Should FNAC be Restricted to an Elite Estigation-an Experience of 20,237 Aspirations Including More than 8000 Aspirations from Head and Neck Region

Table of contents

1. I. Introduction

eedle aspiration cytology was successfully utilized by Greig and Gutheri as early as 1904 for diagnosis of sleeping sickness from cervical lymphnode aspirates 1 .but for the next 50 years this method of diagnosis was largely ignored due to complications like tissue injury and needle track dessimination 2 . Later on Cardoza (1954), Franzen, Geirtz and Zajicek (1960) etc workers introduced the technique of Author ? ? ? ? ¥ §: Medical college, Kolkata. e-mail: [email protected] FNAC with lesser complications and reasonable success rate 3,4 .

Last 4 decades experienced spectacular developments in the field of aspiration cytology and now it has emerged as diagnostic method of preoperative assess -ment any type of swelling. Use of thinner needle has reduced tissue injury to a minimum enabling aspiration from vascular hamartomas or large thyroid lesions 5 . Reported incidence of needle track dissemination after FNAC was also negligible 2 . Even testicular malignancies can now be aspirated safely 6 .

FNAC is also a reasonably accurate method of diagnosis. Different workers reported more than 75% accuracy in predicting a definite diagnosis on cytological evaluation 5,7,8,9,10 . This is quite comparable with success rate of modern radiological or serological investigations. FNAC can also be used in tandem with modern radiological procedures like USG, mammography, CT scans with improved diagnostic accuracy in comparison to outcome of any single procedure employed 9 .

Principal limiting factor of accurate cytodiagnosis is adequacy of aspirate 11 . In spite of repeated aspirations every worker has reported variable percenttage of failed aspirations in their series 5,9,10 . Radiological guidance often helps in obtaining enhanced amount of aspirates at the cost of increased expenditure 12 . Another major handicap of FNAC is diagnosis of a large lesion with heterogeneous tissue composition. In those cases variability of aspirates from different sites causes considerable confusion 11,13 . Guiding methods can be helpful in choosing appropriate site / sites for aspiration in these cases 9,12,13 .

In spite of those two serious drawbacks, FNAC became an important wing of diagnostic medicine because it delivers report with minimum expenditure of money and time in comparison to any other method with comparable safety and accuracy 12 . In our series, a large number of aspirate from all parts of body were evaluated to establish the reliability of this method of diagnosis. Aspirates from head and neck region accounted for almost half of the cases. Our main objectives were: ? To show that interpretation of aspiration in majority of the cases are simple and straight forward. ? To establish that FNAC is a cheap procedure capable of predicting final tissue diagnosis with reasonable accuracy and should be encouraged to be done at grass root level.

2. II. Material and Methods

This method was conducted in the Pathology department of Medical College Hospital, Kolkata for a period of 10 years (1 st January, 2000 to 31 st December 2010). All cases coming to pathology department for FNAC during the mentioned period were included in our study group. FNAC was done using standard procedures and aspirates were stained with May-Grunwald -Giemsa (MGG) stain, Haematoxylin and Eosin (E & O) stain, Papanicolaou stain 12 . Stained slides of each case were evaluated by two separate observers simultan -eously to be categorized into one of the three groups mentioned below:

? Interpretation easy:Two observers reached same definitive diagnosis on initial assessment separately without consultation of any reference material. Lymph nodes were the single most common target of aspiration (28.71%), followed by breast; thyroid, skin etc. intra-abdominal, intra-thoracic sites are the least common. Breast aspirates are easier to interpret (94.64%) but salivary gland aspirates are least easy to interpret (77.8%). Intra-abdominal cases are the most difficult (8.70%) to interpret. IV.

3. III. Observation

4. Discussion

In the present study, 1774 cases (8.77%) were aspirated under various radiological guidance (CT scan, USG, fluoroscopy). These cases were not included in final analysis because of higher expenditure and poor availability of the guiding techniques at peripheral levels. Among the cases aspirated without guidance (18463), 3.16% (584 cases) could not be reported due to inadequate aspirate. Reported incidence of inadequate aspirate in various studies ranges from 32.2% to 2.5% 7,8,14 . Comparatively lower incidence in our series could be attributable to repeated aspiration attempts by multiple persons in more than one sitting.

More than 90% cases (16098 out of 17879) of present group were categorized into easy to interpret, 6.72% cases were moderately difficult and 3.25% were highly difficult demanding highest level of collective expertise -only available at referral centers. Different workers reported incidence of misdiagnosis during cytological evaluation of large number of cases in their series ranging from 0% to as high as 33% 10,9,15,16 .

Head and neck lesion accumulated for majority of the cases (47.3%) in our series. Lymph nodes were the commonest target (37.8%) among head and neck aspirates. Similar data was also published by other researchers 10,12 .

In our study breast aspirates were comparatively easy with less than 2% cases belonging to highly difficult. Similar results were shared by other workers 8,9 . We faced maximum difficulty during distinction between proliferative breast disease with variable dysplasia and breast carcinoma in situ as also by other researchers 17 . In cases of salivary glands only 77.8% were easy to interpret. Different workers admitted various pitfalls and problems during salivary gland aspiration study 18,19 . 8.7% of abdominal aspirates were highly difficult to interpret.

In this study we achieved almost 85% Cytohistological correction. Reported incidences of false positive and false negative malignant cases were 14.93% and 10.48% respectively. Sensitivity, specificity, positive and negative predictive value for detection of malignancy was between 85.07% to 89.52%. These data's quite clearly establish the diagnostic value of aspiration cytology. Comparable results were published by a lot of cytopathologists dealing with large number of cases 7,8,10,16 .

5. V. Conclusion

from the above discussion it is quite clear that FNAC is a reliable method of pathological diagnosis, for lesion of all parts of body including head and neck region.

But we want to interpret our results from another angle. During the last 4 decades diagnostic medicine has undergone a sea of changes. Unfortunately all the diagnostic approaches of recent discovery are much costly. But apart from human resources one has to spend less than RS 1000 for FNAC. Butwith routine stains cost is less than Rs 20. FNAC can quickly diagnose malignancy around 90% of cases. In developing countries FNAC is a very useful tool for tissue diagnosis.

Cytopathology should not be treated as a highly sophisticated diagnostic procedure but a cheap and efficient measure that can be used routinely by trained persons. Hope this change of approach should come soon from our community to bloom the fullest potentiality of this unique diagnostic tool.

Figure 1. N
Volume XIV Issue III Version I© 2014 Global Journals Inc. (US)
Figure 2. Table 1 :
1
Total cases No. of cases needed % No ofcases without %
guidance guidance
20237(100%) 1774 8.77 18463 91.23
Out of 20237 cases 1774 (8.77%) needed guided aspiration.
Table 2 : adequacy of aspiration
No of cases aspirated No. of inadequate % No. of adequate
without guidance aspirates aspirate
18463(100%) 584 3.16 17879 96.84
Despite repeated aspiration 584 (3.16%) cases was failed.
Table 3 : Categorization of aspirates
No. of adequate Interpretative categorization
aspirate Interpretation easy Interpretation moderately Interpretation
difficult highly difficult
17879 (100%) No % No % No %
16098 90.03 1203 6.72 578 3.25
Moderately difficult interpretation was in 6.72 %( 1203) and highly difficult in 3.25%(578).
Table 4 : region wise distribution of cases
No. of cases Regions aspirated
adequately
aspiration Head and Thorax Superior Inferior Abdomen Multiple
neck extrimity extrimity region
17879(100%) 8466 4119 2693 1911 207 (1.10%) 483(2.70%)
(47.30%) (23.10%) (15.10%) (10.70%)
Maximum no of cases (8466 / 17879) 47.30%
were done from head and neck region followed by
thorax (23.1%) & superior extremity (15.1%). Out of the
8466 head and neck aspirates lymph node biopsy are
the most common (37.8%). Closely followed by thyroid
(34.5%).
Figure 3. Table 5 :
5
Total no. of Organ wise distribution
aspirates from
head and Lymph Thyroid Salivary Nasal, naso & Skin and Orbital Multiple
neck region node gland oropharyngeal soft sites
tissue
and oral
8466 (100%) 3205 2923 978 439 (5.2%) 386 (4.5 276 (3.3%) 259 (3.2%)
(37.8%) (34.5%) (11.5%) %)
Figure 4. Table 6
6
: organ wise distribution of all cases with interpretation categorization
No of Sites of aspiration No of cases % Interpretation categorization
adequate Easy Moderately Highly difficult
aspirates difficult
No % No % No %
17879 Lymph node 5134 28.71 4433 86.3 402 7.8 299 5.9
(100%) Breast 3961 22.15 3749 94.64 143 3.61 69 1.75
(max) (min) (min)
Thyroid 2923 16.35 2648 90.6 216 7.38 59 2.02
Skin and soft tissue 1957 10.94 1836 93.82 85 4.34 36 1.84
Bone and joints 1186 6.63 1076 90.72 71 5.99 39 3.29
Salivary glands 978 5.47 761 77.8 189 19.32 28 2.88
(min) (max)
Nasal & 439 2.45 396 90.2 34 7.74 9 2.06
naso/oropharyngeal
Orbital 276 1.54 257 93.11 13 4.71 6 2.18
Intra-abdominal 138 0.77 117 84.78 9 6.52 12 8.70
(max)
Intra-thoracic 65 0.36 54 83.07 6 9.23 5 7.70
Multiple sites 822 4.59 771 93.79 35 4.26 16 1.95
Figure 5. Table 7 :
7
No. of cytodiagnosis No of Histological diagnosis Cases with Cases with
cases cases correction disparity
with histology neoplastic Non- Benign Malignant No % No %
5807 Non-neoplastic 906 752 109 45 4923 84.78 884 15.22
(100%) Benign 2282 50 1943 289
Malignant 2619 38 353 2228
Table 8 : detection of malignancy
No of cytodiag No Histologic False False sensi specific Predi Negativ
cases nosis al positive negative tivity ity ctive e
with diagnosis maligna malignant value predicti
histolo nt cases cases ve value
gy Non mali Mali gna No % No %
gna nt
nt
5807 Nonmalig 3188 285 334 39 14. 334 10.48 85.07 59.52 86.96 87.95
(100) nant 4 1 93
Malignant 2619 391 2228

Appendix A

  1. the accuracy of one stop diagnosis for 1110 patients presenting to a symptomatic breast clinic. A Eltahir , A J Jibril , J Squair . J R Coll. Surg Edinb 1999. august. 44 p. .
  2. can nonproliferative breast disease and proliferative breast disease without atypia be distinguished by fine needle cytology?. A R Frost , A Aksu , R Kurstin , M K Sidway . Cancer (cancer cytopathol) 1997. 81 p. .
  3. Scope of FNAC in the diagnosis of soft tissue tumors -A study from tertiary cancer referral center in India. B Rekhi , B D Gorag , A C Kakadc , R F Chinoy . Cytojournal 2007. 4 p. 20.
  4. Fine needle aspiration cytology of liver. a study of 202 cases. E D Gatphoh , S Gaytri , S Babina , A M Singh . Indian Journa of Medical Sciences 2003. 57 (1) p. .
  5. notes on the lymphatic glands in sleeping sickness. Edm Greig , Ach Grey . Lancet 1904. 1 p. 570.
  6. FNAC of malignant lymphoma in an area with high incidence of T-cell lymphoma. Correlation of cytologic diagnosis with histologic subtype and immunophenotype. I A Park , C W Kim . Acta cytol1999, Nov-Dec. 43 p. .
  7. value of fine needle cytology in the diagnosis of testicular neoplasm. K Verma , T R Ram , K Kapila . Acta Cytol 1989. 33 p. .
  8. Accuracy of fine needle aspirarion of thyroid :a review of 6226 cases and correlation with surgical and clinical outcome. M Amrikachi , I Ramji , S Rubenfled , T M Wheeler . Arch pathol Lab Med 2001. 125 p. .
  9. Thyroid aspiration cytology in Newcastle: a 6 yers cytology/ histology correlation study. M A Tabaqchali , J M Hanson , S J Jhonson , V Wadehra , Twj Lennard , G Proud . Ann R Coll Surg Engl 2000. 82 p. .
  10. FNAC a diagnostic tool in paeditric head and neck lesion. M Jain , D D Majumder , K K Agarwal , A S Bais , M Choudhury . Indian paeditrics 1999. 36 p. .
  11. Breast fine needle aspiration cytology in a Nigerian tertiary hospital. O I Alastice , O O Lalwal , O O Olasode , Ark Adesunkami . East and Central African Journal of surgery 2006.
  12. fine needle aspiration biopsy of salivary gland lesion-a reappraisal of the pitfalls and problems. P Boccatoo , G Altavilla , S Blandamura . Acta Cytol 1998. 42 p. .
  13. , P L Cardoza . 1954. 1980. Loc Cit.
  14. cytological diagnosis of prostatic tumor by transrectal aspiration biopsy. S Franzen , Giertz . Brit J Urol 1960. 32 p. 193.
  15. fine needle aspiration biopsy of salivary gland tumors-problems and pitfalls. S R Orell , Wjs Nettle . Pathology 1988. 20 p. .
  16. Accuracy and cost-effectiveness of fine needle aspiration biopsy. T J Smit , H Safali , E A Foster , R B Reinhold . Am J Surg 1985. p. .
  17. Sources of diagnostic error in fine needle aspiration biopsy. T L Hall , L J Layfield , Phillipe A Rosenthal , DL . AM J Surg 1885. 149 p. .
  18. Investigation of tumour spread in conection with aspiration biopsy. U Engzell , P L Espoti , C Rubio , A Sigurdson , J Zajicek . Acta Cytol 1971. 10 p. .
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Date: 2014-01-15