Smears
• Squash cytology
• Frozen section
Squash Cytology

• One of the simple ways to get a quicker diagnosis in

CNS lesions
• Tissue crushed between two glass slides and
smeared
• More cells released as the tissue spreads out under
the force produced by two glass slides
• Gives excellent cytology, but with few crushing
artefacts
Squash cytology: Procedure
Frozen-section: Procedure
• Select the representative area of tissue for trimming
• Place it on the specimen holder with embedding medium
• Freeze by keeping it on cryostat base (-15 to -20 degree Celsius
• Check the specimen holder check if properly placed and locked
• Retract the specimen holder position till the knife touches block
• Position the antiroll plate
• Cut-sections
• Fix the sections on the slide
• Stain it according to standard protocol
Normal gray matter: Squash preparation

• Produce smooth, relatively pink smears

• Smears hypocellular, which distinguishes them from
tumors and inflammatory disorders
• A few delicate capillaries often stretch around the
smear, whereas larger vessels are dragged off to the
end of the slide
• Neuron and their synapses make up the gray matter
Normal gray matter: Squash preparation
Normal white matter: Squash preparation

• Lacks the neurons and neuropil of gray matter

• Smear has a light, fluffy apperance in low
magnification
• Composed of two populations of cells- the
oligodendrocytes and the astrocytes
• Oligodendrocytes - a dense, small, round, blue
nucleus
• Astrocytes - larger, slightly round nucleus with more
open chromatin
Normal white matter: Squash preparation
Cerebellar cortex in squash preparation

Mainly identified by the:

• Monotony of its granular neurons
• Fine neuropil background, and
• Purkinje cells, occasionally
Cerebellar cortex in squash preparation
Diagnosing CNS lesions based on gross
Gross Probable diagnosis

Rubbery Schwannomas

Bloody Hemangioblastoma,
metastatic melanoma
Cotton-like Gliomas

Liquid Lymphomas, adenomas

Clumps Metastatic carcinomas

Squash Cytology vs Frozen section

Glial tumors
Diffuse astrocytoma

• Diffuse, monomorphous population of tumor cells

clustering around blood vessels.
• Cellularity higher than that of normal brain white
matter ( about 3 times higher).
Diffuse Astrocytoma
Glioblastoma

• Coarsened glial matrix with increased cellularity,

coarse chromatin, inconspicuous nucleoli with
nuclear inclusions.
• Bizzare nuclei
• Abnormal new vessel formation that are easily prone
for thrombosis and can cause infarction.
• New vessel formation in final stages can resemble
renal glomeruli.
Glioblastoma
Pilocytic astrocytoma

• Appear fibrillary.
• Fine capillaries may be present.
• Edge of the clusters show cells that are monotonous,
bipolar and stellate shaped and having piloid
processes
• Rosenthal fibres are also seen.
• No single pathognomic feature to diagnose pilocytic
astrocytoma.
Pilocytic astrocytoma
Pleomorphic xanthoastrocytoma

• Chronic inflammatory cells that cuff the vessels and

infiltrate the tumor
• Cells will be large, bizzare and pleomorphic
• Some fibrosis and reticulin scaffolding may be
present.
Pleomorphic xanthoastrocytoma
Oligodendroglioma

• Composed of round cells with sparse glial matrix and

less convoluted nuclei
• Cell have scant to no cytoplasm and moderately
coarse chromatin
Oligodendroglioma
Ependymoma

• Predilection for perivascular growth, forming pseudo-

rosettes
• More rigid and pipe-like vessels resembling a
caterpiller
• Nuclei form halos around the blood vessels, with glial
processes filling those halos
• Cells have enlarged, oval nuclei and fine to slightly
coarse chromatin
• True ependymal rosettes may or may not be present
Ependymoma
Choroid plexus papilloma

• Bland tumour cells

• Clusters of grape like spherules around fibrovascular
core
• Grapes not solid spheres but hollow shell of tumour
encasing connective tissue and vessel
• Differentiated from normal choroid plexus by cellularity,
fragments which are shed easily
• Histologically nuclei are hyperchromatic, heaped up and
longer than those of choroid plexus…
• Sheets of cells which are stripped off their fibrovascular
cores will present as honeycomb pattern..
Choroid plexus papilloma
Squash Cytology vs Frozen section

Meningioma/ Schwannoma/Pediatric CNS

tumors
Meningioma

• Whorl formation: most characteristic

• Meningothelial lobules and thick cellular bridges
connecting the cells
• Cells have abundant eosinophilic cytoplasm, nuclear
monotony and intercellular bridges
• Psammoma bodies may be present
Meningioma
Schwannoma

• Dense collagenous matrix

• Cells enveloped in tenacious reticulin network
• Difficult smearing due to cohesiveness of the cells
• Needs frozen section for intraoperative diagnosis
Schwannoma
Hemangioblastoma

• Stromal cells, having foamy cytoplasm and large,

often anaplastic/frightening nuclei are characteristic
• Hyperchromatic nuclei with folds
• Coarse chromatin and prominent nucleoli are seen
• Mostly clear cytoplasmic vacuoles, but can be
eosinophilic
Hemagioblastoma
Medulloblastoma

• Smear will show smooth gradient of cells

• Basophilic and cellular smear
• Small cells with scant cytoplasm, salt and pepper
chromatin and no nucleoli, with nuclear membrane
showing surface fold/indentations
• Nuclear moulding and streaking may be present
• Few matrix proteins and weak reactive response
from surrounding brain parenchyma
Medulloblastoma
Squash Cytology vs Frozen section

Others
(metastasis, lymphomas and germ cell
tumors)
Small cell carcinoma (lung) metastasis

• Discohesive cells
• Nuclei show salt and pepper chromatin, along with
nuclear molding
• Apoptotic bodies may be seen
Small cell carcinoma metastasis
Carcinoma breast metastasis

• Most adenocarcinoma metastasis in brain show

similar morphology
• Cells show abundant cytoplasm with sharp
cytoplasmic borders, large nuclei with distinct
nucleoli and occasional cytoplasmic vacuoles
• Lobular breast carcinoma shows a varied morphology
as compared to the ductal carcinoma
Carcinoma breast metastasis
CNS Lymphomas

• Dischoesive cells, enmeshed in glial network

• Perivascular predilection
• Nuclei will be pleomorphic with smaller
intercellular variability
• Primary brain lymphomas: high grade nuclei
with one to several nucleoli and scant
cytoplasm
• Lymphoglandular bodies can be seen
CNS Lymphoma
Germinoma

• Relatively good prognosis

• Very sensitive to radiotherapy and chemotherapy
• Smear shows large pleomorphic cells with vacuolated
cytoplasm ,large nuclei and streaking of lymphoid
cells
Germinoma
 Cellular arrangement

Floating
Cohesive Dyscohesive Fibrillary Attachment to
vessel

•Glioma •Lymphoma Hair like DNT

Sarcoma •Adenoma process Whorls
•Schwannoma
•Meningioma
Wellspaced

Ependymoma
Meningioma
Aggregates
Reactive
Pilocytic
Astrocytoma
 Background

Fibrillary Necrosis Rosenthal Psammoma Keratin

fibers body

•Astrocytoma Meningioma
•Oligodendro •GBM •Pilocytic
•Ependymal •RT •Craniopharyn •Craniopharyngioma
•PCNSL gioma •Dermoid
•PNET

Myxoid matrix
Lymphocytes Neuropil

Neurocytoma Neurofibroma
•PXA chordoma
•Ganglioglioma
•Germ cell tumour
 Cytoplasm

Process Clearing Vacuolated Glassy Granular Scant

•Astrocytoma •Germ cell SEGA •Pituitary

•PCNSL
•Ependymoma •Chordoma adenoma
•PNET
•Meningioma •Melanoma

•Chordoma
•Hemangioblastoma
•Adenocarcinoma
 Nuclear features

Round Oval Indendation Hyperchromatic Pleomorphic

•Oligo •GBM •Astrocytoma

•PCNSL •PCNSL •Adenoma •GBM
•Adenoma •Chordoma •PNET •Metastasis
•Neurocytoma •Germ cell

Nucleoli Pseudoinclusions Salt&Pepper

•Astrocytoma
•Ependymoma •GBM
•Meningioma •Meningioma •Neurocytoma
•Schwannoma •Melanoma •Adenoma
•Choroid plexus •Ependymoma
tumour •PCNSL
•Germ cell
tumour
•Metastasis
Squash Cytology over Frozen Section

• Eliminates freezing artefacts

• Diminish the use of entire sample
• Looks at whole cells and nuclei rather than slices
through them
• Gives better nuclear details in reactive/neoplastic
processes.
• Faster to prepare than frozen section
• Sophisticated equipments not required
Squash Cytology- Demerits

• Useless in examining extremely cohesive tumors

• Can’t look for mitosis due to shearing artefacts
( except in tumors with high mitosis)
• Loss of histologic architecture
Thank you