The diagnostic value of fine needle aspiration in parotid lumps

Mallon DH, Kostalas M, MacPherson FJ et al. The diagnostic value of fine needle aspiration in parotid lumps. Ann R Coll Surg Engl 2013; 95: 258–262 doi 10.1308/003588413X13511609958370We read with interest the article by Mallon et al and would like to make further comment. Their paper documents what is becoming increasingly clear about fine needle aspiration (FNA) in the salivary glands. In experienced hands, it is capable of a high degree of accuracy, and is quick and safe to perform. FNA performance is optimised by the use of ultrasonography guidance, presence of cytologist/cytology technician to allow repeat aspiration and use of ancillary cytology techniques. Outside specialised units, however, the performance of FNA varies widely, as demonstrated in the recent meta-analysis by Schmidt et al.¹Even in optimised circumstances, FNA remains associated with both a high rate of non-diagnostic sampling and also false negative results.¹ These perceived failings have led to investigation into alternative biopsy techniques, which may more reliably provide an accurate preoperative diagnosis, allowing informed patient consent and appropriate operative selection.Ultrasonography guided core biopsy (USCB) has been described recently in the parotid glands, and has been shown to be both highly accurate and well tolerated.² USCB obtains a core of tissue, using a small bore needle (18G or 20G) deployed via an automated biopsy device, which can be sent for immunohistochemical analysis. This enables typing and grading of tumours. Furthermore, it allows improved diagnosis of nodal hyperplasia and the differentiation of reactive node from low grade lymphoma. USCB does not appear to be associated with either the high non-diagnostic and false negative rates or the variability in performance associated with FNA.³ We would recommend that USCB should be considered the biopsy technique of choice for parotid lump diagnosis, particularly in units where FNA is undertaken in non-optimised circumstances.     

The diagnostic value of fine needle aspiration in parotid lumps

Introduction

Fine needle aspiration (FNA) is a safe and quick method of diagnosing superficial lumps, which aids preoperative planning. However, FNA of the parotid gland has not gained the widespread acceptance noted in other head and neck lumps. The aim of this study was to determine the ability of FNA of the parotid gland to differentiate benign and malignant disease, and to determine the impact on surgical outcome.

Methods

A retrospective analysis of 201 consecutive parotid operations with preoperative FNA in a large district hospital in the UK was performed. The diagnostic characteristics were calculated for benign and malignant disease, and the impact on surgical procedure was determined.

Results

In identifying benign disease, FNA has a sensitivity of 85% and a specificity of 76%. In detecting malignant disease, FNA has a sensitivity and specificity of 52% and 92% respectively. A false positive on FNA was associated with a higher incidence of neck dissection.

Conclusions

FNA is a useful diagnostic test. However, owing to low sensitivity, it is necessary to interpret it in the context of all other clinical information.     

Transbronchial fine needle aspiration.

In a pilot study, 21 patients underwent transbronchial fine needle aspiration (TBFNA) using a 45 cm-22 gauge needle guided by means of a semi-rigid metal sleeve, which was introduced through a standard rigid bronchoscope. A total of 33 aspirations were performed from main carina (15), paratracheal (five), and lobar carinal (13) foci. Six aspirations yielded malignant cellular samples, 22 aspirations presented only normal cells, and in five no adequate cellular sample was obtained. Fifteen patients underwent surgical exploration (mediastinoscopy with or without thoracotomy). Four of the cytologically malignant cases were explored and in three the aspiration site was confirmed histologically. In the remaining patients where the site of aspiration was explored, no tumour was demonstrated in the cytologically negative or cytologically inadequate cases. There were no complications from TBFNA. We suggest that TBFNA is useful in determining mediastinal malignant involvement rapidly and with lesser invasion than with current techniques.     

The utility of fine needle aspiration biopsy cytology in the management of thyroid tumors

This report is a retrospective survey of our experience with fine needle aspiration biopsy cytology in the evaluation of thyroid tumors in the years 1974–1978. The method was used as a routine procedure with 17 surgeons involved in the sampling and 4 cytopathologists involved in analyses of the smears. In 264 patients treated surgically, the preoperative cytopathologic diagnoses have been compared to the postoperative diagnoses. In 43 patients (16%), the biopsies were not representative. In patients with representative biopsies, a preoperative benign cytologic diagnosis was obtained in 112 of 160 patients with benign postoperative histology (70%), and a malignant or suspected malignant preoperative cytologic diagnosis was found in 52 of 61 patients (85%) with carcinomas. In 9 patients, the preoperative cytologic diagnoses were false-negative (4.1% of the representative biopsies). No false-positive cytologie diagnosis occurred. Sampling of adequate cellular material was the major problem in our experience. The high diagnostic reliability from representative material makes fine needle aspiration biopsy cytology a useful method in planning operations and in selecting patients for surgery. Due to the risk of false-negative biopsies, a clinical suspicion of malignancy must not be ruled out by this method.

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Résumé L'article revoit notre expérience, entre 1974 et 1978, de la ponctioncytologie pour l'évaluation des tumeurs de la thyroide. La méthode a été utilisée en routine, 17 chirurgiens réalisant les ponctions et 4 pathologistes les analyses. Le diagnostic cytologique préopératoire a été comparé au diagnostic postopératoire chez 264 opérés. Dans 43 cas (16%), la biopsie n'était pas utilisable. Dans les autres cas, la cytologie préopératoire donnait un diagnostic de lésion bénigne dans 112 des 160 cas avec histologie postopératoire bénigne (70%). Sur 61 carcinomes, la cytologie préopératoire était positive ou suspecte de malignité dans 52 cas (85%). Dans 9 cas, la cytologie préopératoire était faussement négative (4.1% des biopsies utilisables). Il n'y a eu aucune cytologie faussement positive. Dans notre expérience, le problème majeur est l'obtention par ponction d'un matériel cellulaire adéquat. Lorsque ce matériel est bon, la fiabilité du diagnostic cytologique après ponction aspiration en fait une technique utile pour sélectionner les malades à opérer et pour planifier l'acte opératoire. Il faut cependant garder à l'esprit le risque de faux négatif: la suspicion clinque de málignité doit rester l'élément primordial dans la décision thérapeutique.

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Professor Peter Heimann, M.D., who initiated this work, died in 1978.     

Role of fine needle aspiration cytology in the management of the discrete parotid lump.

A review of fine needle aspiration cytology (FNAC) indicates that the technique can distinguish benign from malignant parotid, disease in 93% of patients evaluated. However, a surgery of 34 head and neck oncologists revealed that making this distinction when an apparently benign parotid lump was being investigated did not normally alter the surgical management for in the presence of low-grade cancer survival is not improved with radical surgery. As FNAC does not alter treatment of a discrete parotid lump, no consensus is currently possible regarding its most appropriate use. Perhaps its value is as a screening procedure and to provide a little more information when advising the patient.     

Confirmation of the utility of fine needle aspiration biopsy of the renal allograft

Allograft immunobiologic theory would predict that analysis of immunocompetent cells infiltrating the renal transplant would be most instructive. Recently a new aspiration biopsy technique has been developed to permit such analysis in patients which can be safely and repetitively performed. The clinical utility of such a technique has been tested utilizing a randomized prospective trial in which an aspirate was obtained every other day from the third post-operative day until discharge. Analysis included examination of adequacy criteria and the capacity of pathologic diagnosis to corroborate clinical diagnosis from coded specimens. Ninety-six aspirates from 21 consenting transplant recipients were obtained and analyzed. In 94 instances a clinical diagnosis could be made; 80 aspirates fulfilled adequacy criteria. We found the technique to be highly sensitive (greater than or equal to 90%) and highly specific (greater than or equal to 90%) for the clinical diagnoses of acute allograft rejection, post-operative acute renal failure, cyclosporine toxicity, and normal function. We conclude that the fine needle aspiration technique is an important adjunct to analysis of clinical renal transplantation and offers a major advantage to the clinical scholar in understanding transplant biology.     

Value of fine needle aspiration biopsy cytology in the diagnosis of discrete hepatic lesions suspicious for malignancy.

Ninety-five sequential computerized tomography (CT) guided fine needle aspirates (FNA) of the liver, taken between January 1986 and December 1989 were reviewed to assess the accuracy of this method in diagnosing discrete hepatic lesions suspicious for malignancy. Clinical follow-up information, or a tissue diagnosis or both were available in 71 of these cases. False-negative results were found in four of the cases. Forty-six cases in the group gave a positive result with FNA and confirmatory tissue diagnosis was made in 25 of these cases. Detailed clinical follow-up produced additional support for the diagnosis in 20 other cases. Twenty-four cases were negative but clinical follow-up indicated that there were four false-negative diagnoses. The one false-positive case in this series was diagnosed as a hepatocellular carcinoma in a patient with haemochromatosis. Overall, the results gave a sensitivity of 90% and a specificity of 87%.     

细针穿吸细胞学检查对腮腺区肿块诊断及手术美学设计的应用评价

目的:研究细针穿吸细胞学检查对腮腺区肿块诊断及手术美学设计的应用评价。方法:对151例腮腺区肿块患者术前行细针穿吸细胞学检查,根据穿刺诊断设计手术切口及方法,术中冰冻病理诊断,并与术后常规病理诊断作对照。结果:细胞学检查定性诊断的准确率为93.4%,术中冰冻病理诊断的准确率为96.1%,细胞学诊断与组织病理诊断完全一致的诊断符合率,良性肿瘤为93.9%,恶性肿瘤为92.3%。根据穿刺诊断设计手术切口及方法,术后外形恢复良好,无出血、感染、面神经损伤等并发症发生。结论:细针穿吸细胞学检查在腮腺区肿块的诊治中有重要作用,是一种快速、经济、安全、并发症较少和诊断准确率高的细胞学诊断手段。     

Intraoperative fine needle aspiration cytology in pancreatic lesions.

The notes of 129 patients investigated by intraoperative fine needle aspiration biopsy between 1973 and 1977 have been reviewed. Eighty-four of the patients were operated on and punctured at the Department of Surgery, Lund, and 45 at different county hospitals belonging to the region. All aspirates were stained and evaluated at the Department of Cytodiagnostics, Lund. Sixty-four of the 75 patients with pancreatic cancer were correctly diagnosed and in another three patients the cytological diagnosis was "suspicion of cancer." Including these latter cases the sensitivity of the method was 91% in pancreatic cancer. In four out of five patients with endocrine tumors the cytological report was correct i.e., "endocrine tumor." In none of 22 patients with chronic pancreatitis or pancreatic cysts the diagnosis was falsely positive. Twenty-seven patients who during the operation were suspected of having a pancreatic lesion were at follow-up (mean 2.8 years) found not to have any significant pancreatic disease. Among these patients no falsely positive reports were given. In nine of the 129 patients (7%) the aspirates even at re-checking were found to be nonrepresentative or the aspiration unsuccessful. Six of these were performed at county hospitals. In 24 patients with pancreatic cancer total pancreatectomy was performed. In the remaining 105 patients no complications which could be related to the puncture were detected.     

Effects of fine needle aspiration on subsequent mammograms.

The effects of fine needle aspiration on subsequent mammography were studied in a group of women who were referred with palpable breast lumps. Fifty-two women aged between 36 and 73 (median 53) years underwent mammography before and within 5 days of needle aspiration. Preaspiration and postaspiration mammograms were examined 'blind' by one radiologist. In ten cases, a difference was seen between the preaspiration and postaspiration films. In seven (aged 36-50 years) this was due to aspirated cysts. In three the differences were unexpected and were more significant, although the radiological diagnosis was not altered. If this proportion is extrapolated for a large number of patients then significant numbers of artifacts from fine needle aspiration might be seen on mammograms. It is possible that some might be interpreted falsely as malignant and some small cancers might be obscured. Women accepted mammography more readily before aspiration than after.     

Sample size in fine needle aspiration biopsy

The weights of biopsy specimens from bovine liver taken for fine needle aspiration cytology (FNAC) by three groups of physicians, were compared. The groups differed from each other in their extent or degree of experience in FNAC. When the physicians used their normal technique, the mean sample weight increased significantly with experience, from 4.6 mg in the least experienced group to 17.2 mg in the group with the longest experience. Thirty-six per cent of the samples taken by the group with the least experience were in the weight class 0-2 mg, whereas no such samples were encountered for the other groups. When all the physicians were advised to use the same, standard technique there were no statistically significant differences in mean sample weight between the groups or in the proportion of samples in class 0-2 mg. Sample weights correlated significantly (P less than 0.001) with cell counts. This study shows that differences in the technique of FNAC are responsible for differences in sample weights and cell counts, including the number of the acellular samples obtained. This could explain in some part the wide variation in the reported accuracy rates of FNAC.     

Endoscopic ultrasound-guided fine needle aspiration in esophageal cancer

Esophageal cancer has a poor prognosis since it is often diagnosed in the symptomatic and incurable state. Accurate staging at initial diagnosis is imperative as it determines prognosis and influences treatment. Computed tomography (CT) scan is sensitive for identifying metastatic disease but is insensitive for detecting the extent of wall involvement or nodal disease. Endoscopic ultrasound (EUS) has emerged as a powerful tool in staging esophageal cancer with an impressive accuracy. Use of endoscopic ultrasound-guided fine needle aspiration as an adjunct further improves accuracy in nodal staging and allows for histologic confirmation. The impact of this invaluable staging modality in the management of esophageal cancer continues to grow.