Fine needle aspiration biopsy: role in diagnosis of pediatric head and neck masses

OBJECTIVE: To assess the feasibility and role of fine needle aspiration biopsy (FNAB) as a diagnostic tool in children with neck masses. DESIGN: Retrospective chart review. SETTING: Tertiary care children's hospital. PATIENTS: Consecutive series of 71 children with a head and neck mass who underwent FNAB as the primary diagnostic modality. INTERVENTIONS: FNAB was performed and interpreted by a pediatric cytopathologist. Rapid on-site analysis was performed to allow immediate assessment of specimen adequacy and to attain a preliminary diagnosis, after which routine cytologic staining was performed. Flow cytometry was performed on cytological specimens when malignancy was suspected, and open biopsy was performed when the cytologic diagnosis was in question. MAIN OUTCOME MEASURES: Technical feasibility of FNAB in children, complications, cytopathological diagnoses, accuracy of rapid on-site analysis, need for subsequent diagnostic evaluations, clinical outcomes and follow-up. RESULTS: Mean age was 8.4 years (S.D. 5.3 years), with mean follow-up of 4.1 months (S.D. 9.6 months). FNAB was performed under general anesthesia in 54 cases (76%). There were no technical complications. On-site rapid interpretation was completed in 55 cases, 18/55 confirmed adequacy of specimen only, 37/55 yielded a preliminary diagnosis, and in 34/37 cases, was same as final cytopathologic result. Overall, FNAB biopsy demonstrated 64 benign lesions, 3 malignant diagnoses, 2 follicular thyroid neoplasms, and 2 non-diagnostic specimens. FNAB was the only pathological test performed in 54 (76%) cases. The most common diagnosis was reactive lymphoid hyperplasia (n=39), followed by benign granulomatous disease (n=8). Flow cytometry was performed on 7 specimens (non-diagnostic in 5, negative for malignancy in 2). Of the 15 cases with surgical specimens, 3 revealed a pathologic diagnosis different from initial FNAB. There were no cases in which FNAB missed a malignancy, and there were 2 cases where FNAB suggested malignancy, with benign disease subsequently found on open biopsy. CONCLUSIONS: Fine needle aspiration biopsy is developing into a feasible option in diagnosing pediatric neck masses, with its main advantage being its minimally-invasive nature and avoidance of an open surgical procedure for benign persistent lymphadenitis. On-site rapid interpretation can be used successfully to confirm specimen adequacy and to give an accurate preliminary diagnosis for concerned parents. Issues to consider include the need for a specialized pediatric cytopathologist familiar with pediatric differential diagnoses, the need for general anesthesia in many cases, and the possibility of inaccurate diagnosis requiring an open procedure.     

Fine-needle aspiration biopsy of salivary gland lesions in a selected patient population

OBJECTIVE: To report the role of selective use of preoperative fine-needle aspiration biopsy (FNAB) in patients with major salivary gland lesions at a tertiary care cancer center. DESIGN: Retrospective review of FNAB results compared with final histologic diagnosis as the criterion standard. SETTING: An academic tertiary care cancer center. PATIENTS: A consecutive series of 258 patients who underwent FNAB of major salivary gland lesions between 1996 and 2000, of whom 169 had surgical resection. MAIN OUTCOME MEASURES: Predictive value, sensitivity, specificity, and accuracy. RESULTS: FNAB was performed in 169 (37%) of 463 salivary gland lesions undergoing surgical procedures. A total of 126 lesions were in the parotid gland and 44 in the submandibular gland. Seventy-nine lesions (46%) were malignant. There were 150 FNAB specimens (89%) that were satisfactory for evaluation. The FNAB diagnosis of malignant or suspicious lesion had positive and negative predictive values of 84% and 77%, respectively. Ten of 20 false-negative FNAB results were low-grade lymphoma on final histologic assessment. Fine-needle aspiration biopsy diagnosis of a benign neoplasm had positive and negative predictive values of 83% and 88%, respectively. A cytopathologic diagnosis of a nonneoplastic lesion was predictive in only 47% of cases. Fifteen (47%) of 32 lymphocyte-predominant FNAB specimens were lymphoma on final histologic assessment. Ten (20%) of 49 patients with history of a solid, non-head and neck malignancy had evidence of distant metastasis to the salivary gland by histologic and/or cytopathologic assessment. CONCLUSIONS: An FNAB diagnosis of malignant or neoplastic major salivary gland disease is generally predictive of final histologic diagnosis. The predictive value of a negative FNAB finding is low, and should not supersede clinical suspicion. Cytologic findings of a lymphocyte-predominant lesion should prompt further workup to rule out lymphoma.     

Congenital torticollis: Evaluation by fine-needle aspiration biopsy

Fine-needle aspiration biopsy, used extensively for evaluating head and neck masses in adults, also provides an excellent minimally invasive means of evaluating infants with neck masses and torticollis. Three cases of torticollis involving infants are presented. In each case, fine-needle aspiration revealed a benign fibrous lesion, ruling out malignancy. The remaining cytologic differential diagnosis between infantile fibromatosis, fibromatosis colli, and calcifying aponeurotic fibrosis is discussed, with mention of the possible causes of and treatment for congenital torticollis. We conclude that fine-needle aspiration provides a fast and accurate diagnosis of neck masses in infants who have congenital torticollis, thereby avoiding surgical procedures in this very young age group.     

Interobserver variability in the interpretation of fine-needle aspiration biopsy of head and neck masses

Fine-needle aspiration biopsy is gaining acceptance as a clinically useful tool. We set out to evaluate the accuracy of fine-needle aspiration biopsy at our institution by measuring the interobserver variability in cytopathologic interpretation, and by measuring the agreement between cytopathologic and histologic diagnosis. In a prospective study, 253 aspirations were performed on head and neck masses by the otolaryngology service. Specimens were interpreted independently by two cytopathologists (V.J.S. and P.Z.), and interpretations were compared with the surgical histopathologic diagnosis when available. The interobserver variability between cytopathologists was 8% with a specificity of 96% and a sensitivity of 97%. We conclude that fine-needle aspiration biopsy is a safe and useful tool in the diagnosis of head and neck masses. In the diagnosis of epithelial cysts and squamous epithelial malignancies, fine-needle aspiration biopsy is as accurate as open biopsy.     

Transmucosal fine-needle aspiration diagnosis of intraoral and intrapharyngeal lesions.

OBJECTIVES: The effectiveness of fine-needle aspiration biopsy (FNAB) for the diagnosis of neck, thyroid, and salivary gland masses is well documented. Very few reports explore the potential of an intraoral FNAB approach for the diagnosis of submucosal lesions. We describe our technique and present case examples of pertinent differential diagnostic entities. We recommend an expanded role for FNAB of the oral cavity and oropharynx. STUDY DESIGN: Retrospective review. METHODS: A uniform technique was employed for transmucosal FNAB of 76 patients with intraoral masses. In applicable cases, cytology results were compared with traditional biopsy methods and permanent histopathologic specimens for accuracy. RESULTS: Our experience demonstrates the high sensitivity (93%) and specificity (86%) of intraoral FNAB when compared with biopsy by conventional means. FNAB provides distinct advantages for the cytologic diagnosis of submucosal lesions, which may be difficult to reach and adequately sample through conventional biopsy. FNAB of the tonsil and tonsillar fossa provides a safe and effective means of diagnosing both lymphoma and squamous cell cancer. Transmucosal FNAB via the mouth led to rapid diagnosis of a number of benign and malignant lesions. Applying this uniform FNAB technique, we had no significant complications. CONCLUSION: We recommend transmucosal FNAB as an effective means for highly accurate diagnosis of submucosal lesions of the oral cavity and oropharynx. CLINICAL RELEVANCE: Traditional biopsy techniques in the oral cavity may require anesthesia and may have diagnostic difficulties, particularly for submucosal lesions. Transmucosal FNAB overcomes these shortcomings by providing a minimally invasive means to rapid diagnosis of intraoral lesions.     

Parotid tumours: correlation between fine needle aspiration biopsy and histological findings

ObjectivesTo evaluate the role of the fine needle aspiration biopsy (FNAB) in the study of parotid masses.MethodsRetrospective review of FNAB results compared with final histological diagnosis in 148 patients with a parotid mass from 1993 to 2003.ResultsFNAB was performed in 93.92% of parotid masses. Eleven of these were not conclusive. The FNAB diagnosis of malignant o suspicious lesion had 81.25% of sensibility, 96.87% of specificity and positive and negative predictive values of 89.65% and 93.94%, respectively. The FNAB specific histopathologic diagnosis in the benign parotid masses were 92%, and 57.69% in the malign masses.ConclusionsFNAB is a diagnostic tool with a high negative predictive value, very usotul in the study of suspicious malignant parotid masses and whenever surgery is not possible.     

Submandibular gland squamous metaplasia mimicking recurrent squamous cell carcinoma: diagnostic dilemma

New masses in the head and neck region of previously treated patients with cancer are considered suggestive of potential recurrence. Fine-needle aspiration is an excellent primary tool for evaluating these masses but may show atypical squamous cells that mislead clinicians to pursue aggressive treatment. We describe 3 patients in whom submandibular gland masses developed after radiation therapy for squamous cell carcinoma and for whom subsequent excisional biopsy findings showed benign squamous metaplasia. We review distinguishing clinical and histopathologic features that may allow these lesions to be identified. We also propose a treatment algorithm for this uncommon clinical scenario.     

Advances in the use of fine-needle aspiration cytology in the diagnosis of palpable lesions of the head and neck.

Our experience in performing fine-needle aspiration for the investigation of palpable lesions of the head and neck region is reviewed. Three hundred cases were performed over a period of approximately two years. In most circumstances, a diagnosis could be rendered simply on the basis of routine cytomorphologic interpretation. In some situations, it was necessary to employ ancillary techniques such as immunoperoxidase staining, electron microscopy, and flow cytometry to confirm the morphologic diagnosis. Several cases illustrating the clinical utility of the technique are presented in detail. Fine-needle aspiration is a relatively atraumatic, well-tolerated procedure which can be readily performed in the usual outpatient setting. This technique is an excellent first-line method for investigating the nature of palpable lesions in the head and neck region.     

Ultrasound-guided fine-needle aspiration biopsy of neck nodes

The assessment of nodal involvement in patients with squamous cell carcinoma of the head and neck is still a major diagnostic problem. Although the sensitivity of imaging techniques for detection of neck nodes is gradually improving, the specificity for metastases remains low. Cytologic examination could, theoretically, supply additive information. Computed tomographic-and magnetic resonance-guided aspiration techniques have been described, but these were not efficacious and laborious. In 1984, we developed a technique for ultrasound-guided (UG) fine-needle aspiration biopsy (FNAB). This technique is described herein, and the value of UGFNAB is compared with conventional FNAB. All statistical characteristics of UGFNAB appeared to be superior to conventional FNAB (sensitivity, 98% vs 88%; specificity, 95% vs 82%; positive predictive value, 98% vs 93%; negative predictive value, 95% vs 74%; and accuracy, 97% vs 87%). Furthermore, UGFNAB was characterized by less nondiagnostic aspirations. It is concluded that UGFNAB is a reliable technique for differentiation between benign nodes and cervical lymph node metastases and it may, therefore, contribute to a more accurate assessment of the neck in squamous cell carcinoma of the head and neck.     

Fine-needle aspiration biopsy: application to pediatric head and neck masses

Fine-needle aspiration biopsy cytology is widely used to screen masses in adults. The authors present a series of 89 fine-needle aspiration biopsies performed between January 1973 and December 1988 on 86 pediatric patients with clinically significant head and neck masses. All fine-needle aspiration diagnoses were confirmed by subsequent surgical biopsy, autopsy, or clinical follow-up for a minimum of 18 months. Of 21 tumors identified, 19 were malignant. Of the 89 aspirations performed, 67 required no subsequent surgical biopsy. In 11 of these cases, metastatic or recurrent tumor was diagnosed and appropriate therapy instituted. Fifteen of the 89 aspirates revealed previously undiagnosed tumors requiring surgical intervention. One false-negative and two false-positive results were obtained. No radical treatment resulted from the false-positive diagnoses, and no patient delay in treatment occurred because of the false-negative result. The sensitivity was 94.4%, and the specificity was 97.1%. The usefulness and cost-effectiveness of fine-needle aspiration is stressed.     

Preoperative identification of benign versus malignant parotid masses: A comparative study including positron emission tomography

Various diagnostic tools were used in 26 patients with parotid masses to determine their value in preoperative malignant or benign categorization. These tools were positron emission tomography (PET), clinical examination, fine-needle aspiration biopsy (FNAB), computed tomography (CT), and magnetic resonance imaging (MRI). PET identified all 26 lesions and all 12 malignant lesions, but made the correct categorization in only 69% of cases. Thus, it was not as good as the more conventional diagnostic methods, their correct categorizations being 85% (clinical), 87% (CT/MRI), and 78% (FNAB) in the same patients.     

The role of fine needle aspiration biopsy in deep lobe parotid tumors: Comparison of preoperative cytology and postoperative histopathologic results

PurposeMajor salivary gland tumors constitute almost 3% of head and neck tumors. Tumors located exclusively in the deep lobe are not common and 20% of parotid gland tumors originate from deep lobe under the branches of the facial nerve. Accuracy of fine needle aspiration biopsy (FNAB) procedure in salivary gland tumors have been studied extensively, however there isn't any data regarding usefulness of FNAB in tumors located exclusively in deep lobe of parotid gland. In this study we aimed to assess the use of FNAB in deep lobe parotid tumors.Materials and methodsWe retrospectively analyzed 51 patients with deep lobe parotid tumors who underwent surgery in our clinic between January 2013–December 2018. Characteristics of patients were recorded. Preoperative FNAB results and postoperative final histopathologic diagnosis were compared. Statistical analysis was performed using SPSS 24.0 was used for statistical analysis.ResultsThe number of patients that met the inclusion criteria was 51. The mean age of patients were 49.2(14–86). In 40 (78.4) of the patients, tumor was reported as benign and in 11 (21.6) patients FNAB diagnosis was suspicious for malignancy, malignant or non-diagnostic. In final histopathologic diagnosis, 42 of the tumors were benign and 9 were malignant. The most common benign tumor type was pleomorphic adenoma which constitutes 27 of the cases (52.9%). Regarding detection of malignant disease, the sensitivity of FNAB was 90.4%, specificity was 77.7%, positive predictive value was 95%, negative predictive value was 63.6%. There was a substantial agreement between FNAB and final histopathologic diagnosis(kappa = 0,628).ConclusionsFNAB is a safe and reliable tool to evaluate deep lobe parotid tumors. It is an important part of preoperative surgical planning and can help the surgeon in patient counseling. FNAB with ultrasound guidance is recommended for deep lobe tumors.     

Implantation metastasis of head and neck cancer after fine needle aspiration biopsy

One possible complication of the aspiration biopsy of malignant tumors is dissemination of tumor cells along the needle track. However, a search of the literature revealed few definite reports of implantation metastases of head and neck tumors after fine needle aspiration biopsy (FNAB). Here we report two cases of skin metastasis of head and neck cancer after FNAB, including a patient with papillary adenocarcinoma of the thyroid and one with adenoid cystic carcinoma of the submandibular gland. Surgical treatment prevented the spread of the tumor in both cases and there have been no evidence of recurrence to date. This report should alert head and neck surgeons to the possibility of implantation metastasis after FNAB.     

Frozen section in a cytological diagnosis of thyroid follicular neoplasm

OBJECTIVE/HYPOTHESIS: Fine-needle aspiration biopsy is the most accurate diagnostic test for thyroid nodules, its only limitation being the diagnosis of follicular neoplasm that does not distinguish between benign and malignant follicular lesions. STUDY DESIGN: To determine the utility of intraoperative frozen-section analysis in cases of a cytological diagnosis of follicular neoplasm, a retrospective review of 66 patients with a solitary thyroid nodule and follicular neoplasm who underwent thyroid surgery was carried out. METHODS: Fine-needle aspiration was classified following the Papanicolaou Society of Cytopathology Classification, and frozen section was defined as malignant or "deferred." If a malignant diagnosis was made by frozen-section analysis, a total thyroidectomy was carried out. The extension of thyroid surgery in the deferred cases was based on the definitive histological diagnosis. RESULTS: Sixty-four cases were classified as deferred, and two as suspect for malignancy. Among the 64 deferred cases, 15 were malignant in the final pathological findings, and 49 were benign. The two suspect cases were papillary carcinoma. Frozen-section analysis classified 2 of 17 (11.7%) cases as follicular variant of papillary carcinoma that could not be diagnosed by cytological study. However, these two cases had a strong clinical evidence of malignancy. CONCLUSION: The routine use of frozen-section analysis is useless in cases of cytological diagnosis of follicular neoplasm on fine-needle aspiration biopsy, because of the low probability of achieving the diagnosis of follicular carcinoma and the inability to provide additional information apart from the clinical and the cytological data.     

The role of fine needle aspiration in the evaluation of parotid masses

PURPOSE OF REVIEW: Fine needle aspiration is a safe diagnostic technique that is widely employed for lesions of the head and neck. Among head and neck sites, the parotid gland stands apart for the number, diversity and peculiarity of pathologic processes to target this structure. This matchless complexity has prompted a thoughtful discussion regarding the application of the fine needle aspiration to parotid masses--a discussion that has primarily focused on the reliability of the fine needle aspiration as a diagnostic tool, and on its utility in guiding patient management. RECENT FINDINGS: Recent studies have confirmed a high overall accuracy rate for fine needle aspiration evaluation of parotid masses, ranging from 90 to 95%. At the same time, these soaring accuracy rates cannot be uniformly anticipated across all diagnostic scenarios. Fine needle aspiration is notoriously unreliable in recognizing the malignant nature of the parotid carcinoma, providing its precise classification, and establishing its grade. A few malignant neoplasms are particularly prone to diagnostic error. Acinic cell carcinoma is frequently interpreted as benign or even nonneoplastic; and low-grade lymphomas are often discounted as inflammatory processes. SUMMARY: Parotid gland masses are not particularly conducive to diagnostic accuracy and precision by fine needle aspiration. Accordingly, indiscriminant reliance on the fine needle aspiration findings at the expense of the clinical, radiographic, and intraoperative findings is unwarranted. Whether one uses the fine needle aspiration routinely or selectively in patients with parotid masses, the fine needle aspiration findings should contribute to, not displace, the overall diagnostic impression.     

Fine needle aspiration biopsy of pediatric head and neck masses

OBJECTIVE: To determine if fine needle aspiration (FNA) can preclude the requirement for diagnostic open biopsy in suspicious pediatric head and neck masses. METHODS: The records of 40 children presenting to an inner city tertiary care hospital who underwent a total of 50 FNA biopsies during the years 1988-1999 were reviewed. From these 40 patients, 17 children, aged 3 months to 18 years, underwent both clinically indicated FNA biopsy and subsequent open surgical biopsy or excision. Outcome measurements included clinical resolution or surgical pathologic diagnosis. RESULTS: The 17 patients who underwent open surgical biopsy subsequent to the FNA had a total of 21 FNAs performed. Three of these patients had more than one needle biopsy prior to surgery. The histologic diagnosis of the surgical excision confirmed the FNA biopsy cytologic diagnosis in all but two cases. FNA cytologic diagnostic categories included reactive lymph node/non-specific inflammation (25 biopsies), benign cystic process (four), granulomatous disease (eight), malignant neoplasm (three), and benign neoplasm (one). Eight of nine FNAs initially non-diagnostic had either complete resolution of the mass or a diagnosis obtained by subsequent FNA or open biopsy. CONCLUSIONS: FNA is a valuable diagnostic tool in the management of children with the clinical presentation of a suspicious neck mass. The technique reduces the need for more invasive and costly procedures. Early surgical biopsy, however, should be considered in rapidly enlarging masses, in the presence of persistent systemic symptoms, and when repeated FNA cytology is non-diagnostic.     

Screening for lymph nodes in the neck with ultrasound

In a study of the value of ultrasound in staging patients with head and neck malignancies, we performed ultrasound of the neck. The results of this investigation were compared with palpation. A fine needle aspiration biopsy and/or histologic examination was carried out on lymph nodes which were found. One hundred and six patients were included in this study. In 44 of the patients no lymph nodes could be detected, either on palpation or by ultrasound examination. In the other 62 patients all palpable lymph nodes were also demonstrated by ultrasound. However, in 20 patients with negative palpatory findings, ultrasound revealed lymph nodes: 11 metastases and 9 benign nodes. In 40 patients an ultrasound guided fine needle aspiration biopsy (UGFNAB) was performed. In 85% of these patients a cytological diagnosis could be made. From these results we conclude that ultrasound and UGFNAB are of considerable value in staging head and neck malignancies.     

Clinical significance of fine-needle aspiration biopsy in major salivary gland tumors

We compared preoperative evaluations of 93 fine-needle aspiration biopsies (FNAB) of major salivary gland tumors done over a 5 year period with pathologic diagnoses of surgically resected specimens. The overall accuracy was 88.5%. Eight of 15 aspirates from malignant tumors were correctly diagnosed by FNAB, for a sensitivity of 53.3%, while 69 of 72 aspirates from benign tumors were correctly diagnosed by FNAB, for a specificity of 95.8%. Five malignant tumors diagnosed as benign by FNAB were squamous cell carcinoma, carcinoma in pleiomorphic adenoma, malignant lymphoma, low-grade mucoepidermoid carcinoma, and acinic cell carcinoma. The false negatives in the first 2 cases appeared to be due to inaccurate placement of the aspiration site. The other 3 cases showed lack of atypia, leading to a benign diagnosis. Malignant lymphoma is difficult to diagnose as malignant, even in properly aspirated specimens, so we recommend open biopsy when malignant lymphoma is suspected from physical and radiological examinations. A case confirmed pathologically as benign myoepithelioma was diagnosed as adenoid cystic carcinoma preoperatively, based on the finding of a cribriform pattern containing mucin. It should be borne in mind that myoepithelioma and adenoid cystic carcinoma are difficult to distinguish by FNAB. Although FNAB is useful in diagnosing major salivary gland tumors, its low sensitivity (high percentage of false negatives) is undesirable. It may thus be helpful in intraoperative decision-making when combined with frozen sectioning.     

Diagnostic value of needle biopsy and frozen section histological examination in the surgery of primary parotid tumors

The necessity of fine-needle aspiration biopsy (FNAB) in the diagnosis and treatment of parotid gland lesions is still controversial. We examined the accuracy of cytology and histology in a review of 128 parotid gland tumors who underwent surgery with FNAB, n = 102 and/or frozen section examination (FS), n = 94. The diagnostic sensibility and specificity for malignant or benign lesions was respectively 81.5% and 97.5% for FNAB and 75% and 100% for FS as compared with definite histology (110 tumors were benign and 18 malignant). Insufficient material for FNAB evaluation was found in 12 patients mainly with small tumors (p = 0.043) or with tumors located in the deep process of the parotid gland (p = 0.029). Surgery was inappropriate (superficial lobe resection for malignant tumor) because of 4 false negative FS diagnoses. FNAB offers valuable information in the diagnosis of nonsurgical lesions and permits to avoid FS if FNAB identify a benign lesion. FS remains mandatory if FNAB evaluation is not possible or suggests a neoplastic tumor.     

Parathyroid cysts: a case report and review of the literature.

OBJECTIVES/HYPOTHESIS: Parathyroid cysts are rare clinical entities. They frequently present as a clinical diagnostic problem. They may mimic solitary thyroid nodules. The purpose of the study was to review the literature and present a case of a 22-year-old euthyroid woman presenting with recurrent swelling in the neck. Her complaints included choking and dysphagia. Fine-needle aspiration of the mass revealed clear, watery fluid with an extremely high level of calcium and c-terminal midmolecule parathyroid hormone assay in excess of 8000 pg/mL. Treatment consisted of neck exploration and removal of a 6 x 5-cm cystic encapsulated mass. Pathological diagnosis revealed a benign parathyroid cyst. The role of needle aspiration in diagnosing thyroid masses and the importance of parathyroid hormone assay in diagnosing parathyroid cyst are emphasized.