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

             \author[1]{Malabika  Misra}

             \affil[1]{  Medical college kolkata}

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\date{\small \em Received: 15 December 2013 Accepted: 2 January 2014 Published: 15 January 2014}

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\begin{abstract}
        


Objectives: Cytological evaluations of a vast number of cases were presented in this study. More than 2/5th of the cases were reported from head and neck region. Our objectives were to prove the diagnostic value of FNAC and to judge its feasibility in peripheral health institutes.Method: this study was done in pathology department of Me -dical College & Hospital, Kolkata for a period of 10 years. Aspirates were classified into one of the three interpretation groups (easy, moderately difficult, and highly difficult) according to set up criteria. Cytohistological correlations were done in all possible cases.Results: out of total 20,237 cases undergoing cytological evaluation during study period, 1774 cases (8.77%) needed guidance for aspiration.3.16%of the rest 18,463 cases could not be reported for lack of adequate aspirate.

\end{abstract}


\keywords{fnac, interpretative categorization, large series.}

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\let\tabcellsep& 	 	 		 
\section[{I. Introduction}]{I. Introduction}\par
eedle aspiration cytology was successfully utilized by Greig and Gutheri as early as 1904 for diagnosis of sleeping sickness from cervical lymphnode aspirates \hyperref[b0]{1} .but for the next 50 years this method of diagnosis was largely ignored due to complications like tissue injury and needle track dessimination \hyperref[b1]{2} . Later on Cardoza (1954), Franzen, Geirtz and  Zajicek (1960) etc workers introduced the technique of Author ? ? ? ? ¥ §: Medical college, Kolkata. e-mail: misra\textunderscore malabika@rediffmail.com FNAC with lesser complications and reasonable success rate \hyperref[b2]{3,}\hyperref[b3]{4} .\par
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 \hyperref[b4]{5} . Reported incidence of needle track dissemination after FNAC was also negligible \hyperref[b1]{2} . Even testicular malignancies can now be aspirated safely \hyperref[b5]{6} .\par
FNAC is also a reasonably accurate method of diagnosis. Different workers reported more than 75\% accuracy in predicting a definite diagnosis on cytological evaluation \hyperref[b4]{5,}\hyperref[b6]{7,}\hyperref[b7]{8,}\hyperref[b8]{9,}\hyperref[b9]{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 \hyperref[b8]{9} .\par
Principal limiting factor of accurate cytodiagnosis is adequacy of aspirate \hyperref[b10]{11} . In spite of repeated aspirations every worker has reported variable percenttage of failed aspirations in their series \hyperref[b4]{5,}\hyperref[b8]{9,}\hyperref[b9]{10} . Radiological guidance often helps in obtaining enhanced amount of aspirates at the cost of increased expenditure \hyperref[b11]{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 \hyperref[b10]{11,} {\ref 13} . Guiding methods can be helpful in choosing appropriate site / sites for aspiration in these cases \hyperref[b8]{9,}\hyperref[b11]{12,} {\ref 13} .\par
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 \hyperref[b11]{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. 
\section[{II. Material and Methods}]{II. Material and Methods}\par
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 \hyperref[b11]{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:\par
? 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. 
\section[{III. Observation}]{III. Observation} 
\section[{Discussion}]{Discussion}\par
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\% \hyperref[b6]{7,}\hyperref[b7]{8,}\hyperref[b12]{14} . Comparatively lower incidence in our series could be attributable to repeated aspiration attempts by multiple persons in more than one sitting.\par
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\% \hyperref[b9]{10,}\hyperref[b8]{9,}\hyperref[b13]{15,}\hyperref[b14]{16} .\par
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 \hyperref[b9]{10,}\hyperref[b11]{12} .\par
In our study breast aspirates were comparatively easy with less than 2\% cases belonging to highly difficult. Similar results were shared by other workers \hyperref[b7]{8,}\hyperref[b8]{9} . We faced maximum difficulty during distinction between proliferative breast disease with variable dysplasia and breast carcinoma in situ as also by other researchers \hyperref[b15]{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 \hyperref[b16]{18,}\hyperref[b17]{19} . 8.7\% of abdominal aspirates were highly difficult to interpret.\par
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 \hyperref[b6]{7,}\hyperref[b7]{8,}\hyperref[b9]{10,}\hyperref[b14]{16} . 
\section[{V. Conclusion}]{V. Conclusion}\par
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.\par
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.\par
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.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}N}\end{figure}
  \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.4567057837384744\textwidth}P{0.12183570829840736\textwidth}P{0.07552388935456832\textwidth}P{0.02137468566638726\textwidth}P{0.029212070410729252\textwidth}P{0.04203688181056161\textwidth}P{0.019949706621961442\textwidth}P{0.05129924559932942\textwidth}P{0.02778709136630344\textwidth}P{0.004274937133277452\textwidth}}
\multicolumn{4}{l}{Total cases No. of cases needed}\tabcellsep \%\tabcellsep \multicolumn{3}{l}{No ofcases without}\tabcellsep \%\\
\tabcellsep \multicolumn{2}{l}{guidance}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{guidance}\\
\multicolumn{2}{l}{20237(100\%)}\tabcellsep 1774\tabcellsep \tabcellsep 8.77\tabcellsep \tabcellsep \multicolumn{2}{l}{18463}\tabcellsep 91.23\\
\multicolumn{8}{l}{Out of 20237 cases 1774 (8.77\%) needed guided aspiration.}\\
\tabcellsep \multicolumn{6}{l}{Table 2 : adequacy of aspiration}\\
\multicolumn{2}{l}{No of cases aspirated}\tabcellsep \multicolumn{3}{l}{No. of inadequate}\tabcellsep \%\tabcellsep \multicolumn{2}{l}{No. of adequate}\\
\multicolumn{2}{l}{without guidance}\tabcellsep \multicolumn{2}{l}{aspirates}\tabcellsep \tabcellsep \tabcellsep \tabcellsep aspirate\\
\multicolumn{2}{l}{18463(100\%)}\tabcellsep 584\tabcellsep \tabcellsep \multicolumn{2}{l}{3.16}\tabcellsep \tabcellsep 17879\tabcellsep 96.84\\
\multicolumn{7}{l}{Despite repeated aspiration 584 (3.16\%) cases was failed.}\\
\tabcellsep \multicolumn{6}{l}{Table 3 : Categorization of aspirates}\\
No. of adequate\tabcellsep \tabcellsep \multicolumn{6}{l}{Interpretative categorization}\\
aspirate\tabcellsep \multicolumn{2}{l}{Interpretation easy}\tabcellsep \tabcellsep \multicolumn{4}{l}{Interpretation moderately}\tabcellsep Interpretation\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{difficult}\tabcellsep highly difficult\\
17879 (100\%)\tabcellsep No\tabcellsep \%\tabcellsep \tabcellsep No\tabcellsep \tabcellsep \tabcellsep \%\tabcellsep No\tabcellsep \%\\
\tabcellsep 16098\tabcellsep 90.03\tabcellsep \tabcellsep \multicolumn{2}{l}{1203}\tabcellsep \tabcellsep 6.72\tabcellsep 578\tabcellsep 3.25\\
\multicolumn{8}{l}{Moderately difficult interpretation was in 6.72 \%( 1203) and highly difficult in 3.25\%(578).}\\
\tabcellsep \multicolumn{7}{l}{Table 4 : region wise distribution of cases}\\
No. of cases\tabcellsep \tabcellsep \tabcellsep \multicolumn{4}{l}{Regions aspirated}\\
adequately\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
aspiration\tabcellsep Head and\tabcellsep \multicolumn{3}{l}{Thorax Superior}\tabcellsep \multicolumn{2}{l}{Inferior}\tabcellsep Abdomen\tabcellsep Multiple\\
\tabcellsep neck\tabcellsep \multicolumn{3}{l}{extrimity}\tabcellsep \multicolumn{2}{l}{extrimity}\tabcellsep region\\
17879(100\%)\tabcellsep 8466\tabcellsep 4119\tabcellsep \multicolumn{2}{l}{2693}\tabcellsep \multicolumn{2}{l}{1911}\tabcellsep 207 (1.10\%) 483(2.70\%)\\
\tabcellsep (47.30\%)\tabcellsep (23.10\%)\tabcellsep \multicolumn{2}{l}{(15.10\%)}\tabcellsep \multicolumn{2}{l}{(10.70\%)}\\
\multicolumn{4}{l}{Maximum no of cases (8466 / 17879) 47.30\%}\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{4}{l}{were done from head and neck region followed by}\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{3}{l}{thorax (23.1\%) \& superior extremity (15.1\%). Out of the}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{3}{l}{8466 head and neck aspirates lymph node biopsy are}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{3}{l}{the most common (37.8\%). Closely followed by thyroid}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
(34.5\%).\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{P{0.18422053231939162\textwidth}P{0.06787072243346008\textwidth}P{0.09049429657794676\textwidth}P{0.05171102661596958\textwidth}P{0.19714828897338404\textwidth}P{0.11958174904942966\textwidth}P{0.09695817490494296\textwidth}P{0.04201520912547528\textwidth}}
Total no. of\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{Organ wise distribution}\tabcellsep \\
aspirates from\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
head and\tabcellsep Lymph\tabcellsep \multicolumn{2}{l}{Thyroid Salivary}\tabcellsep Nasal, naso \&\tabcellsep Skin and\tabcellsep Orbital\tabcellsep Multiple\\
neck region\tabcellsep node\tabcellsep \tabcellsep gland\tabcellsep oropharyngeal\tabcellsep soft\tabcellsep \tabcellsep sites\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep tissue\tabcellsep \\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep and oral\tabcellsep \\
8466 (100\%)\tabcellsep 3205\tabcellsep 2923\tabcellsep 978\tabcellsep 439 (5.2\%)\tabcellsep 386 (4.5\tabcellsep \multicolumn{2}{l}{276 (3.3\%) 259 (3.2\%)}\\
\tabcellsep (37.8\%)\tabcellsep (34.5\%)\tabcellsep (11.5\%)\tabcellsep \tabcellsep \%)\tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 5 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{6} \par 
\begin{longtable}{P{0.041109530583214794\textwidth}P{0.3059032716927454\textwidth}P{0.04473684210526315\textwidth}P{0.060455192034139404\textwidth}P{0.051991465149359886\textwidth}P{0.11123755334281649\textwidth}P{0.05440967283072546\textwidth}P{0.06770981507823613\textwidth}P{0.04594594594594595\textwidth}P{0.06650071123755334\textwidth}}
\tabcellsep \multicolumn{8}{l}{: organ wise distribution of all cases with interpretation categorization}\tabcellsep \\
No of\tabcellsep \multicolumn{2}{l}{Sites of aspiration No of cases}\tabcellsep \%\tabcellsep \tabcellsep \multicolumn{4}{l}{Interpretation categorization}\tabcellsep \\
adequate\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{Easy}\tabcellsep \multicolumn{2}{l}{Moderately}\tabcellsep \multicolumn{2}{l}{Highly difficult}\\
aspirates\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{difficult}\tabcellsep \tabcellsep \\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep No\tabcellsep \%\tabcellsep No\tabcellsep \%\tabcellsep No\tabcellsep \%\\
17879\tabcellsep Lymph node\tabcellsep 5134\tabcellsep 28.71\tabcellsep 4433\tabcellsep 86.3\tabcellsep 402\tabcellsep 7.8\tabcellsep 299\tabcellsep 5.9\\
(100\%)\tabcellsep Breast\tabcellsep 3961\tabcellsep 22.15\tabcellsep 3749\tabcellsep 94.64\tabcellsep 143\tabcellsep 3.61\tabcellsep 69\tabcellsep 1.75\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep (max)\tabcellsep \tabcellsep (min)\tabcellsep \tabcellsep (min)\\
\tabcellsep Thyroid\tabcellsep 2923\tabcellsep 16.35\tabcellsep 2648\tabcellsep 90.6\tabcellsep 216\tabcellsep 7.38\tabcellsep 59\tabcellsep 2.02\\
\tabcellsep Skin and soft tissue\tabcellsep 1957\tabcellsep 10.94\tabcellsep 1836\tabcellsep 93.82\tabcellsep 85\tabcellsep 4.34\tabcellsep 36\tabcellsep 1.84\\
\tabcellsep Bone and joints\tabcellsep 1186\tabcellsep 6.63\tabcellsep 1076\tabcellsep 90.72\tabcellsep 71\tabcellsep 5.99\tabcellsep 39\tabcellsep 3.29\\
\tabcellsep Salivary glands\tabcellsep 978\tabcellsep 5.47\tabcellsep 761\tabcellsep 77.8\tabcellsep 189\tabcellsep 19.32\tabcellsep 28\tabcellsep 2.88\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep (min)\tabcellsep \tabcellsep (max)\tabcellsep \tabcellsep \\
\tabcellsep Nasal \&\tabcellsep 439\tabcellsep 2.45\tabcellsep 396\tabcellsep 90.2\tabcellsep 34\tabcellsep 7.74\tabcellsep 9\tabcellsep 2.06\\
\tabcellsep naso/oropharyngeal\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\tabcellsep Orbital\tabcellsep 276\tabcellsep 1.54\tabcellsep 257\tabcellsep 93.11\tabcellsep 13\tabcellsep 4.71\tabcellsep 6\tabcellsep 2.18\\
\tabcellsep Intra-abdominal\tabcellsep 138\tabcellsep 0.77\tabcellsep 117\tabcellsep 84.78\tabcellsep 9\tabcellsep 6.52\tabcellsep 12\tabcellsep 8.70\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep (max)\\
\tabcellsep Intra-thoracic\tabcellsep 65\tabcellsep 0.36\tabcellsep 54\tabcellsep 83.07\tabcellsep 6\tabcellsep 9.23\tabcellsep 5\tabcellsep 7.70\\
\tabcellsep Multiple sites\tabcellsep 822\tabcellsep 4.59\tabcellsep 771\tabcellsep 93.79\tabcellsep 35\tabcellsep 4.26\tabcellsep 16\tabcellsep 1.95\end{longtable} \par
 
\caption{\label{tab_3}Table 6}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{7} \par 
\begin{longtable}{P{0.0998272884283247\textwidth}P{0.07046632124352331\textwidth}P{0.0616580310880829\textwidth}P{0.023488773747841103\textwidth}P{0.055785837651122626\textwidth}P{0.08661485319516407\textwidth}P{0.11303972366148532\textwidth}P{0.010276338514680483\textwidth}P{0.10276338514680483\textwidth}P{0.01614853195164076\textwidth}P{0.09395509499136441\textwidth}P{0.06606217616580311\textwidth}P{0.024956822107081174\textwidth}P{0.022020725388601035\textwidth}P{0.002936096718480138\textwidth}}
\multicolumn{2}{l}{No. of}\tabcellsep \multicolumn{4}{l}{cytodiagnosis No of}\tabcellsep \multicolumn{4}{l}{Histological diagnosis}\tabcellsep Cases with\tabcellsep Cases with\\
\multicolumn{2}{l}{cases}\tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{cases}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep correction\tabcellsep disparity\\
\multicolumn{2}{l}{with histology}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{neoplastic Non-}\tabcellsep \multicolumn{3}{l}{Benign Malignant}\tabcellsep No\tabcellsep \%\tabcellsep No\tabcellsep \%\\
\multicolumn{2}{l}{5807}\tabcellsep \multicolumn{3}{l}{Non-neoplastic}\tabcellsep 906\tabcellsep 752\tabcellsep \tabcellsep 109\tabcellsep 45\tabcellsep 4923 84.78 884 15.22\\
\multicolumn{2}{l}{(100\%)}\tabcellsep \tabcellsep Benign\tabcellsep \tabcellsep 2282\tabcellsep 50\tabcellsep \tabcellsep 1943\tabcellsep \multicolumn{2}{l}{289}\\
\tabcellsep \tabcellsep \multicolumn{2}{l}{Malignant}\tabcellsep \tabcellsep 2619\tabcellsep 38\tabcellsep \tabcellsep 353\tabcellsep \multicolumn{2}{l}{2228}\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{6}{l}{Table 8 : detection of malignancy}\\
No of\tabcellsep \multicolumn{2}{l}{cytodiag}\tabcellsep No\tabcellsep \multicolumn{2}{l}{Histologic}\tabcellsep \multicolumn{2}{l}{False}\tabcellsep \multicolumn{2}{l}{False}\tabcellsep sensi\tabcellsep specific\tabcellsep Predi\tabcellsep Negativ\\
cases\tabcellsep \multicolumn{2}{l}{nosis}\tabcellsep \tabcellsep \tabcellsep al\tabcellsep \multicolumn{2}{l}{positive}\tabcellsep \multicolumn{2}{l}{negative}\tabcellsep tivity\tabcellsep ity\tabcellsep ctive\tabcellsep e\\
with\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{diagnosis}\tabcellsep \multicolumn{2}{l}{maligna}\tabcellsep \multicolumn{2}{l}{malignant}\tabcellsep value\tabcellsep predicti\\
histolo\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{nt cases}\tabcellsep \multicolumn{2}{l}{cases}\tabcellsep ve value\\
gy\tabcellsep \tabcellsep \tabcellsep \tabcellsep Non mali\tabcellsep Mali gna\tabcellsep No\tabcellsep \%\tabcellsep No\tabcellsep \%\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep gna\tabcellsep nt\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep nt\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
5807\tabcellsep \multicolumn{2}{l}{Nonmalig}\tabcellsep \multicolumn{2}{l}{3188 285}\tabcellsep 334\tabcellsep 39\tabcellsep 14.\tabcellsep \multicolumn{3}{l}{334 10.48 85.07}\tabcellsep 59.52\tabcellsep 86.96\tabcellsep 87.95\\
(100)\tabcellsep \multicolumn{2}{l}{nant}\tabcellsep \tabcellsep 4\tabcellsep \tabcellsep 1\tabcellsep 93\tabcellsep \tabcellsep \\
\tabcellsep \multicolumn{5}{l}{Malignant 2619 391 2228}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_4}Table 7 :}\end{figure}
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\end{document}
