2016, Volume 32, Number 1, Page(s) 027-034
A Critical Appraisal of the Spectrum of Image Guided Fine Needle Aspiration Cytology: A Three Year Experience from a Tertiary Care Centre in Delhi
Mukta PUJANI1, Sujata JETLEY1, Zeeba S JAIRAJPURI1, Sabina KHAN1, Mohd Jaseem HASSAN1, Safia RANA1, Mukesh KUMAR2
1, Department of Pathology, Hamdard Institute of Medical Sciences & Research, NEW DELHI, INDIA
1, Department of Radiology, Hamdard Institute of Medical Sciences & Research, NEW DELHI, INDIA
Keywords: Fine needle aspiration, Image guided biopsy, Ultrasound, Computerized tomography
Image guided fine needle aspiration cytology (FNAC) is a safe, simple, rapid, cost effective and accurate modality in evaluation of deep seated lumps (abdominal, pelvic and intrathoracic masses) which are unapproachable by blind FNAC. In this study, a critical analysis of the utility of image guided FNAC in deep seated and otherwise inacessible mass lesions was carried out.
Material and Method: Fifty-four ultrasound (USG) or computed tomography (CT) guided FNACs from lumps at any location in the body, that is, thoracic, abdominal, pelvic etc over a period of 3 years (January 2012- December 2014) were included in the study. The most common site aspirated, the indications for a guided aspiration and the accuracy of aspiration cytology in comparison to the histological diagnosis were evaluated, wherever possible.
Results: Fifty-four image guided FNACs were performed (46 USG guided and 8 CT guided). Inconclusive, inflammatory, benign tumors, suspicious and malignant lesion rates were 5.6%, 29.6%, 11.1%, 5.6%, and 48.1%, respectively. The most common site was the liver (25.5%), followed by the thyroid (18.5%), lung (14.8%), gallbladder (11.1%), and lymph nodes (7.4%). Cytohistological correlation could be performed in 32 cases with a diagnostic accuracy of 100%.
Conclusion: FNAC coupled with a diagnostic imaging technique such as USG or CT can improve the diagnostic yield and a definite diagnosis
can be reached in most of the cases.
Fine needle aspiration cytology (FNAC) has been used
as a primary modality for evaluation of all the palpable
lumps in the body for a long time. However, its application
is limited in cases with deep seated lumps, smaller sized
lesions which are not readily palpable or if a small swelling
is present in a crucial location, adjacent to major vessels.
In such case scenarios, FNAC coupled with diagnostic
imaging techniques such as ultrasound (USG) or computed
tomography (CT) can improve the diagnostic yield and a
definite diagnosis can be reached in most of the cases.
Image guided FNAC is a widely accepted diagnostic
technique nowadays, and the applications are growing day
by day. The technique is safe, simple, rapid, cost effective
and accurate in the evaluation of deep seated lumps which
are unapproachable by blind FNAC. Many studies over
the years have evaluated the role of USG guided FNAC of
Image guided FNAC (both USG and CT guided) has a
special role to play in abdominal, pelvic and intrathoracic
masses. The relatively newer locations which are being
explored include the thyroid9,10. The most significant
advantage of USG guidance is that while performing the
FNAC, one can visualize simultaneously whether the needle
tip is within the target lesion. Moreover, if two pathologies
coexist in a lump, blind FNAC may not yield the desired
result while image guided FNAC can help localise a solid
focus within an otherwise cystic lesion, especially in thyroid
lesions. Thus, the precise focus with different echotexture
can be sampled and an accurate diagnosis obtained.
Moreover, mapping the vascularity of the lesion during
FNAC can help the pathologist by avoiding vessel injury.
The added advantage is that this provides an opportunity
for a mutual interaction between the pathologist and the
radiologist for the benefit of the patient. Any difference
of opinion regarding diagnosis of a particular case can be
addressed directly through discussion and a diagnosis of
consensus can be arrived at.
The aim of this study was to analyze the spectrum of
cytological diagnoses in deep seated mass lesions among
the patient population catered to by our hospital. A critical
analysis of the utility of image guided FNAC in the deep
seated and otherwise inaccessible mass lesions was carried
out. The most common site aspirated, the indications for
a guided aspiration, utility over palpation guided FNAC,
and the accuracy of aspiration cytology in comparison to
histological diagnosis were evaluated, wherever possible.
We also aimed to identify the lacunae in the guided FNAC
procedure and reporting and to take the necessary measures
to improve the service.
The study was conducted by the Department of Pathology
in collaboration with the Department of Radiology of our
institute. We provide a general cytology service so included
all cases of USG and CT guided FNACs referred to the
pathology department from lumps at any location in the
body, that is, thoracic, abdominal, pelvic, etc., over a period
of 3 years (January 2012- December 2014). A total of 54
image guided FNACs were performed during this period.
The ultrasound machines which were used included the
GE Voluson S-6 and Philips 350 Pro having color Doppler
facility. The SIEMENS, SOMATOM Emotion 16 slice
Multidetector CT scanner was used for CT guided FNAC.
The aspirations were performed by a pathologist in
conjunction with a radiologist. Both air dried and 95%
alcohol fixed smears were prepared and stained with
Giemsa, Papanicolaou, and Hematoxylin & Eosin (H&E)
stains, respectively. Special stains such as Ziehl-Neelsen
stain and Periodic Acid Schiff (PAS) were used when
required. The FNAC diagnosis was correlated with clinical and radiological findings. The lesions were divided into the
following categories: inconclusive, inflammatory, benign
tumors, suspicious for malignancy, and malignancy.
A total of 54 image guided FNACs were performed during
the study period. Image guided FNACs accounted for 6%
of all the FNAC done during this time period. The study
group consisted of 61% males and 39% females. Most of
the patients belonged to the 41-60 years age group while
malignancies were most frequently encountered in the 61-
80 years age group. The most common reason for image
guided FNAC over a blind procedure was a deep seated
location accounting for 74% of the cases, followed by
small sized lesion to aid in localization (14.8% of cases)
and close proximity to the vasculature (11.1% of cases).
Out of the total 54 FNACs, 46 FNACs were performed
under USG guidance while 8 were performed under CT
guidance. The detailed clinical profile of the study group
is depicted in Table I
. We analysed the requisition forms
for their completeness and appropriateness of clinical and
radiological details and observed that 75% of the forms did
not have details like location of lump, laterality (left/ right/
bilateral), ultrasound findings, solid/cystic lump, size, and
site from where FNAC was performed.
Out of a total of 54 cases, 3 FNACs (5.6%) either yielded
inadequate material or degenerated cells which were
inconclusive for an opinion. These 3 cases were one each
from USG guided FNAC of lesions from the liver, thyroid
and CT guided FNAC from a lung lesion. Sixteen cases
(29.6%) were reported as inflammatory lesions including
abscess, cysts, granulomatous lesion and tuberculosis.
Benign tumors accounted for 11% of the cases while 5.6% were suspicious for malignancy as they only partly met
the criteria for malignancy. The majority of the cases,
that is 48.2%, were diagnosed as malignancy. The pattern
of distribution of cytological diagnoses is shown in Table
II. Most of the cytology reports (82%) were descriptive
followed by an impression, and did not follow a uniform
standard format of reporting. The most common sites
were liver (25.5%), followed by thyroid (18.5%), lung
(14.8%), gallbladder (11.1%), and lymph node (7.4%).
Cytopathology images from some interesting cases are
shown in Figures 1-5.
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|Table II: Pattern of distribution of lesions based on cytological
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|Figure 1: USG guided FNAC of liver mass (metastatic
adenocarcinoma) showing atypical epithelial cells in clusters at
places forming acinar pattern (inset) (Giemsa; x400).
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|Figure 2: USG guided FNAC of thyroid
lesions. A) Hurthle cell neoplasm
showing sheets of cells displaying anisonucleosis
B) Papillary carcinoma with monolayered
branching sheets and papillaroid
clusters of follicular epithelial cells
(Giemsa; x100) with intranuclear
inclusions (inset, H&E; x400).
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|Figure 3: CT guided FNAC of lung lesions.
A) Poorly differentiated carci-noma showing
cluster of pleomorphic epithelial cells displaying
anisonucleosis (Giemsa; x400).
B) Squamous cell carcinoma with sheets
of atypical epithelial cells (H&E; x100) and
atypical squamous cell (tadpole cell) with
dyskeratosis and hyperchromatic nucleus
(inset, Papanicolaou; x400).
Click Here to Zoom
|Figure 4: USG guided FNAC of intestinal mass. Mucin secreting
adenocarcinoma showing sheets of atypical epithelial cells
with mild to moderate anisonucleosis (H&E; x100) against a
background of mucin (inset, acinar pattern, Giemsa; x400).
Click Here to Zoom
|Figure 5: USG guided FNAC of ovarian masses.
A) Endometriosis showing sheets of epithelial
cells with few spindle cells (H&E; x100).
B) Ovarian carcinoma showing clusters of
atypical epithelial cells (H&E; x400).
Among the hepatic lesions (n=14), 3 cases turned out
to be benign regenerative lesions, 4 were reported as
abscesses while 1 case showed inadequate material.
Among the malignancies, most of them were metastatic
adenocarcinoma (5 cases) and only one case was diagnosed
as hepatocellular carcinoma. Out of the 5 cases of metastatic
carcinoma, 3 were from gall bladder carcinoma, and 1 each
from stomach and lung. The cytological features which
favoured a primary liver malignancy over a metastastatic
malignancy were thickened cell cords (trabeculae) wrapped
by endothelial cells, acinar pattern, transgressing vessels,
macronucleoli, intranuclear inclusions and intracellular
bile pigment. The diagnosis was suggested after
Image guided thyroid FNAC was mainly performed for
adequate localization of small thyroid lesions. Papillary
carcinoma was detected in 3 cases, Hurthle cell neoplasm
in 2 cases and one case each of colloid nodule, thyroiditis,
follicular neoplasm, poorly differentiated carcinoma and
FNAC of lung lesions were performed solely under CT
guidance. Out of a total of 8 cases, 6 turned out to be
malignant with adenocarcinoma being the most common (3
cases) while squamous cell carcinoma, small cell carcinoma
and poorly differentiated carcinoma accounted for one
case each. Histopathology was available for 4 cases with
3 being compatible with cytological diagnosis. One case
was reported as an inflammatory lesion which was treated
by antibiotic therapy. The case diagnosed as small cell
carcinoma was referred to an oncology centre for chemo
and radiotherapy. However, a case of poorly differentiated
carcinoma was lost to followup.
Image guided FNAC of the gall bladder (n=6) yielded only
malignant diagnoses, all adenocarcinomas. Guided FNAC of
lymph nodes were performed either due to close proximity to
a major vessel or on account of the deep seated location. Two
cases turned out to be tubercular (1 in cervical nodes and 1
intraabdominal) while 2 were metastatic (one from papillary
carcinoma of the thyroid and the other from gall bladder
adenocarcinoma. Among GIT lesions for which USG guided
FNAC was performed, 1 turned out to be inflammatory while
2 were diagnosed as adenocarcinoma. There were 2 cases of
ovarian lesions, one being a case of primary infertility where
endometriosis was suspected radiologically and confimed
cytologically, the second case was diagnosed as a epithelial
malignancy. The detailed cytological diagnosis of all the
lesions is depicted in Table III.
Cytohistological correlation could be performed in 32
of the total 54 cases. The overall sensitivity was 92.59%
(calculated as percentage of true positive cases from a total
of true positives and false negatives), and specificity 100%
(calculated as percentage of true negatives from a sum of
false positives and true negatives). The diagnostic accuracy
was 100% (calculated as percentage of sum total of true
positive and true negative cases from the total number of
cases). The discrepant cases included a case of USG guided
FNAC liver which showed only regenerating hepatocytes
without any atypical cells. On biopsy, it turned out to be
adenocarcinoma. A case of CT guided FNAC lung revealed
only inflammatory cell infiltrate and was reported as
negative for malignancy. However, on histopathology it
was a case of squamous cell carcinoma with dense stromal
inflammation. Cytohistological correlation of all cases is
depicted in Table IV.
The amalgamation of imaging modalities such as USG and
CT with FNAC has improved the accuracy of diagnosis in
patients presenting with deep seated lumps. USG guided
FNAC has been in use for a long time now. In the initial
phases, the applications of USG guided FNAC were limited
to intra-abdominal lumps. Nowadays, newer locations are
The inadequacy rates for guided FNAC have a very wide range
from 2.8% to 33.6%8,11. The factors which influence this
include: facility for on site adequacy evaluation, number of
passes done, and the expertise of the pathologist and guiding
radiologist. In the present study, the inadequacy rate was
low (5.6%) on account of using 2-3 passes per patient and
all FNAC being performed by either consultants or senior
residents. Ghosh et al. analysed the spectrum of cytological diagnosis and clinicoradiological correlation of guided
FNAC over a period of 10 years12.The cases included
234 CT guided and 266 USG guided FNAC. Adequacy
ranged from 87.6% in CT guided FNAC to 91.7% in USG
guided FNAC. They observed that an increased number of
inadequate aspirates were obtained from very small sized
and deeper lesions. In the index study, there were only 3
cases which did not yield diagnostic material including one
case each of image guided FNAC of liver, lung and thyroid.
The reasons were small size of lesion in case of the thyroid
and lung and a very deep seated lesion of the liver.
When going through the literature, we came across various
studies on image guided FNAC from various sites and
observed that most of the authors reported fairly good
sensitivity, specificity and diagnostic accuracy. Sheikh et
al. evaluated 120 cases of abdominal and thoracic masses through image guided FNAC and found a sensitivity and
specificity of 80% and 59% respectively when a combination
of clinical and radiological features were taken into account1. Ahmad et al. studied 200 patients with abdominal
masses who were subjected to USG guided FNAC. The
cyto-histological correlation revealed an overall sensitivity
of 94.11%, specificity of 100% and diagnostic accuracy of
95.7%2. Parajuli et al. also studied the role of USG as well
as CT guided FNAC in intra-abdominal and intrathoracic
lesions over a period of 4.5 years, including 53 abdominal
and 47 thoracic masses5. Hemalatha et al.. evaluated
USG guided FNAC of abdominal and pelvic masses and
reported the diagnostic accuracy as 100%, 96%, and 94.4%,
respectively for benign, malignant, and non neoplastic
On search of the literature, we came across few studies
on USG guided FNAC of thyroid. Guided FNAC for
thyroid lesions is usually recommended for lesions which
are difficult to palpate or following a non-contributory
palpation guided FNAC. However, any thyroid lesion
with suspicious features on sonography like local
invasion, microcalcifications, solid component, marked
hypoechogenicity, increased vascularity, lymph node
metastasis, etc. should be considered for USG guided
FNAC13,14. Kim et al. in their review of USG guided
FNAC of thyroid nodules concluded that this technique
is useful for the diagnosis of palpable as well as non
palpable nodules9. The routine use of this technique
can significantly alter patient management. Lee et al.
compared the cytological results of USG guided FNAC of thyroid nodules to sonographic findings10. They found
that the positive and negative predictive values of the USG
categories were 59.1% and 97% and those of cytological
results were 93.7% and 98.9%. The USG categories were
significantly correlated with the final diagnosis in the
benign (p=0.014) and suspicious for malignancy (p<0.001)
cytological results group. In the present study, USG guided
thyroid FNAC was performed in 10 cases and yielded
a variety of diagnoses ranging from non neoplastic to
neoplastic lesions. Only one case was inconclusive. The
distribution of the thyroid cases is a bit unusual, and this
could be due to the fact that we considered only guided
FNACs for which non-guided FNAC was either noncontributory
or could not be performed (due to small
size or deep seated location). An interesting observation
was that USG guided FNAC of the thyroid was very
helpful in two cases of papillary carcinoma which did not
yield diagnostic material on palpation guided FNAC but
were subjected to image guided FNAC on account of the
doubtful looking thick colloid and radiological suspicion.
Cytohistological concordance was reached in the five cases
where histopathology was available. These cases included 3
cases of papillary carcinoma, and 1 case each of Hurthle cell
neoplasm and follicular neoplasm.
CT allows the performance of FNAC in situations in which
USG or conventional x-rays do not correctly visualise
the lesion or the needle tract. Most of the studies in the
literature on CT guided FNAC have applied it to evaluate
lung lesions15-19. In our study as well, CT guided FNAC
was performed only for lung lesions.
Arslan et al. evaluated a total of 316 cases of CT guided
FNAC of lung lesions and found that the sensitivity for
malignancy and specificity for benign lesions were 88% and
100%, respectively17. Positive and negative predictive
values were 100% and 53%, respectively. They concluded
that the procedure has high diagnostic accuracy and an
acceptable rate of complications. Wallace et al. studied the
accuracy of percutaneous CT-guided fine-needle aspiration
biopsy (FNAB) of small (< or =1.0-cm in diameter)
pulmonary lesions and concluded that it can yield high
diagnostic accuracy rates approaching those of larger
lesions18. We encountered 8 cases of CT guided lung,
out of which one case was inconclusive due to inadequate
sampling. There was one false negative case (inflammatory on cytology and malignant on histopathology). This could
be due to cystic change and dense exudate in a squamous
cell carcinoma that masked the malignancy.
Mangla et al. conducted an audit of USG guided FNAC
over a period of one year in a general cytopathology service
based in Delhi catering to a similar patient population as
in the present study20. They observed that only 112
USG guided FNACs were performed out of a total of
7795 FNAC. The most frequent sites were intraabdominal
(40.17%), followed by thyroid (32.14%), breast (9.82%),
superficial lymph nodes (8.92%) and soft tissue and
miscellaneous lesions (8.92%). The cytology reports were
diagnostic in 39.28%, non diagnostic descriptive in 31.25% and inadequate in 29.46%. They emphasized that there
should be an attempt to improve documentation of all
relevant clinical, radiological details and indication for
guided FNAC on the cytology forms.
In conclusion, although the present study included a variety
of organs where guided FNAC was performed, larger series
are required for each organ to arrive at definite conclusions.
The small sample size for each organ served as the limitation
for this study.This article may help in creating awareness
of this modality and thereby improve its applications
for all such deep seated lesions where it was not possible
earlier, so as to benefit the patients using cost effective and
simple techniques. Moreover, the need to have complete
documentation of clinical and radiological details on the
cytology requisition forms cannot be overemphasized.
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