ABSTRACT
Objective: To assess the
accuracy of cytological examination of non thyroid neck masses and to correlate
the findings between cytology and subsequent histopathology examination at Queen Alia
Military Hospital
between 2001 and 2005.
Methods: This study was
carried out at Queen
Alia Military
Hospital between January 2001
and December 2005. The records of 104 adult patients, over a five-year period were
reviewed. The definitive diagnosis of the palpable mass was determined by
review of the patient’s case notes.
Results: Sixty-four
(61.5%) of all neck masses were originally classified by fine needle aspiration
as benign, 30 (28.8%) as malignant, and 10 (9.6%) as nondiagnostic.
Histopathology of all the excised 104 specimens revealed that 70 (67.3%) had
benign disease and 34 (32.7%) had malignant disease. The most common benign
disease was pleomorphic adenoma with a sensitivity of 88.2%, a specificity of
98.1%, and an overall accuracy of 93.3%. The most common malignant pathology
was squamous cell carcinoma with a sensitivity of 88.9%, a specificity of 100%
and an overall accuracy of 98.0%. Overall, for benign and malignant tumors
combined, sensitivity, specificity, and accuracy were 86.9, 96.3, and 92.3%,
respectively.
Conclusion: Fine needle aspiration biopsy in experienced
hands is a good screening test with acceptable sensitivity and specificity in
the assessment of non thyroid neck masses.
Key words: Carcinoma, Cyst,
Fine needle aspiration, Neck.
JRMS March 2010; 17(1): 33-37
Introduction
Neck lumps
include reactive lymphadenopathy, inflammatory salivary gland enlargement,
thyroid gland masses, brachial cysts and benign neoplasms.(1) More than 50% of symmetrical neck lumps
are malignant tumors either primary (usually lymphoma) or secondary (usually
carcinoma)(2) therefore, the accurate diagnosis of the nature
of a neck swelling is of paramount importance.(3) The
standard procedure for the diagnosis of a neck mass is open biopsy of the mass with
histological examination of the excised tissue, however, open biopsy has been
reported to lead to a higher incidence of wound complications, regional neck
recurrence and distant metastases, than in patients who have no biopsy
performed prior to definitive treatment.(4) To avoid all complications, an open biopsy is
generally contraindicated in the presence of an undiagnosed mass in the head
and neck.(3)
Fine needle
aspiration procedure is minimally invasive, easily performed, has rapid results
and detects the presence of carcinoma, salivary gland tumors and other
neoplasms with high degree of accuracy.
Fine needle
aspiration biopsy (FNAB) has low cost, complication-free and first choice diagnostic
tool for the study of palpable head and neck masses, excluding abscesses and
vascular neoplasms.(5,6)
FNAB enables high accuracy in identifying the
nature of a lesion, differentiation of benign from malignant disease,
differentiation of the specific tumor cell type and determination of site of
origin.(7)
FNAB is not usually associated with
seeding of malignant cells or interference with subsequent histological
examination. Several large studies sampling parotid, prostate, renal cell
carcinoma and breast masses suggest that FNAB is not associated with
significant needle tract seeding.(8,9)
The unexpected finding
of malignancy in an excised mass which had been considered benign
pre-operatively is still encountered in occasions; such failure to identify
malignancy pre-operatively has serious consequences. For example, urgent cases
may be dealt with non-urgently, leading to delay in diagnosis and, thus, a
delay in definitive treatment.(3.5) In addition, the
treatment of such patients may entail additional morbidity. Thus patients with
unsuspected squamous cell carcinoma may require radiotherapy in addition to surgery
as part of their definitive treatment.
With these
considerations in mind, the present study was undertaken to assess the accuracy
rates of FNAB in non thyroid neck masses.
Methods
The study was
conducted in a 200-bed military hospital in Amman-Jordan, Queen Alia Military
Hospital (QAMH) from January 2001 till December 2005. The records of 104 adult
patients were reviewed. The indication for performing FNAB and the results of
this procedure were recorded. The diagnosis of the neck lump in each case was
determined by the examination of the case notes of all the patients.
The FNAB was
performed by pathologist using a 22-gague needle attached to a 20ml syringe. Usually
one pass was required but some cases needed more. Smaller lumps were biopsied
under ultrasound guidance but larger ones were done clinically. The aspirated
material was evacuated and spread on glass slide for staining. When Papanicolaou’s
stain was done slides were fixed with 95% alcohol, but when Geimsa stain was
used the slides were air dried.(7)
In cases where the neck lump was subsequently
removed, the final diagnosis of the lump was established by histological
examination of the excised tissue.
Results
Of the 104
FNABs, 64 (61.5%) were originally classified as benign, 30 (28.8%) as
malignant, and 10 (9.6%) as non-diagnostic. Histopathology of all the excised
specimens revealed that 70 patients (67.3%) had benign disease and 34 (32.7%)
had malignant disease (see Table I).
FNAB correctly
identified 62 out of 70 benign lesions (sensitivity: 88.6%) (see Table II). Of
the eight was a false-negative result (see Table III), and seven were actually
non-diagnostic rather than malignant. Therefore, when the non-diagnostic
results were excluded from the analysis, the sensitivity of FNAB for benign
disease was 94.1%. The specificity of FNAB for benign disease was 94.1% overall
and 93.5% when non-diagnostic results were excluded (there were two false
positives (Table III]). The positive predictive value (PPV) for benign disease
was 0.969, and NPV was 0.080. Therefore, the overall accuracy of FNAB for
benign disease was 90.4% (Table II). The most common benign disease in this
study was pleomorphic adenoma, where FNAB had a sensitivity of 88.2%, a
specificity of 98.1%, and an overall accuracy of 93.3% (Table II).
The overall
sensitivity of FNAB for malignant disease in general was 85.3%. Of the five
false-negative results (Table III), three were actually non-diagnostic rather
than benign. Therefore, when the non-diagnostic results were excluded, the
sensitivity of FNAB for malignant disease was 93.5%. The specificity of FNAB
for malignant disease was 98.6% overall and 98.4% when the non-diagnostic
results were excluded (there was one false-positive, see Table III). The PPV
was 0.967, the NPV was 0.932, and the overall accuracy was 94.2% (Table II).
Table I. Pathology of excised benign and
malignant specimens
|
%
|
No.
|
Pathology
|
|
67.3
|
70
|
*Benign
|
|
72.9
|
51
|
Pleomorphic Adenoma
|
|
11.4
|
8
|
Warthin’s Tumor
|
|
5.7
|
4
|
Adenoma (other)
|
|
4.3
|
3
|
Chronic sialadenitis
|
|
4.3
|
3
|
Epidermoid Cyst
|
|
1.4
|
1
|
*Oncocytoma
Benign
Myofibroblastic Tumor
|
|
32.7
|
34
|
*Malignant
|
|
52.9
|
18
|
Squamous Cell Carcinoma
|
|
11.8
|
4
|
Acinic Cell Carcinoma
|
|
8.8
|
3
|
Melanoma
|
|
8.8
|
3
|
Adenocarcinoma
|
|
5.9
|
2
|
Lymphoma
|
|
2.9
|
1
|
Adenoid Cystic Carcinoma
|
|
2.9
|
1
|
Malignant Histiocytoma
|
|
2.9
|
1
|
Myoepithelial Carcinoma
|
|
2.9
|
1
|
Poorly differentiated carcinoma
|
Table II. Accuracy of
FNAB
|
Accuracy
|
NPV*
|
PPV*
|
Specificity
|
Sensitivity
|
Pathology
|
|
90.4%
|
0.800
|
0.969
|
94.1%
|
88.6%
|
Benign (n=70)
|
|
93.3%
|
|
|
98.1%
|
88.2%
|
Pleomorphic Adenoma (n=51)
|
|
94.2%
|
0.932
|
0.967
|
98.6%
|
85.3%
|
Malignant (n=34)
|
|
98.0%
|
|
|
100%
|
88.9%
|
SCC (n=18)
|
|
92.3%
|
0.866
|
0.968
|
96.3%
|
86.9%
|
Overall
|
*
PPV: positive predictive value NPV:
negative predictive value
Table III. False negatives
and false positives for benign and malignant disease
|
No.
|
Pathology
|
|
|
*False
negatives, benign (n=8)
|
|
2
|
Plemorphic
adenoma
|
|
3
|
Oncocytoma
|
|
1
|
Cysadenoma
|
|
1
|
Myofibroplastic
tumor
|
|
1
|
Warthin’s
tumor
|
|
|
*False positive,
benign (n=2)
|
|
1
|
Adenocarcinoma
|
|
1
|
Lymphoma
|
|
|
*False
negatives malignant (n=5)
|
|
2
|
Lymphoma
|
|
1
|
Adenocarcinoma
|
|
1
|
Adenoid
cystic carcinoma
|
|
1
|
Melanoma
|
|
|
*False
positives, malignant (n=1)
|
|
1
|
Pleomorphic
adenoma
|
Squamous cell
carcinoma was the most common malignant pathology in our study combarable with
other studies.(10) Where the sensitivity of FNAB was 88.9%,
its specificity was 100%, and its overall accuracy was 98.0% (Table II).
Overall, for benign and malignant tumors combined, sensitivity, specificity,
and accuracy were 86.9%, 96.3%, and 92.3% respectively (Table II).
Discussion
The sensitivity
and specificity of FNAB for benign and malignant disease in our study were
comparable to previously reported rates,(5-9,15,16) Table IV. The overall accuracy of cytological diagnosis based on FNAB has been reported to range from 65 to 99%; our overall accuracy rate was 92.3%. For benign lesions, the reported sensitivity of FNAB ranges from 84 to 95%; ours was 88.6%.
Table
IV. Previous
study results of FNA cytology of neck masses
|
Accuracy%
|
Specificity%
|
Sensitivity %
|
No. of histological specimens
|
Study
|
|
--
|
97.5
|
95
|
216
|
Piromalli et al (6)
|
|
65
|
52
|
84
|
53
|
Holleman et al (7)
|
|
--
|
97
|
92
|
345
|
Sanders et al (8)
|
|
80
|
78
|
88
|
184
|
Leonard et al (9)
|
|
99
|
99.8
|
90
|
827
|
Lopez et al (10)
|
|
|
96
|
93
|
625
|
Bakhos et al (11)
|
|
--
|
--
|
--
|
100
|
Sruojjieh
et al (12)
|
|
92.3
|
96.3
|
86.9
|
104
|
Present
study
|
--:
not determined
When FNAB is
non-diagnostic, which we encountered in 9.6% of our cases, some authors
recommend performing an ultrasound-guided core biopsy to obtain a tissue
diagnosis.(11) Some of the false-negative and
false-positive results in the present study are worth to be mentioned. First,
two of the five specimens that were falsely negative for malignancy was low grade
non Hodgkin's lymphomas. These were the only
cases of lymphoma in our group of patients. The fact that both were not
reported as malignant on FNAB is consistent with other reports that lymphoma is
difficult to diagnose by FNAB.(6,8,9,12,13,16) Most pathologists state that the diagnostic
accuracy for lymphoma is between 50% and 60%.(3) If non
Hodgkin lymphoma is suspected , flow
cytometry of FNAB can be a useful diagnostic aid.(12)
Second, the only false positive for malignancy
in our study was reported as “large malignant cells suggesting carcinoma” on
cytology. This tumor was later found to be a pleomorphic adenoma on histopathology.
Conversely, a finding of pleomorphic adenoma on FNAB does not completely exclude
the presence of adenocarcinoma on histology.(14)
There are other
concerns about the use of FNAB preoperatively, namely that FNAB can cause histological
changes that can obscure a histologic diagnosis. However, the findings of at
least one large study appear to disprove this idea. Mukunydazi et al.
found that while FNAB may produce changes such as infarction and hemorrhage;
these changes were usually not extensive enough to compromise a histological
diagnosis.(17 )
Conclusions
Fine needle
aspiration biopsy is an accurate means of diagnosing both benign and malignant
neck tumors. It is especially useful in excluding squamous cell carcinoma.
Although it is important to be mindful of the possible pitfalls of FNAB, we
believe it plays a useful role in the assessment of non thyroid neck masses.
FNAB in
experienced hands is a good screening test in the assessment of non thyroid
neck masses. Repeating FNAB in cases where the original result is negative for
carcinoma may increase the sensitivity of FNAB especially in the detection of
cystic carcinomas.
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