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ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 177-181  

Computed tomography guided fine needle aspiration cytology of pulmonary mass lesions in a tertiary care hospital: A two-year prospective study


Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India

Date of Web Publication4-Feb-2014

Correspondence Address:
Kaushik Saha
42/9/2, Sashi Bhusan Neogi Garden Lane, Baranagar, Kolkata - 700 036, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.126333

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  Abstract 

Background: Percutaneous or transthoracic fine needle aspiration cytology (FNAC) is a rapidly emerging diagnostic modality to assess the nature of radiologically demonstrated lung lesions. Aims: The present study was conducted to evaluate the usefulness of computed tomography (CT)-guided FNAC in the diagnosis of pulmonary mass lesions. Materials and Methods: The present prospective study was carried out on 74 cases of radiologically diagnosed pulmonary mass lesions involving the periphery of the lung parenchyma with strong clinical suspicion of pulmonary neoplasm. CT-guided transthoracic fine needle aspiration was performed and cytology smears were stained with May-Grόnwald-Giemsa (MGG) stain and conventional Papanicolaou (Pap) stain. Smears were broadly categorized into unsatisfactory, benign, suspicious of malignancy and malignant lesion. The cytological diagnosis was compared with subsequent histopathology report where it was necessary. Results: A total of 74 cases of pulmonary mass lesions were included in the present study, of which 58 were males (78.4%). The mean age of the patients was 51.6 years, but the mean age in case of malignant lesions was 62.5 years. Cough was the most common respiratory symptoms (100%) followed by weight loss (91.9%) and fever (62.2%). Maximum cases of benign lesions were chronic non-specific inflammation (10.8%; 8 cases) followed by tuberculosis (8.1%). Regarding the malignant categories, non-small cell carcinoma, not otherwise specified (NOS) (13.5%; 10 cases) was the most common malignancy followed by adenocarcinoma (10.8%; 8 cases), small cell carcinoma (8.1%; 6 cases) and squamous cell carcinoma (6.7%, 5 cases) respectively. All the 38 cases of malignant lesions were confirmed by histopathology. Out of 10 cases of non-small cell carcinoma, NOS 4 cases were diagnosed histopathologically as poorly differentiated adenocarcinoma, 2 cases as high grade squamous cell carcinoma, 2 cases as large cell carcinoma, 1 case as pleomorphic carcinoma and 1 case as adenosquamous carcinoma. Conclusion: CT guided FNAC is a less expensive, simple, fast and reliable method for diagnosis of pulmonary mass lesions.

Keywords: Computed tomography, fine needle aspiration cytology, pulmonary mass


How to cite this article:
Sengupta M, Saha K. Computed tomography guided fine needle aspiration cytology of pulmonary mass lesions in a tertiary care hospital: A two-year prospective study. Med J DY Patil Univ 2014;7:177-81

How to cite this URL:
Sengupta M, Saha K. Computed tomography guided fine needle aspiration cytology of pulmonary mass lesions in a tertiary care hospital: A two-year prospective study. Med J DY Patil Univ [serial online] 2014 [cited 2020 May 25];7:177-81. Available from: http://www.mjdrdypu.org/text.asp?2014/7/2/177/126333


  Introduction Top


Percutaneous or transthoracic fine needle aspiration cytology (FNAC) is a rapidly emerging diagnostic modality to assess the nature of radiologically demonstrated lung lesions. [1],[2],[3] Early initiation of specific therapy is possible as FNAC helps to differentiate between benign and malignant nature. Fine needle aspiration with computed tomography (CT) guidance has accuracy and sensitivity of 76-96% for the detection of malignancy in lung nodules. [4],[5],[6],[7] The modality selected to diagnose a suspected lung cancer is based on the size and the location of the primary tumors. [8] Fear of neoplastic implantation in the needle track may have initially inhibited its use but have proven groundless. [9] Recognition of accuracy of FNAC and simpler methods of treating pneumothorax have brought this method within the reach of most hospital radiologist and pathologist. [10],[11],[12],[13] In this context, the present study was conducted to evaluate the usefulness of CT-guided FNAC in the diagnosis of pulmonary mass lesions.


  Materials and Methods Top


The present single-center, prospective, cross-sectional study was carried out in the Department of Pathology in association with the Department of Chest Medicine and Radiology on 74 patients of pulmonary mass lesions, who underwent CT-guided transthoracic fine needle aspiration after obtaining the proper approval from the ethical committee of the institution and informed consent from the patients, during the study period of 2 years (01.05.2009-30.04.2011). Patients having radiologically diagnosed peripheral pulmonary mass lesions that can be approachable through transthoracic FNAC with strong clinical suspicion of pulmonary neoplasm with their sputum samples negative for acid fast bacilli on three consecutive days were included in the study. The lesions that were surrounded by normal lung parenchyma without any CT evidence of endobronchial abnormalities were considered as peripheral pulmonary lesions. [14] Patients having a history of bleeding disorder, severe chronic obstructive pulmonary disease, pulmonary arterial hypertension, arteriovenous malformation, uncontrollable coughing, suspected echinococcal cyst and contralateral pneumonectomy were excluded from the study. Uncooperative patients, who were unable to suspend respiration on request, were also excluded. Before performing FNAC, a detailed history was taken and clinical examination was done. FNAC was performed as an outpatient procedure in the presence of a pathologist, radiologist and clinician after explaining the risks and benefits to the patients. An axial scan of area of interest was carried out to accurately localize the lesion and to judge the best patient positioning, i.e., supine or prone was judged depending on the shortest distance from the lesion to the visceral surface of lungs, except the presence of overlying skeletal structures or large pulmonary vessels. FNAC was performed in the pulmonary lesions using a 22-gauge disposable lumbar puncture needle with needle length 90 mm, which was introduced during the suspended respiration directing the tip of needle towards the lesion. When the tip of the needle reached the outer edge of the lesion, a repeat slice of the area of interest was taken to check the exact position of the tip. The aspirate was obtained by to and fro and rotating movements of the needle within the lesions by the pathologist using aspiration with a 10 ml syringe. No FNAC syringe gun was used. The aspirate was smeared on 5-6 slides and half of the slides were fixed in 95% ethyl alcohol. Air-dried smears were stained with May-Grünwald-Giemsa (MGG) stain, whereas alcohol-fixed smears were stained with conventional Papanicolaou (Pap) stain. A repeat slice in the area of interest was taken to rule out pneumothorax. The patients were kept under observation for 24 h and a chest X-ray was carried out after 24 h to rule out any subsequent development of pneumothorax. If there was no complication after 24 h of observation the patient was safely discharged from the hospital. Histopathological confirmation of the cytological diagnosis was done where it was necessary. Smears were broadly categorized into unsatisfactory, benign, suspicious of malignancy and malignant lesion depending on cytomorphologic features. The well-prepared, properly stained, well-visualized smears with minimum obscuring elements were considered as satisfactory smears and the smears, which failed to reveal any morphologic features to reliably distinguish benign from malignant specimens even after careful reexamination were diagnosed as suspicious of malignancy.


  Results Top


A total of 74 cases of pulmonary mass lesions were included in the present study, of which 58 were males (78.4%) and the rest 16 were females (21.6%). About 44 (59.5%) lesions were localized in the left lung [Table 1] and 30 (40.5%) in the right. The age of the patients ranged from 14 to 78 years with the mean age of 51.6 years, but the mean age in case of malignant lesions was 62.5 years. The size of the lesions varied from 1.8 to 7.6 cm. As per as the presenting symptoms were concerned, cough was the most common respiratory symptoms (100%) followed by weight loss (91.9%) and fever (62.2%). In the present study, 38 patients (51.4%) out of 74 patients were smokers. Cytological diagnoses were broadly classified [Table 2] into four major categories - unsatisfactory (8.1%), benign (32.4%), suspicious of malignancy (8.1%), and malignancy (51.4%). Among the benign lesions, maximum cases [Table 3] belong to chronic nonspecific inflammation (10.8%; 8 cases) followed by tuberculosis (8.1%), abscess (5.4%), granulomatous inflammation (4%) [Figure 1]a, Histoplasmosis (2.7%) [Figure 1]b and Aspergillosis (1.4%) respectively. We had used the Ziehl-Neelsen stain and periodic acid Schiff stain to confirm the suspected lesions of tuberculosis and fungal infections respectively. In the present study, a total of 38 malignant cases were detected by FNAC. Regarding the malignant categories, non-small cell carcinoma, not otherwise specified (NOS) (13.5%; 10 cases) [Figure 2]a was the most common malignancy followed by adenocarcinoma (10.8%; 8 cases) [Figure 2]b, small cell carcinoma (8.1%; 6 cases) [Figure 3]a and squamous cell carcinoma (6.7%, 5 cases) [Figure 3]b respectively. We had also received a single case of bronchioloalveolar carcinoma [Figure 4]a. All the 38 cases of malignant lesions were confirmed by histopathology, i.e., there was no false positive case. Out of six cases of suspected malignancy, four were diagnosed as malignant lesions and two were diagnosed as non-specific reactive and inflammatory changes. Thus, FNAC diagnosed and suggested malignancy in 44 cases and histopathologically 42 cases proved to be as malignant lesions. Regarding the type of malignancy, all the cases corroborated histopathologically except one case of cytologically diagnosed squamous cell carcinoma, which later proved to be an adenosquamous carcinoma. Out of 10 cases of non-small cell carcinoma, NOS 4 cases were diagnosed histopathologically as poorly differentiated adenocarcinoma, 2 cases as high grade squamous cell carcinoma, 2 cases as large cell carcinoma, 1 case as pleomorphic carcinoma and 1 case as adenosquamous carcinoma. We found one case each of metastatic hepatocellular carcinoma and renal cell carcinoma with known primary site of tumor. Cytologically diagnosed spindle cell sarcoma later proved to be as inflammatory myofibroblastic tumor. The primary site of the single case of malignant melanoma [Figure 4]b remained unknown.
Table 1: Clinical profile of the patients

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Table 2: Diagnostic categories of pulmonary mass lesions

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Table 3: Cytological diagnoses of benign and malignant pulmonary mass lesions

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Figure 1: (a) Photomicrograph showing a well-formed granuloma formed by epithelioid cells (May-Grünwald-Giemsa [MGG] ×400). (b) Cytological smear of Histoplasmosis showing intracellular organisms within the macrophages (MGG ×1000)

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Figure 2: (a) Photomicrograph showing non-small cell carcinoma, not otherwise specified (May-Grünwald-Giemsa ×400). (b) Photomicrograph showing features of adenocarcinoma having prominent vacuolated cytoplasm (Papanicolaou ×100)

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Figure 3: (a) Cytological smear of small cell carcinoma showing features of nuclear streaking, nuclear molding, scanty to absent cytoplasm and stippled nuclear chromatin (Papanicolaou [Pap] ×400) (b) Photomicrograph of squamous cell carcinoma showing large hyperchromatic nuclei and intercellular bridges (Pap ×400)

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Figure 4: (a) Photomicrograph showing cytological features suggestive of bronchioloalveolar carcinoma of lung (May-Grünwald-Giemsa [MGG] ×400) (b) Cytological smear of malignant melanoma showing disperse cells with macronucleoli (MGG ×400)

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  Discussion Top


Cytopathologic techniques have the potential to provide useful diagnostic information from specimens of pulmonary lesions obtained through minimally invasive procedures including expectorated sputum, washings, lavages, brushings and aspiration procedures. [15] In a study of more than 13,000 pulmonary fine needle aspiration (FNA) specimens from 436 institutions, the diagnostic sensitivity was 89% for the procedure itself and 99% for the pathologist's interpretation. [16]

FNA is of greatest benefit to patients for whom it spares a more invasive surgical procedure. Surgical intervention, in fact, can be avoided in up to 50% of patients with clinically suspected lung cancer. [17] With regard to the management of patients with primary lung cancer, the most important consideration is to discriminate between small cell and non-small cell carcinoma of the lung, which is possible in more than 95% of cases diagnosed by FNA. [18]

The cytology of the respiratory tract has been revolutionized by a combination of two factors: Evolution of highly sophisticated radiologic imaging techniques, making possible the precise visualization and localization of masses in the lungs and reintroduction of a sampling technique of such visualized lesions by inserting a fine bore needle into them. A fine needle attached to a syringe is passed through the chest wall or bronchial wall into the pulmonary mass visualized by fluoroscopy, CT or bronchoscopy. [19] Among the imaging modalities, CT is the most popular. [20]

Transthoracic FNAC has been recognized since the 1970's as a critically important diagnostic technique and is particularly valuable in the diagnosis of space-occupying lesions located in the periphery of the lung and in the mediastinum that are inaccessible to the bronchoscope and do not desquamate cells into the bronchial tree. CT or, less commonly, ultrasound is used to guide the direction and depth of insertion of the needle. The technique is used with increasing frequency to investigate pulmonary infiltrates as well as more discrete masses in the lung. [21] It is also considered the tool of choice for the morphological characterization of patients suspected of having small peripheral lung cancers (<2 cm). [22] A peripheral lung lesion is often an adenocarcinoma that represents a primary or metastatic neoplasm. This type of lesion is best approached by computer tomography guided needle aspiration/biopsy procedure combined with immediate cytologic evaluation for the best probability of attaining an adequate sample. [15]

In patients with lesions 5-10 mm in size, the prevalence of lung cancer ranges from 6% to 28% and for nodules over 2 cm it varies from 64% to 82%: Morphological characterization is necessary in all such patients. [23] In the present study, all the malignant lesions were larger than 2 cm in diameter.

Literature reveals that 70% of the primary lung cancers are diagnosed as non-small cell carcinomas, whereas small cell carcinomas are found to comprise around 20% of all primary lung tumors. [24]

Gangopadhyay et al. [25] observed 96% sensitivity and 100% specificity in diagnosing lung tumors by CT-guided FNAC. Adenocarcinoma (54.2%) was the most common malignant tumor in their study group. In our study, most common malignant tumor was non-small cell carcinoma, NOS. This difference is probably due to the smaller size of the sample. Mukherjee et al. [26] carried out their study on solitary pulmonary nodules and found most of the patients of malignant lesions (76%) were in the age group of 40-70 years and most were males (85%). They noticed 97.7% sensitivity and 100% specificity for CT-guided FNAC as a diagnostic procedure. These findings are comparable with our study. Mondal et al. [27] compared the findings of CT guided FNAC of pulmonary mass lesions and subsequent histopathological diagnosis. They observed almost perfect agreement between cytological and histological diagnosis. Fassina et al. [28] evaluated the role and accuracy of rapid on-site evaluation (ROSE) of CT-guided FNAC of lung nodules. They concluded FNA with ROSE as a safe and useful tool in the diagnostic work-up of lung cancer patients.

Finally, the reasons to explain discrepancies between cytological and histological diagnosis are manifold. Sampling bias and tumor heterogeneity are likely cause for the misdiagnosis. To improve diagnostic accuracy of FNAC, especially in poorly differentiated and doubtful tumors, it might be useful to integrate morphology with validated ancillary techniques, like immunocytochemistry. [29]


  Conclusion Top


CT guided FNAC is a simple, safe, minimally invasive and reliable procedure with good diagnostic accuracy for the diagnosis and categorization of pulmonary mass lesions. It can be safely utilized as an outdoor procedure in the diagnosis of lung masses.

 
  References Top

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