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jhc-2019-jul-v-3-n-2-ultrasound-ahmed-nu

Ultrasound Guided Fine Needle Aspiration Cytology and Histopathology in the Diagnosis of Ovarian Mass

 *Ahmed NU,1 Saha NK,2 Bhowmik DK,3 Mazumder AR,4 Shariar S,5 Hira AD,6 Keya SA7

  1. *Dr. Nasir Uddin Ahmed, Assistant Professor, Department of Pathology, Faridpur Medical College. nasirdr32@yahoo.com
  2. Naba Kumar Saha, Professor, Department of Pathology, Sylhet MAG Osmani Medical College.
  3. Dilip Kumar Bhowmik, Professor, Department of Gynaecology & Obstetrics, Sylhet MAG Osmani Medical College.
  4. Ashikur Rahman Mazumder, Professor, Department of Radiology & Imaging, Sylhet MAG Osmani Medical College.
  5. Sakib Shariar, Pathologist, Railway General Hospital, Dhaka.
  6. Ananda Dyuti Hira, Pathologist, Department of Pathology, Khulna Medical College.
  7. Shamim Ara Keya, Lecturer, Department of Pathology, Shaheed Suhrawardy Medical College, Dhaka.

* For correspondence

 Abstract

Objective: The study was designed to evaluate the efficacy of ultrasound guided fine needle aspiration cytology in the diagnosis of ovarian mass and to correlate with histopathological diagnosis.
Methods: This  cross sectional study was done on 60 patients. FNA smears were prepared before surgical procedure. Histopathological examination was done by collection of surgical specimens. Cytomorphological findings were noted and correlated with histomorphological diagnoses.
Results: The age of patients ranged from 16 to 70 years with a mean of 36 years. Study showed 59 (98.33%) were unilateral and 1(1.67%) tumor was bilateral. Among 60 histopathologically diagnosed cases, 7(11.67%) were non-neoplastic cysts, 40 (66.67%) were benign tumors, 2(3.33%) were borderline tumors, 10(16.67%) were malignant tumors and 1 (1.66 %) was inflammatory lesion. All hemorrhagic cysts and cystic lesions were considered benign because they were cytologically negative for malignancy. Concordant diagnosis between cytology and histopathology was in 57 (95%) cases.
Conclusion: USG guided FNAC showed a relatively safe, quick, cost effective and patient compliant procedure with minimal morbidity.

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):117-124]

 Key words: Ultrasound Guidance, Fine Needle Aspiration Cytology, Histopathology, Ovarian Mass.

 Introduction

Tumors of the ovary are incredibly varied. This multiplicity is due to the presence of three cell types in the normal ovary: the multipotent surface (coelomic) epithelium, the totipotent germ cells, and the sex cord–stromal cells, each of which gives rise to a number of different tumors.1 The clinicopathological evaluation of ovarian masses is a challenging field. Difficulty in gaining access to the tumor site is itself a major obstacle and the wide spectrum of lesions present an enigmatic picture to the pathologist. Although histopathology remains the gold standard, in recent times image guided aspiration is being increasingly used as a rapid, inexpensive and efficient method for the pre-surgical diagnosis of ovarian masses as well as planning and evaluation of treatment.2 Historically, gynaecologists are hesitant to aspirate ovarian masses in view of the possibility of seeding of an early stage ovarian cancer. The magnitude of risk of such a procedure is unknown and not substantiated by convincing evidence. It is rather overestimated and has not been pathologically confirmed.3

 However, a lot of studies have clearly documented that risk of tumor spreading by needle tract is negligible in comparison to the potential benefits of this simple, quick and effective modality of diagnosis.4 With sonographic support, any structure visualized radiologically can usually be reached precisely in any desired plane, thus increasing the cytological yield. Nevertheless, as with any technique, image-guided FNAC has its short comings; false-negative results are usually due to failure of the needle to enter the mass and failure to sample representative areas.5 In the preoperative diagnosis of ovarian masses, acellular fluid should not be considered non-diagnostic, because it represents benign cysts in a majority of the cases. Literature search failed to trace any study to see the effectiveness of USG guided FNAC in comparison with histopathology in the diagnosis of ovarian masses in our country. With this background, the study was designed to evaluate the efficacy of ultrasound guided fine needle aspiration cytology in the diagnosis of ovarian mass and to correlate with histopathological diagnosis.

 Methods

The cross sectional study was carried out in the Department of Pathology, Sylhet MAG Osmani Medical College, Sylhet in collaboration with the Department of Obstetrics and Gynaecology and Department of Radiology and Imaging, Sylhet MAG Osmani Medical College Hospital, Sylhet from 1st July 2014 to 30th June 2015. All patients with ovarian masses attended the inpatient department of Obstetrics & Gynaecology were considered as the target population and those who fulfilled the inclusion and exclusion criteria were considered as study population. Patient of all ages with ovarian mass were included in this study and patients with hemorrhagic diathesis, those who refused to undergo  USG guided FNAC and surgery, diagnosed cases under treatment and ovarian mass with pregnancy were excluded from this study. Aspirations were done by expert radiologist in radiology and imaging department. The tumors were located by USG and needle was inserted into the lesion without negative pressure. The content of the needle was expelled on to a glass slide and then allowed the aspirated material to spread by gently pulling apart two slides in opposite direction. The smeared slides were promptly dropped in 95% ethyl alcohol for fixation and kept for at least 30 minutes. This smears were then stained according to Papanicolaou method. The cytopathological examination of the stained slides was carried out on the same day or following day. Surgical specimens were collected from all patients in whom USG guided FNAC were done. All the specimens were preserved in 10% formalin. Routine tissue processing with paraffin impregnation was done and stained with hematoxylin and eosin. The diagnoses of ovarian tumors were done according to the cytopathological and histopathological findings and then cytopathological diagnoses were compared with the histopathological diagnoses.

After meticulous checking, all the relevant collected data were compiled first on a master table. Then the data were organized by using scientific calculator and standard computer based statistical software SPSS-21. Percentages were calculated to find out the proportion of the findings. The results were presented in tables, graphs and diagrams. The efficacy of USG guided FNA cytology for the diagnosis of ovarian mass was determined by calculating sensitivity, specificity, positive predictive values, negative predictive values and accuracy.

 Results

Total 62 cases were selected considering inclusion and exclusion criteria. Tissue for histopathological examination was available in 60 cases for comparison with cytopathological diagnosis. The age of patients ranged from 16 to 70 years with a mean of 36 years. Highest frequency 18 (29.03%) was found in 21- 30 age group (Table-I).

Categorization of neoplastic ovarian masses according to cell of origin

 Of the 60 histopathologically diagnosed cases, benign, borderline and malignant tumors were 40, 2 and 10 respectively. Among the benign tumors, surface epithelial tumors, germ cell tumors and sex cord-stromal tumor were 30, 9 and 1 respectively. All the malignant and borderline tumors were surface epithelial in origin. Table II shows categorization of neoplastic ovarian masses according to cell of origin.

All the smears obtained from USG guided FNA of ovarian masses were satisfactory for cytological evaluation and cytological diagnosis was made in most of the smears. Among 62 cases, 31(50%) were diagnosed as benign tumors, 7 (11.29%) were borderline tumors, 4 (6.45%) were malignant tumors, 1(1.61%) was inflammatory lesion and 19 (30.65%) were benign cystic lesions. Cytopathological diagnoses of ovarian masses are shown in Table III.

 Histopathological diagnoses of ovarian masses

Among 60 histopathologically diagnosed cases, 7(11.67%) were non-neoplastic cysts, 40 (66.67%) were benign tumors, 2(3.33%) were borderline tumors,10(16.67%) were malignant tumors and 1 (1.66 %) was inflammatory lesion.  Histopathological diagnoses of ovarian masses are shown in Table IV.  

Histopathological examination of 60 ovarian masses was performed and comparison between cytological and histopathological diagnoses of ovarian masses is shown in Table V.

Discussion

In present study, age of the patients ranged from 16 to 70 years. The maximum number of cases 18 (29.03%) were seen in third decade which is  similar to the studies done by Sengupta et al & Agarwal et al.4,6 Ellenson and Pirog found maximum number of cases in  third & fourth decades.7  Among the 40 benign tumors, 39 (97.50%) cases were found unilateral and 1 (2.50%) case was bilateral. All the malignant, borderline and non-neoplastic lesions were found unilateral in this study. Ray S  reported that 76.56% of non-neoplastic lesions and benign tumors were unilateral and 23.44% were bilateral, 35.71% malignant tumors were unilateral and 64.29% malignant tumors were bilateral.8 This discrepancy is probably due to small sample size in the current study. On gross evaluation of the 60 ovarian masses, 46 (76.67%) were cystic, 2(3.33%) were solid and 12 (20%) were partly solid and partly cystic (mixed). Ray S  reported 64 benign tumors, of which 51(79.69%) were cystic, 7(10.94%) were solid and 6(9.37%) were mixed. Of the 14 malignant tumors, 2(14.28%) were cystic, 7(50%) were solid and 5(35.72%) were mixed in consistancy.8 These findings are  almost similar to the findings of this study. In the present study, among the 52 neoplastic ovarian masses, 42 (80.77%) were surface epithelial, 9 (17.30%) were germ cell and 1(1.93%) was sex- cord stromal origin. Out of 40 benign tumors, 30(75%) were surface epithelial, 9(22.5%) were germ cell and 1(2.5%) was sex- cord stromal origin. All borderline and malignant tumors were found surface epithelial in origin. Similar findings were found in study by Tushar, Asaranti and Mohapatra.9 They showed out of67 ovarian tumors, 53(79.10%) were surface epithelial, 11(16.41%) were germ cell, 1(1.50%) was sex-cord stromal origin and 2 (2.98%) cases were metastatic tumors. In the present study, out of 62 USG guided FNA of ovarian masses, 31(50%) were benign tumors, 7(11.29%) were borderline tumors, 4(6.45%) were malignant tumors, 1(1.61%) was inflammatory lesion and 19(30.65%) were benign cystic lesions.

Agarwal et al. reported 110 USG guided FNA diagnoses of ovarian masses. Out of 110 ovarian masses, 17 (15.50%) were non-neoplastic, 50 (45.5%) were benign and 43 (39%) were malignant tumors.6 In the present study, cytologically mucinous cystadenoma was the most common benign tumor accounting for 12 (19.35%) and mucinous cystadenocarcinoma was the most common malignant tumor accounting for 2(3.23%). Most of the internationally published journal shows, cytologically most common benign tumor is serous cystadenoma and most common malignant tumor is serous cystadenocarcinoma.3,5,6,10 The findings of present study differ from the findings of internationally published journal which may be due to small sample size. If large sample size was taken, the findings of our study might coincide with the findings of international journals. In histopathological diagnosis of 60 cases, 7(11.67%) were non-neoplastic cysts, 40 (66.67%) were benign tumors, 2(3.33%) were borderline tumors, 10(16.67%) were malignant tumors and 1 (1.66 %) was inflammatory lesion. Similar findings were found in study of 77 cases by Ray et al.3  Out of 77 cases, 43 (55.84%) were benign, 22 (28.57%) were malignant and 12 (15.59%) were non-neoplastic lesions. In the present study, histopathologically most common benign tumor was serous cystadenoma accounting for 16 (26.66%) and most common malignant tumor was mucinous cystadenocarcinoma accounting for 6(10%). Agarwal et al. reported that the most common benign tumor was serous cystadenoma accounting for 17 (24.63%) and most common malignant tumor was serous cystadenocarcinoma accounting 10 (14.50%).6 These findings are partially consistent with the current study. Among the 31 cytologically diagnosed benign tumors, 29 cases were diagnosed correctly in histopathology and 2 cases were diagnosed as malignant tumor. Cytologically diagnosed 4 malignant tumors were also diagnosed as malignant in histopathology. In cytologically diagnosed 7 borderline tumors, histopathologically 04 were malignant, 2 were borderline and 1 was benign tumor. One inflammatory lesion diagnosed correctly both in cytology and histopathology. All 17 benign cystic lesions diagnosed cytologically, were also benign in histopathology. Concordant diagnosis between cytology and histopathology was in 57 (95%) cases.

 Conclusion

USG guided FNAC is a relatively safe, quick, cost effective and patient compliant procedure with minimal morbidity and fair diagnostic accuracy. In the preoperative diagnosis of ovarian masses, acellular fluid should not be considered non-diagnostic, because it represents benign cysts in a majority of the cases. False negative results are due to paucicellularity and secondary degenerative changes of epithelial cells. Most of the hospitals in our country are not equiped with frozen section facilities.  USG guided FNAC has particular value as a preoperative diagnostic procedure where frozen section facilities are not available. USG guided FNAC in the diagnosis of ovarian masses can be practised in any centre where the help of sonologist and cytopathologist is available.

 References

  1. Sattar HA. Female Genital System and Breast. In: Kumar V, Abbas AK, and Aster JC, eds. Robbins Basic Pathology, 9th ed. Philadelphia, USA: Elsevier Saunders 2013: pp.681-714.
  2. Afzal S, Ansari H, Ansari M, Maheshwari V, Mehdi G. Image- guided fine-needle aspiration cytology of ovarian tumors: An assesment of diagnostic efficacy. Journal of Cytology 2010; 27(3): 91-95.
  3. Ray S, Gangopadhyay M, Bandyopadhyay A, Majumdar K, Chaudhury N. USG guided FNAC of ovarian mass lesions: A cyto-histopathological correlation, with emphasis on its role in pre-operative management guidelines. Journal of the Turkish German Gynecological Association 2014; 15: 6-12.
  4. Sengupta S, Mondal R, Bose K, Ray R, Jana S, Deoghoria D. Evaluation of role of ultra sound guided fine needle aspiration cytology for diagnosis of ovarian lesions with particular references to diagnostic pitfalls. Bangladesh Journal of Medical Science 2014; 13(2):158-162.
  5. Goel S, Agarwal D, Goel N, Naim M, Khan T, Ekrammulah. Ultrasound guided fine-needle aspiration cytology in ovarian neoplasms: An assesment of diagnostic accuracy and efficacy and role in clinical management. The Internet Journal of Pathology 2010; 11(2): 1-10.
  6. Agarwal N, Garg S, Aggarwal N, Santwani PM. Ovarian Neoplasm: Diagnostic accuracy of ultrasound guided fine needle aspiration cytology with histopathological correlation. IOSR Journal of Dental and Medical Sciences 2014; 13(7): 24-28.
  7. Ellenson LH, Pirog EC. The Female Genital Tract, In: Kumar V, Abbas AK, Fausto N, Aster, JC, eds. Robbins and Cotran Pathologic Basis of Disease, Philadelphia, USA: Elsevier Saunders 2010: pp.1039 -1052.
  8. Ray S. The role of imprint cytology in the diagnosis of ovarian lessions [ M. Phil thesis]. Sylhet MAG Osmani Medical College 2008,
  9. Tushar K, Asaranti K, Mohapatra PC. Intra-operative cytology of ovarian tumors. The Journal of Obstetrics and Gynaecology of India 2005; 55(4): 345-349.
  10. Khan N, Afroz N, Aqil B, Khan T, Ahmad I. Neoplastic and non-neoplastic ovarian masses: Diagnosis on cytology. Journal of Cytology 2009; 26(4):129-133.
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jhc-2019-jul-v-3-n-2-concurrent-sharmin-s

Concurrent Core Needle Biopsy with Fine Needle Aspiration Biopsy in The Diagnosis of Palpable and Clinically Suspicious Breast Lesions

 *Sharmin S,1 Dewan MR,2 Jinnah SA,3 Sharmin R,4 Runa NJ,5 Ambiya AS,6 Rahman N,7 Afrin SS,8 Hussain M9

 

  1. *Dr. Shegufta Sharmin, Assistant Professor, Department of Pathology, US Bangla Medical College, Dhaka. sheguftasharmin1982@gmail.com
  2. Md. Rezaul Karim Dewan, Professor & Head, Department of Pathology, Dhaka Medical College, Dhaka.
  3. Shahed Ali Jinnah, Associate Professor, Department of Pathology, Dhaka Medical College, Dhaka.
  4. Rumana Sharmin, Lecturer, Department of Pathology, Dhaka Medical College, Dhaka.
  5. Nusrat Jahan Runa, Assistant Professor, Department of Pathology, Dhaka Central Inrernational Medical College, Dhaka.
  6. Ahmed Shahed e Ambiya, Resident Medical Officer, Department of Medicine, Holy Family Red Crescent Medical College Hospital, Dhaka.
  7. Najibur Rahman, Assistant Professor (Rtd), Department of Pathology, Dhaka Medical College Hospital, Dhaka.
  8. Syeda Sadia Afrin, Resident, Department of Pathology, Dhaka Medical College Hospital, Dhaka.
  9. Maleeha Hussain, Professor of Pathology Department, Dhaka Medical College Hospital, Dhaka.

 *For correspondence

Abstract

Background: Breast lump is one of the most common surgical problem in female patients. Though excision biopsy of palpable breast lump is considered to be the gold standard method for diagnosis, there should be an improved and definitive method for establishing an accurate diagnosis of breast masses prior to surgery.
Objectives: The aim of this study was to determine the diagnostic accuracy of concurrent fine needle aspiration biopsy (FNAB) and core needle biopsy (CNB) in cases of suspicious breast lesions and to study the discordance between them.
Methods: This descriptive cross sectional study included 72 female patients with breast lumps, presented to Dhaka Medical College Hospital over a period of two years and subsequently underwent concurrent FNAB and CNB in the same sitting. The results were then compared with final histopathological findings and the correlations between FNAB and CNB were determined.
Results: Out of 72 cases included in the study, histopathological diagnosis was available in 42 cases. There were four false negative cases in FNAB (14.28%) and two false negative cases (7.14%) in CNB.  The false negative rate in the combined approach was 3.57% which is lower than the rate in individual tests. The sensitivity of combined approach was 96.5%, where FNAB and CNB had 85.71% and 92.85% respectively. The specificity and positive predictive value of both FNAB and CNB were individually 100%, so the concurrent result was also the same. The diagnostic accuracy of combined FNAB and CNB was higher than individual results, which was statistically significant (p<0.05).
Conclusion: Concurrent FNAB and CNB can provide accurate preoperative diagnosis of breast lesions and provide important information for appropriate treatment. Identification of discordant results and, therefore, careful correlation can reduce false negative rate.

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):107-116]

 Key Words: Breast lesions, FNAB, CNB, Histopathology

Introduction

Breast cancer is the second most common cancer in the world and the most frequent cancer among women with an estimated 1.67 million new cancer cases diagnosed in developing countries in 2012.1 Breast cancer is the leading cause of cancer death in women in the less developed regions (324,000 deaths, 14.3% of total) and the second cause of cancer death in the more developed countries  (198,000 deaths, 15.4%) after lung cancer.2 According to the Globocan estimate, more than half of the 1.67 million new breast cancer cases were diagnosed in developing countries in 2012 which is about 52.9%, whereas the corresponding figure for 1980 was only 35%.3,4 In Bangladesh, the number of new cases of breast cancer in the year 2008 was 17,781.5

Breast cancer usually presents with a palpable breast lump. Most breast lumps are benign and of no serious consequence. Fine needle aspiration biopsy (FNAB) and core needle biopsy (CNB) are both used in the evaluation of breast lesions and play an important role in the management.6 Both have their specific advantages and limitations. Recent studies have shown the high accuracy and cost effectiveness of FNAB to identify cancer in patients with palpable breast lump.7

FNAB is often used as a first priority investigation in patients with breast lump, but this technique is highly dependent on the skill and expertise of the aspirator.8 FNAB cannot confirm the presence of tumor invasion and therefore cannot be used to differentiate between invasive and in situ neoplasia. In addition, low grade breast lesions, such as atypical ductal hyperplasia, ductal carcinoma in situ and tubular carcinoma cannot be accurately diagnosed using this modality alone. Therefore, erroneous diagnosis can occur due to sampling error or due to misinterpretation.

Tru cut biopsy, also known as core needle biopsy (CNB) is now one of the most useful means of obtaining histopathological diagnosis.9 Besides, core biopsy allows the discrimination between in situ and invasive lesions and is a more accurate method to distinguish between invasive ductal and invasive lobular carcinoma.9 A well sampled CNB specimen usually has greater diagnostic efficacy and provides more tissue for ancillary studies.10 However, CNB still has some pitfalls.11 In some cases, even with image guidance, CNB can miss the lesion and yield inadequate material.12 During the procedure, blood vessels may be injured by large bore needles; in such cases the invasive biopsy procedure will only yield clotted blood on repeated puncture.13 In these instances, core biopsies cannot produce adequate samples which in turn will cause a delay in the histological interpretation.

If FNAB and CNB are used concurrently in cases of suspicious breast lesions, the sensitivity and specificity may be better than either alone.

This study was aimed to find out the diagnostic accuracy of concurrent CNB and FNAB of palpable and clinically suspicious breast lesions.

 Methods

The present cross sectional study was carried out in the Department of Pathology, Dhaka Medical College over a period of two years from January 2015 to December 2016. Female patients of any age group with clinically suspicious and palpable breast lumps who were advised for FNAB or CNB were enrolled and were subjected to concurrent FNAB and CNB in the same sitting with their informed written consent.

With proper aseptic measures, fine needle aspiration was done using a 5 cc or 10 cc disposable syringe for each puncture and for each patient and two to six smears were prepared in glass slides for each patient according to need.  The core needle biopsy was performed by an automated biopsy device equipped with a 14 gauge needle having a sample notch of 15 mm in length. Samples were obtained from different areas of the lesion, usually from the center and close to the borders at the 3, 6, 9 and 12 O’clock positions and were placed in a vial containing 10%  neutral buffered formalin. For each CNB procedure, the number of biopsies taken was recorded. The outcomes of FNAB and CNB were reported using the standard National Health Service Breast Screening Programme (NHSBSP) criteria.

In this study, histopathological examination of mastectomy or lumpectomy or excisional biopsy was considered as gold standard. Statistical analysis of the results was obtained by window based computer software devised with Statistical Packages for Social Sciences (SPSS).

 Results

A total 72 cases were included in the study in whom FNAB and CNB were performed, and subsequently lumpectomy or mastectomy specimen were available in 42 cases. Histopathological diagnosis was the gold standard of the study. Individual and combined FNAB and CNB were compared and validity test results were calculated. It was observed that the majority (44.4%) of patients belonged to the age group of 31-40 years. The mean age was found 40.94±7.9 years with range from 28 to 62 years (Table I).


More than one third (43%) of the samples were cytologically diagnosed as malignant, 07(9.72%)were diagnosed as suspicious and 09(12.5%) showed atypia. 25(34.72%) cases were cytologically diagnosed as benign(Table II). On the other hand in CNB, 34 (47.2%) cases were found to be malignant cases, 26(36.11) benign , 06 suspicious of malignancy, 05(6.94%) of uncertain malignant potential and 01 (1.38%) unsatisfactory tissue (Table III). Finally, after histopathology of the 42 cases, where surgical biopsy were available, 28(66.66%) cases were confirmed as malignant and 14(33.33%) cases were found to have benign lesions. It was observed that 25(59.52%) patients with duct cell carcinoma was the most frequent diagnosis, followed by 2(4.8%) papillary carcinoma and 1(2.3%) lobular carcinoma (Table IV)

Of the 20 malignant cases and 4 suspicious cases diagnosed by FNAB, all proved to be malignant by histopathology. Among the 05 cases presented with atypia in FNAB, 4 were diagnosed histologically as malignant and 1 was benign. None of the benign cases diagnosed by FNAB was otherwise in histology (Table V).Of the 19 patients diagnosed as malignancy by CNB, 17(79.2%) were diagnosed as duct cell carcinoma, 01(100.0%) as lobular carcinoma and 01(100.0%) as papillary carcinoma by histopathology (Table VI). All 07 suspicious cases in CNB were histologically diagnosed as malignancy and the 04 cases presented with atypia in CNB, ultimately diagnosed as benign in 03 cases and malignant in 01 case (Table VI).

ith concurrent FNAB and CNB, true positive cases were 27 in number, true negative cases were 14 and false negative cases was 1 in number. There were no false positive case (Table VII). In the present study, the sensitivity of FNAB is 85.71%, specificity 100%, PPV (positive predictive value) 100%, NPV (negative predictive value) 77.77% and accuracy 90.47%. In comparison, the sensitivity of CNB is 92.85%, specificity 100%, PPV (positive predictive value) 100%, NPV (negative predictive value) 87.5% and accuracy 95.23%. When both FNAB and CNB are combined, the sensitivity is 96.05%, specificity 100%, PPV (positive predictive value) 100%, NPV (negative predictive value) 93.33% and accuracy 97.61% (Table VIII). So the combined results are superior to FNAB or CNB alone (p<0.05) statistically significant


Discussion
Fine needle aspiration biopsy and core needle biopsy currently are the most widely used methods for pathological diagnosis of breast lumps. They have their specific advantages and limitations. To minimize the limitations of individual procedure, in the current study simultaneous FNAB and CNB was used for the diagnosis of clinically suspicious and palpable breast lumps. Results of the combined approach were compared with FNAB and CNB separately.

With a population of over 163 million, Bangladesh is one of the most densely populated countries in the world.14 Not much information on breast cancer in Bangladesh is available as there is no population based cancer registry in our country. However, the only hospital based cancer registry at the National Institute of Cancer Research and Hospital tracks new cancer cases systematically in this country. According to NICRH report, 5255 breast cancer cases were diagnosed during the period of 2005-2010.15,16 The data of NICRH states that breast cancer has overtaken cervical cancer as the most common female cancer in Bangladesh. (Breast cancer cases 26% and cervical cancer cases 21.1% during the period 2008-2010: NICRH, Cancer registry report).16

In the present study, a total of 72 cases of clinically suspicious and palpable breast lumps were included. FNAB and CNB were done in all of them but surgical biopsy was available in 42 cases only. Of these 42 cases, 28 were malignant and 14 were benign. The firm to hard consistency, irregularity and larger size of the lumps in these 14 benign cases made them to be clinically suspicious. Histopathology was the gold standard in this study and the validity test results of FNAB and CNB were evaluated and compared with it.

In this study, among the 48 cancer patients diagnosed either by core needle biopsy or fine needle aspiration biopsy, age ranged from 33 years to 62 years with a mean age of 42.5 years. In this present study, 26(54.16%) cancer patients out of 48 malignant cases were premenopausal and 22(45.83%) cases were postmenopausal.

Fine needle aspiration biopsy is a routine procedure in the diagnosis of breast lesions in our laboratories. It is a relatively rapid, inexpensive, maintains tactile sensitivity and allows multidirectional passes allowing a broader sampling of the lesions and immediate reporting where it is necessary. However, it has some limitations in the assessment of tumor invasion, tumor grade or receptor status. In this perspect, use of core needle biopsy has been shown to be an excellent tool while working with the tissue specimens because it permits the evaluation of both the architectural and cytological patterns and provides adequate material to perform diagnostic ancillary studies.

However, the performance of CNB has a few disadvantages. Missampling can occur, even with image guidance.12 Improper processing of small tissue fragments may lead to tissue distortion and challenge sample adequacy. These technical errors or missampling can lead to false negative results. The study showed that the sensitivity of FNAB was 85.71% in the diagnosis of breast cancer with a false negative rate of 14.28%. The specificity was 100%. This result is similar to other studies done by Mahmood H. Hasssan in Iraq (2014).17 Mohammed Bdour et al (2008) in Pakistan18 and Tiwarie M. in Nepal (2007).19

All four false negative cases in FNAB belonged to proliferative breast disease with atypia group. The false negative results of FNAB were mainly due to underestimation of cellular atypia.

In our study, CNB had a sensitivity of 92.85% and specificity of 100% in the diagnosis of breast cancer. The false negative rate was 7.14%. The results are comparable to others studies done by Mahmood H. Hasssan in Iraq(2014),17 Mohammed Bdour in Pakistan (2008),18 Karimian F. in Iran (2008),9 AD Baildum in UK (1989)19 and Stanley Minkowitz in USA (1986)20 which showed 95.0%, 90.0%, 98.07%, 95.0% and 89.0% sensitivity, respectively .

We found that, there were two false negative cases in CNB. Out of the two cases, one showed cystic change in ultrasonography. The repeated missing of the lesion in core biopsy may be due to this cystic change. . In this case as FNAB could cover much more area, it yielded adequate material from solid area.

Though accuracy of CNB is superior to FNAB,to minimize the limitation, the aim of pathologist should be to diagnose all the breast cancers confidently and not a single case should be missed. With this aim, the concurrent FNAB was done in this study and it showed sensitivity of 96.5%. In this present study, the number of cores taken from each patient was four or above. The combined approach of FNAB and CNB yielded better diagnostic accuracy than FNAB and CNB alone. The sensitivity of combined approach is 96.5%, where FNAB and CNB had 85.71% and 92.85% respectively. The specificity and positive predictive value of both FNAB and CNB are individually 100%, so the concurrent result is also the same. The 100% specificity of FNAB or CNB should not be generalized for all breast lesions in this study, because all the cases in the present study had breast lumps more than 2 cm in size and all were palpable.

The false negative rate in the combined approach was 3.57% which is lower than the rate in individual tests (14.28% in FNAB and 7.14% in CNB). A false negative diagnosis may delay the treatment of breast cancer. The concurrent examination of FNAB and CNB reduced the false negative rate by 50 %(7.14% to 3.57%), in comparison to CNB alone.

Conclusion
It is established that CNB is superior to FNAB regarding sensitivity and specificity. 9,10,11,13 In our country with poor resource setting, guided FNAB and CNB are not always possible. So to increase the sensitivity and to reduce the numbers of false negative cases of CNB, combined approach are helpful.

Reference
1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D and Bray F. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. International journal of cancer, 2015;136(5):359-86.
2. Globocan, IARC 2012 IARC, 2012. Latest world cancer statistics Global cancer burden rises to 14.1 million new cases in 2012: Marked increase in breast cancers must be addressed. http://globocan.iarc.fr.
3. IARC, 2012. Latest world cancer statistics Global cancer burden rises to 14.1 million new cases in 2012: Marked increase in breast cancers must be addressed. http://globocan.iarc.fr.
4. Forouzanfar MH, Foreman KJ, Delossantos AM, Lozano R, Lopez AD, Murray CJ and Naghavi M, Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis. The lancet, 2010; 378(9801):1461-84.
5. IARC, 2008. World cancer report 2008. International Agency for Research on Cancer. http://globocan.iarc.fr/
6. Cochrane RA, Singhal H, Monypenny IJ, Webster DJT, Lyons K and Mansel RE. Evaluation of general practitioner referrals to a specialist breast clinic according to the UK national guidelines. European Journal of Surgical Oncology (EJSO), 1997; 23(3):198-201.
7. Touhid Uddin Rupom, Tamanna Choudhury, Sultana Gulshana Banu. Study of Fine Needle Aspiration Cytology of Breast Lump:Correlation of Cytologically Malignant Cases with their Histological Findings. BSMMU J, 2011;4(2):60-64.
8. Yong WS, Chia KH, Poh WT and Wong CY. A comparison of trucut biopsy with fine needle aspiration cytology in the diagnosis of breast cancer. Singapore medical journal, 1999;40(9):587-89.
9. Karimian F, Aminian A, Hashemi E, Meysamie AP, Mirsharifi R and Alibakhshi A. Value of core needle biopsy as the first diagnostic procedure in the palpable breast masses. Shiraz E Medical Journal, 2008;9(4):188-192.
10. Pieter J, Westenend Ali R, Sever, Hannie JC., Beekman-de Volder et al. A comparison of Aspiration Cytology and Core Needle Biopsy in the evaluation of breast lesions. Cancer cytopathol 2001,93:146-150.
11. Liberman L, Dershaw DD, Rosen PP, Giess CS, Cohen MA, Abramson AF and Hann LE. Stereotaxic core biopsy of breast carcinoma: accuracy at predicting invasion. Radiology, 1995;194(2):379-81.
12. Yao-Lung Kuo, Tsai-Wang Chang. 2010, :Can concurrent core biopsy and fine needle aspiration biopsy improve the false negative rate of sonographically detectable breast lesions? BMC cancer, 2010;10(371):1-7.
13. Berner A, Davidson B, Sigstad E, Risberg B. Fine needle aspiration cytology vs. core biopsy in the diagnosis of breast lesions. Diagnostic cytopathology, 2003;; 29(6):344-8.
14. CIA. The world factbook; 2014.
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17. Mahmood H. Hassan Ahmed R, HizamSafa, M. Al-Obaidi. The role of Tru-cut needle biopsy in the diagnosis of palpable breast masses. J Fac Med Baghdad, 2014;56: 292-295.
18. Mohammed Bdour, Saleh Hourani, WaseemMefleh, Ashraf Shabatat, Samer K.A. Radsheh, et al. Comparision between Fine needle aspiration cytology and Tru-cut biopsy in the diagnosis of breast cancer: Journal of surgery Pakistan international 2008: 13; 19-21.
19. Tiwari M. Role of fine needle aspiration cytology in diagnosis of breast lumps.Kathmundu University Medical Journal, 2007;5:215-17.
20. Baildam AD, Turnbull L, Howell A, Barnes DM and Sellwood RA, 1989. Extended role for needle biopsy in the management of carcinoma of the breast. British Journal of Surgery, 1989;76(6):553-58.
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Analysis of the Diagnostic Value of Cytological Smear Method Versus Cell Block Method in Pleural Effusion Fluid of Suspected Lung Cancer Patients

 *Ray S,1 Zinnah SA,2 Awal N,3 Hassan I,4 Dewan RK,5 Jeba R,6 Hussain M7

 *Dr. Subrata Ray, Assistant Professor, Department of Pathology, Jashore Medical College. subrataray29@gmail.com

  1. Shahed Ali Zinnah, Associate Professor, Department of Pathology, Dhaka Medical College.
  2. Dr . Naila Awal , Assistant Professor, Department of Pathology, Greenlife Medical College.
  3. Imran Hassan, Assistant Professor(CC), Department of Pathology, (Col) Malek Medical College, Manikgonj.
  4. Rezaul Karim Dewan, Professor and Head, Department of Pathology, Dhaka Medical College
  5. Dr . Ruksana Jeba, Associate Professor, Department of Pathology, Dhaka Medical College.
  6. Dr Maleeha Hussain, Professor, OSD, DGHS.

 *For correspondence

 Abstract

Background: For any kind of lungs pathology accompanying pleural effusion pleural biopsy guided with thoracoscopy, of course, may provide important results. Since biopsy is an invasive procedure, the priority is to do,  a cytological examination of pleural fluid obtained with thoracentesis, which  is very crucial for the disease staging and treatment strategy. In this purpose, even though conventional cytosmear techniques have been used generally till this day, cell block technique is also being used recently.
Methods: In our study, 100 pleural effusion fluid sample were included. All the fluid specimen was subjected to cytosmear (CS) and cytoblock (CB).
Results: By using conventional CS method, 85 fluid specimens were diagnosed as negative for malignancy (85%), 5 cases were diagnosed as positive for malignancy (5%) and the remaining 10 cases were diagnosed as suspicious for malignancy (10%). On the contrary by using CB, complimented by combined PAS-Alcian blue stain where required, 90 cases were diagnosed as negative for malignancy (90%) and 10 cases were diagnosed as positive for malignancy. Thus, by the CB method, an additional 5 more cases were diagnosed as positive for malignancy, that is, 5% more diagnostic yield for malignancy.
 Conclusion: CB technique could be considered as a useful adjunct in evaluating malignant cells in MPE for a final cytodiagnosis, along with the routine CS method.

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):99-106]

 Key Wards: Cell block , Pleural effusion , Lung cancer 

Introduction

Development of pleural effusion is a common complication in patients with lung cancer either primary or secondary. There may be presence of neoplastic cells in the pleural effusion which is called malignant effusion (MPE) or it may be a para-malignant effusion, which is  pleural effusion with absence of cytological evidence of tumor cells in a known setting of malignancy. In UK, 40000 people per year are affected by MPE and it is estimated that up to 50% of the patients  with metastatic malignancy  develop a pleural effusion – either at the time of diagnosis or during the evaluation of cancer.1,2,3  The common etiologies of MPE are lung cancer, breast cancer, lymphoma, ovarian cancer and gastric cancer in order of decreasing percentage.

For any kind of lung lesion accompanying pleural effusion, pleural biopsy guided with thoracoscopy, of course, may provide important results, but has the risk of being an invasive procedure and it depends on the experience and efficiency of the surgeon. So, in a country with poor resource settings, the priority should be a cytologic examination of pleural fluid obtained by thoracentesis. It not only helps in diagnosis but also can help in disease staging and treatment strategy.4

In conventional cytological smear (CS), discrimination of the reactive mesothelial cells and malignant cells is the most important diagnostic problem. Distinguishing benign from malignant cellular changes may require meticulous screening, careful scrutiny of cellular features and an understanding of the range of reactive changes. Since the introduction of cell block (CB) technique by Bahernburg nearly a century ago,  it has been used routinely for processing fluid.5 CB has the advantage of recognition of the histological pattern of disease, possibility of study multiple sections by routine staining, special staining and immunological procedures.

In this study, we assessed the utility of CB and CS techniques and evaluated whether the CB, when it complements conventional CS, can increase the diagnostic yield.

Methods

This is an analytic study, carried out at the Department of Pathology, Dhaka Medical College, Dhaka from  July 2015 to  June 2017, over 100 pleural effusion fluid specimen of suspected lung cancer patients.

 10 ml of fresh pleural fluid sample was obtained by thoracentesis from each patient during clinical evaluation. Each sample was divided into two equal parts.

For conventional smear technique, 5 ml fluid specimen was centrifuged at 2500 rmp for 10 min. A minimum two smears were prepared from the sediment. They were immediately fixed in 95% alcohol and stained with the Papanicoloau and Haematoxylin- Eosin stain.

 

For cell block, we used AAF (95% ethyl alcohol + acetic acid + 10% formalin). After centrifuge at 2500 rmp for 10 min, cell sediments were mixed with thrice the volume of AAF fixative and again centrifuged at 2000 rmp for 10 min. The centrifuged tube was aside undisturbed for six hours. The cell button was scraped out and wrapped in filter paper and processed in automatic tissue processor for routine histopathological sections. The cell blocks were embedded in paraffin and sectioned at 4 micro meter thickness.

 The samples were studied in detail taking into account the available clinical and radiological data and various investigation reports. Each individual slide was objectively analyzed for cellularity, background blood, nuclear and cytoplasmic details and arrangement of the cells using the point scoring system described by Mair et al., (1989).6 All these criteria were put together and each cases was categorized as Benign, Suspicious for malignancy and Malignant effusion. Special stain of cell blocks, including combined PAS-Alcian blue stain was done whenever needed. In cases, where pleural biopsy of the same patients was available, used to confirm the diagnosis.

Results

In our study, 100 pleural effusion fluid sample were included. The age-rang from 26 to 82 years. Most of the patients are between the age group 51-60 years (30%). The male female ratio was 1.8:1. All the fluid specimen was subjected to CS and CB. By using connectional CS method, 85 fluid specimens were diagnosed as negative for malignancy (85%), 5 causes were diagnosed as positive for malignancy (5%) and the remaining 10 causes were diagnosed as suspicious for malignancy (10%).On the contrary by using CB, complimented by combined PAS-Alcian blue stain where required , 90 cases were diagnosed as negative for malignancy (90%) and 10 cases were diagnosed as positive for malignancy. Thus by the CB method, an additional 5 more cases were diagnosed as positive for malignancy, that is, 5% more diagnostic yield for malignancy .

Among the 10 malignant cases, diagnosed by CB, 9 cases were subcategorized as adeno carcinoma (90%) and 1 cases was diagnosed as lymphoma.

The malignant effusion was more common in male (70%) than female (30%). The male female ratio was 7:3.

When the cytological smear and cell block techniques were studied for their quality using the point scoring system of Mair et al, (1989).6  it was noticed that 5% of the CS and 6% of the CB was inadequate and unsuitable for diagnosis. 50% of the CB and 32% of the CS showed highest cellularity. 41% of the CB and only 11% of the CS yielded highest morphological details. Wilcoxon Signed Rank test was done to measure the level of significant, which was highly significant in CB compared to CS regarding cellularity and morphological details.


Table V: Distribution of patients according to point scoring system adopted by Mair et al,(1989)6 in CS

 

 

Discussion

Lung cancer, whether primary or secondary, is invariably accompanied by pleural effusion. The cell population in sediment of pleural fluid represent much larger surface area than obtained by needle biopsy.  Malignant cells first involve the visceral pleura and tend to be focal in the parietal pleura.7 This explains why, pleural fluid cytology is a more sensitive diagnostic test than closed percutaneous pleural biopsy.8,9

Thoracentesis followed by cytological examination is the first investigation performed in a pleural effusion fluid of a suspected lung cancer patients and has been accepted as a routine laboratory procedure. The differentiation of a malignant effusion from a para-malignant effusion is extremely important, not only in the diagnosis of a malignant lesion, but also in staging, prediction of prognosis and to reform a proper treatment protocol.10

In our study, 100 pleural effusion fluid specimen of radiologically and clinically suspected lung cancer patients were examined by using conventional CS and CB techniques. In CS, of 85 patients, the fluids were diagnosed as negative for malignancy (85%).

All the 85 negative cytosmear cases were confirmed by CB. In conventional CS method 10 cases were diagnosed as suspicious for malignancy, of which 5 cases turned to be negative and another 5 cases   proved to be positive for malignancy in CB. In conventional CS method, reactive mesothelial cells, an abundance of inflammatory cell and paucity of representative cells contributed to the considerable difficulties in making conclusive diagnosis of malignancy.

The false positive diagnosis in CS was secondary to the marked atypia of the mesothelial cell which may be due to the microbiological, chemical, physical, immunological or metabolic insult to the serous membrane or due to the subtle cytomorphological features of some malignant neoplasm, particularly well differentiated adenocarcinoma.11 The problem was compounded by artifact   caused by poor fixation, preparation and staining technique. In our settings, fixation and transportation are contributory factors. Generally the reactive mesothelial cells appears rounded and have single centered or eccentric nucleus. Some of the mesothelial cells form cell ball, clusters and takes a signet-ring cells appearance, thus closely mimicking malignancy. The malignant cells have irregular nuclear membrane, nuclear molding and prominent nucleoli with absence of windows. However, these differentiating features are sometimes difficult to identify.

By using CB method, 5 more malignant cases were diagnosed, which were diagnosed as suspicious for malignancy by conventional CS, thus increasing the diagnostic yield by 5% (5/10). Further special stain (PAS-Alcian blue) supported the diagnosis of malignancy.

Another 5 cases were diagnosed as negative for malignancy by CB, which were diagnosed as suspicious for malignancy by conventional CS. The benign cells did not take PAS-Alcian blue stain.

In a parallel study on effusion fluid, Shivakumaraswamy et al, (2012)5 found   15% more diagnostic yield for malignancy on CB.   Bhanvadia et al., (2014)12 in another study observed    10% more diagnostic yield in CB. Thapar et al, (2009)4  also   showed 13% more diagnostic yield by CB.

In our study, after the final diagnosis as benign or malignant effusion, a critical evaluation was made for diagnostic yield taking a consideration on cellularity, morphology, architecture and background blood. The conventional CS and CB technique were studied for their quality by using point scoring system of Mair et al, (1989).6 In CB, 41% ensured highest morphological details where as in CS, highest morphological detail was acquired in only 11% cases. The comparative result of our point scoring system was analyzed by Wilcoxson Signed Ranks test which was highly significant in respect of cellularity and cellular morphology.

Reactive mesothelial cells have in the past been responsible for simulating malignancy in CS, largely due to the formation of rosettes, pseudo acini or acini, with or without the presence of prominent nucleoli. The CB effectively puts both the features in their proper prospective. That is, the nucleoli does not appear as prominent in CS and the pseudoaciner or acinar strictures can be better appreciated when present in the CB. Similar findings were noticed in the Dekker and Bapp (1978)(13) study. More important is, this CB is a valuable tool in the evaluation of well differentiated adenocarcinoma, where the presence of true acini is seen in the CB with mucin. Positive stain  for mucin in CB  indicated  malignancy.

In our study, we noticed a significant number of macrophages admixed with malignant cells having large pleomorphic nuclei simulating malignant cells. Multiple large PAS positive granules were identified by special stain that were diagnosed as suspicious for malignancy by CS. We also noticed pericellular lacunae in many of the cases of adenocarcinoma specially of mucin secreting type, characterized by cell clusters and Bull’s eye (Target) inclusion like finding was seen in one case of metastatic carcinoma.

There had not been yet any standard method for the preparation of CB from effusion fluid. Our study was done by using 10% alcohol formalin fixative. In our paraffin embedded CB section our attention was drawn by the presence of large clusters of cells either malignant or reactive mesothelial cells in a separate peripheral layer leaving a  thick amorphous proteinaceous material in the center. These helped in reducing background artifact and ensured more nuclear details for the distinction between reactive mesothelial cells and malignant cells. Few inflammatory cells were noticed in a less peripheral separate layers admixed with other cells in malignant cases. The other advantage of CB was concentration of cellular materials in one small area that can be evaluated at a glance with all cells lying in the same focal plane of microscope. It bridges the gap between cytology and histology

Conclusion

The cell block made by using 10% formalin-alcohol as a fixative, is a simple, inexpensive method, and does not require any special training or instrument. Multiple sections could be obtained required, for special stain. Therefore, CB technique could be considered as a useful adjunct in evaluating malignant cells in MPE for a final cytodiagnosis, along with the routine CS method.

References

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