Computed Tomogram Guided Fine-Needle Aspiration Cytology of Lung and Mediastinal Masses: A Study of 166 Cases

Computed Tomogram Guided Fine-Needle Aspiration Cytology of Lung and Mediastinal Masses: A Study of 166 Cases

*Alam MA,1 Islam MR,2 Haque MR, Nath SK4

 Abstract
Computed tomogram guided fine needle aspiration cytology (FNAC) is an important and useful investigation to differentiate between benign and malignant lesions of lung and mediastinum. To evaluate the lung and mediastinal masses and to analyze and compare the results with cytological findings, 166 patients were retrospectively studied who underwent CT guided FNAC over a period of January 2015 to December 2016. The study was carried out in patients who presented with respiratory symptoms with a localized lung and mediastinal masses which were confirmed by radiologically was sent for FNAC. 155 cases of lung masses and 11 cases of mediastinal mass were included in this study. Patients’ age ranged from 15 to 95 year and the male to female ratio was 4:1. Radiologically, out of 166 cases, 140 cases were diagnosed as malignant, 8 cases as benign and 18 cases as inflammatory lesions. Cytologically, 146 cases were diagnosed as malignant, 20 cases were benign inflammatory lesion. Most common lung malignancy was squamous cell carcinoma (72 cases) followed by adenocarcinoma (32 cases), small cell carcinoma (10 cases), large cell carcinoma (8 cases), 18 cases of lung metastasis were seen. Compared to biopsy, CT guided FNAC shortens the diagnostic interval and helps in differentiating lung malignancy into different cytopathological types which aids in proper management of the malignant lesion. Out of 11 mediastinal masses 6 cases were malignant lymphoma, 3 cases specific inflammatory lesions (tuberculosis) and 2 cases was non-specific inflammatory lesions.

[Journal of Histopathology and Cytopathology, 2018 Jan; 2 (1):19-22]

Keywords: Computed tomogram, Cytology, Guided FNAC, Lung mass, Mediastinal mass.

 

  1. *Dr. Md. Ashraful Alam, Associate Professor, Department of Pathology, Rangpur Medical College. drashraful09@gmail.com
  2. Md. Rezaul Islam, Senior Consultant, Radiology & Imazing, Sadar Hospital, Nilphamari.
  3. Md. Rashedul Haque, Associate Professor, Department of Biochemistry, Rangpur Medical College.
  4. Professor Swapan Kumar Nath, Department of Radiotherapy, Rangpur Medical College.

 

* For correspondence

 Introduction

A Computed tomography (CT) guided fine needle aspiration cytology (FNAC) is a well known modality for characterization of mediastinal masses. CT guided FNAC of lung lesions is a well established technique for the cytologic diagnosis of peripheral malignant lung lesions, with a reported diagnostic accuracy rate more than 93% and a sensitivity rate less than 95%.1,2 It has been used to differentiate mediastinal masses into benign, malignant and inflammatory types. Furthermore, its use has been extended in differentiating lung malignancy into different cytopathological types which aids in proper management of the malignant lesions. CT guided FNAC is widely recognized technique in indeterminate mass. It is a simple diagnostic method of relatively low cost, with negligible mortality and limited morbidity.3 The accuracy of CT guided FNAC for discriminating benign from malignant lesion has been recorded to vary from 64% to 97%.4 Several post procedural complications have been reported for CT guided FNAC such as pulmonary hemoptysis and pneumothorax. The risk for developing pneumothorax has been observed to be 22% – 45% due to high sensitivity of CT in detecting pneumothorax.5 Relative contraindications to image guided FNAC are severe chronic obstructive airway disease, bleeding diathesis, contra lateral pneumonectomy and pulmonary arterial hypertension.6 The purpose of our study is to evaluate the accuracy of CT and CT guided FNAC in differentiating and recording the pathological spectrum of the mediastinal and lung masses.

 Methods

This is a retrospective study conducted in a private medical college hospital at Rangpur and two private laboratories in Rangpur city from Janary 2015 to December 2016.The study was carried out in 166 patients who presented with lung and mediastinal mass attended to different physicians and Rangpur Medical College Hospital and were sent for Fine needle aspiration cytology. Relevant clinical history and investigations were obtained from the patient to narrow down the differential diagnosis and to decide if patient was eligible for FNAC, such as history of bleeding diathesis, thrombocytopenia, dyspnea, uncontrolled cough, other feature of chronic obstructive airway diseases (COPD), pulmonary arterial hypertension etc. CT guided FNAC was performed in patients with peripheral lung and mediastinal mass or masses which were only approachable by spinal needle. Patient inclusion criteria included: cooperative patient who was able to hold breath for a short while, no bleeding tendency, patient who was to undergo chemo or radio-therapy and lesions not approachable by USG. Informed and written consent was taken from the patient explaining the risk and benefits of the procedure. Axial section of the area of interest was taken after a scanogram. A feasible approach was judged and the patient positioned accordingly with radiopaque marker placed at the site of puncture. Then under all aseptic precaution aspiration done by 21-22 G spinal needle and 10 cc disposable syringe and smear was prepared in glass slide for fixation in 95% alcohol. Routine Papaniculau stain were done in all cases.

 Results

The data were collected from January 2015 to December 2016. Our study included 166 patients, out of which 155 with lung and 11 with mediastinal mass were subjected to CT guided FNAC. Their ages ranged from 15 to 95 years with mean age of 65 years (Table I). The male to female ratio was 4:1. Out of 155 lung  malignant cases squamous cell carcinoma (Fig 1, 72 cases) was the commonest followed by adenocarcinoma ( fig 2, 32 cases), 10 cases of small cell carcinoma, 8 cases of large cell carcinoma were seen. Out of 18 cases of metastatic tumors, 10 cases were from gastrointestinal tract, 2 cases from testis and 6 cases from thyroid follicular carcinoma (Table IV). Out of 15 inflammatory cases 7 cases was specific inflammatory (tuberculosis) 8 cases was non- specific inflammatory lesion was observed. (Table IV). Out of 11 mediastinal masses 6 cases were malignant lymphoma,3 cases ware specific inflammatory lesions(tuberculosis) and 2 cases were non-specific inflammation was observed (Table V).

Table I: Age distribution (n=166)

Age Groups
(Years)
Male Feamle Total %
15-25 6 3 9 5.42%
26-35 5 3 8 4.81%
36-45 13 4 17 10.42%
46-55 24 13 37 22.28%
56-65 30 12 42 25.30%
66-75 34 3 37 22.28%
>75 15 1 16 9.6%

 

Table II: Sites of the lesions (n=166)

Sites No %
Pulmonary 155 93.37
Mediastinal 11 6.62

Table III: Lung lesions by site and sex

 

Sex Site
Right Lung Left lung Total
Male 102(76.69%) 31(18.67%) 133(80.12%)
Female 20(60.60% 13(39.39%) 33(19.87%)
Total 122(73.49%) 44(26.50%) 166

 

Table IV: CT guided FNAC diagnosis of intrathoracic and mediastinal masses (n=166)

 

Cytological Findings: No(%)
Squamous cell carcinoma 72(43%)
Adenocarcinoma 32(19.27%)
Small cell carcinoma 10(6.02%)
Large cell carcinoma 8(4.81%)
Metastatic carcinoma 18(10.84%
Malignant Lymhoma 6(3.61%)
Specific Inflammatory lesions(TB) 10(6.02%)
Non specific inflammatory lesion 10(6.02%)

 

Table V: CT guided FNAC diagnosis of mediastinal masses (n=11)

 

Cytological Findings: No (%)
Malignant lymphoma 6(54.54%)
Specific Inflammatory lesion(TB) 3 (27.27%)
Non-specific inflammatory lesion 2(18.18%)

TB=Tuberculosis

 

 

 

 

 

 

Figure 1. Photomicrograph of sqamous cell carcinoma of lung (Cytopathology)

 

 

 

 

 

Figure 2. Photomicrograph of adeno carcinoma of lung (Cytopathology)

 Discussion

CT guided transthoracic FNAC is a safe and accurate means of diagnosing benign and malignant intrathoracic lesions. In this study, Out of 166 patients 5.42% were in the age group from 15-25 years and 25.30%were in the age group of 56-65 years which is not similar with the study of Sarker RN et. al 7 who found patients of intra-thoracic mass 36% in the age group ranging from 46-55 years and 21% in the age group of 56-65 years, these two groups were predominant in terms of age. There were 133  male (80.12%) and 33 female (19.67%). In the study of Sarker RN et. al7 out of 100 cases there were 77 men (77%) and 23 (23%) were women. This correlates with the well-known fact that intrathoracic mass occurs most commonly in older age group and in males than in females. Female cases are less because malignant pulmonary lesions are less in females in our population. Male: Female ratio was 4:1 in our study. That is similar to the study done by Ahmed et al.8 The locations of the pulmonary lesions were in right lung 122 (73.49%), and 44 (26.50%) in left lung. In the study of Ahamad et al8 lesion in right lung was 98 (60.49%), in left lung 64 (39.41). In the final diagnosis, squamous cell carcinoma was the commonest malignant tumour followed by adenocarcinoma and metastatatic carcinoma. These findings are similar to the findings of the study done by Mostafa et al9 although his study was not guided by CT and the number of cases was less. Our experience is similar to the study of Singh et al10 where fatal complications like tension pnemothorax, air embolism, endo bronchial haemmorhage etc were absent. The complication rate depends on the distance of the lesion from pleura and lesion size. The more the amount of the lung tissue traversed by the needle the more was the complication rate and smaller the lesion the more was the complication rate. In this study fine needle of 21- 22G was used where the chance of complication seems to be minimum which correlates well with the study of Zavala et al.11  Saha A et al12 in their series have reported cases of mediastinal masses, 3 (5.6%) cases was NHL and (1cases) was Hodgkin’s lymphoma.In our study 6 cases (54.54%) was malignant lymphoma. This discrimination may be due to total number of cases.

Conclusion

This study concludes that CT guided lung and mediastinium needle aspiration cytology by spinal needle is a highly effective procedure in the diagnosis and sub- classification of mass lesions. It is a relatively simple, cost effective procedure with good patient compliance and low morbidity. The use of CT-guided FNAC of intrathoracic mass lesions reduces the diagnostic interval and cost. It also avoids unnecessary thoracotomy for diagnostic purposes. As the facilities continue to improve; it is likely to have a greater role in the initial evaluation of intrathoracic and mediastinal mass in the near future.

 References

  1. Wallace MJ, Krishnamurthy S, Broemeling LD, Gupta S,Ahrar K, Morello FA Jr, et al. CT-guided percutaneous fine needle aspiration biopsy of small (<1 cm) pulmonary lesions. Radiology 2002; 225:823-8.
  2. Laurent F, Latrabe V, Vergier B, Mountadon M, MernejouxJM, Dubrez J. CT-guided transthoracic needle biopsy of pulmonary nodules smaller than 20 mm: results with an automated 20-gauge coaxial cutting needle. Clin Radiol 2000; 55:281-7.
  3. Santambrogio L, Nosotti M, Bellaviti N et al. CT Guided Fine Needle Aspiration Cytology of Solitary Pulmonary Nodules. Chest1997; 112:423-5.
  4. Mohammad GM. CT guided fine needle aspiration cytology in diagnosis of thoracic lesions. JIMA 2001; 99(10):1-5.
  5. Herman PG, Hessel SJ. The diagnostic accuracy and complications of closed lung biopsies. Radiology 1977; 125:11-4.
  6. Hensell DM: Interventional techniques. In Armstrong P,Wilson AG, Dee P, et al (eds): Imaging Of Diseases Of TheChest. 2nd ed . St. louis, Mosby, 1995, p. 894-912.
  7. Sarker RN, Rabbi AF, Hossain A, Quddus MA, Chowdhury N, Sarker T. Computed tomography guided transthoracic fine needle aspiration cytology in the diagnosis of Sonographically non-approachable intrathoracic masses-A study of 100 cases.J Dhaka Med Coll 2011; 20(1):25-31.
  8. Ahmed S, Ahamad M S U. Computed tomography guided fine needle aspiration cytology of lung lesions: A study of162 cases. JCMCTA 2009; 20 (1):50-2.
  9. Mostafa MG. Computed tomographic guided fine needle aspiration cytology in the diagnosis of thoracic lesions. J Indian Med Assoc 2001; 99(10): 550-3.
  10. Singh JP, Garg L, Setia V. Computed tomography (CT) guided transthoracic needle aspiration cytology in difficult thoracic mass lesions – not approachable by USG. IJRI, 2004; 14(4):395-400.
  11. Zavala DC, Bedell GN. Transthoraciclung biopsy with a cutting needle. Am Rev Respir Dis 1972; 106: 186-93.
  12. Saha A, Kumar K, Choudhuri M K. Computed tomography – guided fi ne needle aspiration cytology of thoracic mass lesions: A study of 57 cases. J cytol 2009; 26 (2):55-9.

 

CT Guided FNAC of Lung Mass – A Retrospective Study of Disease Spectrum

CT Guided FNAC of Lung Mass – A Retrospective Study of Disease Spectrum

 *Ahmed Z,1 Israt T,2 Raza AM,3 Hossain SA,4 Shahidullah M5

 

Abstract

Lung cancer is the major cause of cancer related deaths all over the world. CT guided FNAC of lung mass is an effective modality to diagnose lung cancer. The study was carried out in a specialized diagnostic center at the district of Feni, Bangladesh. A total of 100 cases were studied for a period of 2 years from July 2015 to July 2017. Aim of our study was to evaluate the pathological spectrum of diseases in the lesions of the lung  through CT guided FNAC. Total 100 cases were evaluated retrospectively for a period of 2 years. Out of 100 cases 66% were male and 34% patients were female. Mean age was 54. 34 years. In 56 cases lesions were at the right lung and in 44 cases were in left lung. 68%  cases had malignant lesion and 32% cases were have inflammatory conditions. Squamous cell carcinoma was the predominant malignant tumour. Among the complications, 2 cases developed pneumothorax which were managed conservatively, 3 had chest pain, 3 had mild haemorrhage from the lesion area and 1 had breathlessness. All were managed conservatively. CT guided FNAC can diagnose pulmonary lesion fairly accurately leading to early diagnosis which causes less morbidity and mortality as treatment can be started early.

[Journal of Histopathology and Cytopathology, 2018 Jul; 2 (2):109-113]

Keywords: Computed tomography (CT), FNAC, Lung mass.

 

  1. *Dr. Zaman Ahmed, Assistant Professor of Pathology, Abdul Malek Ukil Medical College, Noakhali. drzahmed74@gmail.com
  2. Tasnim Israt, Assistant Professor of Pathology(CC), Cumilla Medical College, Cumilla.
  3. AKM Maruf Raza, Associate Professor of Pathology, Jahurul Islam Medical College, Kishoregonj .
  4. Shaikh Alamgir Hossain, Senior Consultant (Pathology), Bangladesh Secretariat Clinic, Dhaka.
  5. Mohammad Shahidullah,  Associate Professor (CC) of Medicine,  Abdul Malek Ukil Medical College, Noakhali.

 *For correspondece

Introduction

Computed tomography (CT) guided fine needle aspiration cytology (FNAC) is a well known modality for characterization of lung masses. It has been used to differentiate lung masses into benign, malignant and inflammatory types. Furthermore its use has been extended in differentiating lung malignancy into different cytopathological types which aids in proper management of the malignant lesion. CT guided FNAC is widely recognized technique in evaluating lung mass. It is a simple less invasive diagnostic method of relatively low cost, with negligible mortality and limited morbidity.1 In 1976 Haaga and Alfidi reported CT guided biopsy and since then this procedure has be shown to be both effective and accurate. The diagnostic accuracy is reported to be more than 80% in benign disease and more than 90% in malignant disease.2 Several post procedural complications have been reported for CT guided FNAC such as pulmonary hemorrhage, hemoptysis and pneumothorax. Pneumothorax has been observed to be 22% – 45% due to high sensitivity of CT in detecting pneumothorax.3 Relative contraindications to image guided FNAC are severe chronic obstructive airway disease, bleeding diathesis, contralateral pneumonectomy and pulmonary arterial hypertension.4

In Bangladesh CT guided FNAC of lung lesion is relatively a newer diagnostic technique and done mostly in the major cities. The purpose of this study was to evaluate the disease spectrum of lung lesion by CT guided FNAC in a district level diagnostic center.

Methods

The study was carried out in a specialized diagnostic center in the district of Feni. A total of 100 cases were studied for a period of 2 years from July 2015 to July 2017. CT guided FNAC was performed by pathologist in co-ordination with radiologist. Risk and benefit were explained and informed consent taken from each patients or his/her relatives. Skin was cleaned by betadine and 22G spinal needle was introduced through percutaneous transthoracic approach. The exact position of lesion was established by CT scan with site, angle, depth and route of needle introduction was determined. After the needle placement, CT scan done to ascertain that the tip of the needle was within the mass. The aspirate was obtained by to and fro movement of needle within the mass. All slides were fixed in 95% ethyl alcohol and were stained with papaniculaou stain.  All the slides were evaluated by an experienced pathologist. Patients were kept under observation for 2 hours to see any immediate complication.

 Statistical analysis

Microsoft Excel 2016 was used to generate tables. Only descriptive statistics were used to infer results.

 Results

Out of 100 cases 66 were male and 34 were female. Age group was from 25 years to 90 years with mean age of 54.34 years. In 56 cases lung lesion was in right lung and 44 cases were in left lung. Among 56 right lung lesion 45 were male and 11 were female. In 44 left lung lesion 31 were male and 13 were female (Table I).

Among 100 cases, 32 cases were inflammatory or benign lesion. Among the benign lesion, tubercular inflammation were the most common, accounting for 15 cases followed by chronic non specific inflammation 14 cases, suppurative inflammation 2 cases and Benign cystic lesion 1 case. 68 cases were malignant with squamous cell carcinoma exceeding adenocarcinoma, 35 and 25 cases respectively. Small cell carcinoma were 6 cases and poorly differentiated carcinoma were 3 cases (Table II).

Among the complications, 2 cases developed pneumothorax who were managed conservatively, 3 had chest pain, 3 had mild haemorrhage from the lesion area and 01 had breathlessness. All were managed conservatively (Table III).

Figure I show a radiological picture showing needle tip at the lesional site. Figure Ii and figure III show  picture of cytopathological slides of tubercular granuloma and adenocarcinoma respectively.

 

Table I: Lung lesion by site and sex (n=100)

 

Sex Site
Right lung Left lung Total (%)
Male 45 31 66 (66%)
Female 11 13 34 (24%)
Total 56 (56%) 44 (44%) 100 (100%)

Table II: Spectrum of disease in lung lesion on CT guided FNAC (n=100)

Disease Number of cases %
Squamous cell carcinoma 35 35
Adenocarcinoma 25 25
Small cell carcinoma 06 6
Undifferentiated carcinoma 02 2
Tubercular granuloma 15 15
Chronic nonspecific inflammation 14 14
Suppurative inflammation 02 2
Benign cystic lesion 01 1
Total 100 100

 

Table III: Complication of CT guided FNAC in this study (n=9)

Complication Number of cases %
Pneumothorax 02 22.2%
Chest pain 03 33.3%
Mild hemorrhage from overlying skin 03 33.3%
Breathlessness 01 11.1%
Total 09 100%

 

 

 

 

 

 

 

 

Figure 1. Showing needle inside the lung lesion

 

 

 

 

 

 

Figure 2. Showing tubercular granuloma in lung (Paps stain, 40X)

 

 

 

 

 

 

Figure 3. Showing adenocarcinoma of lung (Paps stain, 40X)

Discussion

CT guided transthoracic needle aspiration cytology is safe and accurate method for diagnosis and categorization of malignant and benign lesion. Accuracy of procedure varies in range from 64% to 97%.3 In this present study, 100 cases were studied over a period of 2 years time period. Conclusive cytodiagnosis were made in all the 100 cases. Most Patients tolerated the procedure well. Most common complaint was pain at the procedure site and mild bleeding at the skin puncture site which subsided without medicine in 2 hours. Two cases had pneumothorax which was mild and resolved conservatively. No chest tube insertion was needed. All the cases were adult. The mean age was 54.34 years similar to other studies. Mondal et al and Singh et al in their study found mean age 56.6 years and 56.4 years respectively, which is similar to our study.5,6 This indicates lung mass lesion especially malignant lung tumour come to clinical attention at middle to old age. There was male preponderance (66%) among the patients undergone FNAC for lung lesion. In this study, out of 100 patients male patient were 66% and female patient were 34%. Percentage of male patients in the studies by Saha et al7 78.9% and Tan et al8 71.1%. Bandyopadhyay et al9 found male patient 80.6%  which is high to other study and also high comparing to this study.

Out of the 100 cases, 32% were inflammatory or benign condition and 68% cases were malignant tumour. Mondal et al had benign lesion in 8.07% and malignant lesion in 91.93%.cases.5 This high percentage of malignant patient in this study and study done by Mondal et al probably due to as most of the inflammatory conditions are now a days effectively treated by antibiotics. The tuberculosis cases and malignant cases are non responsive to antibiotics and they suffer chronically and come to diagnostic CT guided FNAC.

The incidence of squamous cell carcinoma (35% cases) was higher than adenocarcinoma (25% cases) in our study similar to the study by Shah S.10 In their study, most common tumour was squamous cell carcinoma (45%) followed by adenocarcinoma (22%), small cell carcinoma (16%) and large cell carcinoma (8%).11 In his study adenocarcinoma was the most common malignant tumour. In that study, adenocarcinoma cases were 30%, squamous cell carcinoma 22.5% and undifferentiated carcinomas was 7.5%. The proportion of adenocarcinoma has risen in the last fifteen years. Adenocarcinoma is the most common histological type in women and the rising proportion of women in the lung cancer population is undoubtedly a factor in the relative increase in the incidence of adenocarcinoma.12

 Conclusion

CT guided FNAC is a well accepted, simple, accurate, safe and cost effective method for diagnosing a lung lesion with low morbidity rates. Combined with CT the aspiration needle can be guided safely into the lesion to improve the diagnosis of the cytological material. CT guided FNAC provides early diagnosis and sub classification of the lung masses hence directing the clinicians in proper management. Complication due to this procedure is not high and can be managed conservatively.

 References

  1. Martin HE, Ellis EB. Biopsy by needle puncture and aspiration. Ann Surg. 1930 Aug;92(2):169-81.
  2. Geraghty PR, Kee ST, Mc Farlane G, Razavi MK, Sze DY, Dake MD. CT-guided transthoracic needle aspiration biopsy of pulmonary nodules: needle size and pneumothorax rate.Radiology.2003 Nov;229(2):475-81.
  3. Herman PG, Hessel SJ. The diagnostic accuracy and complications of closed lung biopsies. Radiology. 1977 Oct;125(1):11-4.
  4. Mohammad GM. CT guided fine needle aspiration cytology in the diagnosis of thoracic lesions. JIMA 2001:99(10):1-5.
  5. Mondal SK, Nag D, Das R, Mandal PK, Biswas PK, Osta M. Computed tomogram guided fine-needle aspiration cytology of lung mass with histological correlation : A study in Eastern India. South Asian J Cancer. 2013 Jan;2(1):14-8. doi: 10.4103/2278-330X.105881.
  6. Singh JP, Garg L, Setia V. Computed tomography guided fine needle aspiration cytology in difficult thoracic mass lesions-not approchable by USG. Indian J radiology. Imaging 2004 May:14:395-400.
  7. Saha A, Kumar K, Choudhuri MK. Computed tomography-guided fine needle aspiration cytology of thoracic mass lesions: A study of 57 cases. J Cytol. 2009 Apr;26(2):55-9. doi: 10.4103/0970-9371.55222.
  8. Tan KB, Thamboo TP, Wang SC, Nilsson B, Rajwanshi A, Salto-Tellez M. Audit of transthoracic fine needle aspiration of the lung : cytological subclassification of bronchogenic carcinomas and diagnosis of tuberculosis. Singapore Med J. 2002 Nov; 43(11):570-5.
  9. Bandyopadhyay A, Laha R, Das TK et al. CT guided fine needle aspiration cytology of thoracic mass lesions: A prospective study of immediate cytological evaluation : Indian J pathological Microbiology. 2007 Jan; 50(1) : 51-5.
  10. Shah S, Shukla K, Patel P. Role of fine needle aspiration cytology in diagnosis of lung tumours-a study of 100 cases. Indian J Pathol Microbiol. 2007 Jan; 50(1):56-8.
  11. Madan M and Bannur H. Evaluation of FNAC in lung disease. Turk J pathology. 2010 Nov; 26(1): 1-6.
  12. Arslan S, Yilmaz A, Bayramgurler B, Uzman O, Unver E, Akkaya E: CT-guided transthoracic fine needle aspiration of pulmonary lesions: accuracy and complications in 294 patients. Med Sci Monit 2002, 8: 493-497.