3 FINE NEEDLE ASPIRATION NEEDLE ASPIRATION.pdf · INTRODUCTION : Fine needle aspiration cytology...

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Journal of Dental Sciences University University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 03 University J Dent Scie 2017; No. 3, Vol. 1 Research Article 1 2 3 4 5 Amrita Raj ,Amit Pandey , Ankita Raj , Gauri Mishra , Abhinav Misra , Saket Nigam 1. Reader, Department of Oral and Maxillofacial Pathology, Rama Dental College, Hospital & Research Centre, Kanpur. 2. Reader, Department of Periodontology and Oral Implantology, Rama Dental College, Hospital & Research Centre, Kanpur. 3. Reader, Department of Oral and Maxillofacial Surgery, Rama Dental College, Hospital & Research Centre, Kanpur. 4. Associate Professor, Department of Dentistry. Government Medical College Jalaun, Orai. 5. Associate Professor, Department of Dentistry. Government Medical College, Kannauj. 6. Associate Professor, Department of Radiodiagnosis, Rama Medical College, Mandhana, Kanpur. INTRODUCTION : Fine needle aspiration cytology (FNAC) is a well established diagnostic tool for the lesions of the head and neck region, especially for swellings in the thyroid gland, salivary gland, and lymph nodes. Preoperative aspiration cytology can be practiced on almost any anatomic region evident visually. [1] The goal of FNAC is to yield diagnosis by causing minimum tissue trauma and producing quick results. It can obviate the need for surgery in non- neoplastic conditions or inflammatory lesions and metastatic tumors. Its low cost, minimal morbidity, rapid turn around time and relatively high sensitivity and specificity makes it a useful method of evaluating suspicious masses in outpatient and hospital setting. FINE NEEDLE ASPIRATION CYTOLOGY IN OROFACIAL SWELLINGS- A USEFUL TOOL Keywords- Source of support : Nil Conflict of interest: None Fine needle aspiration cytology, FNAC, Oropharyngeal Lesions, Diagnostic Accuracy, Oro-facial Swellings. ABSTRACT: Fine needle aspiration cytology (FNAC) is a well established diagnostic tool for the lesions of the head and neck region, especially for swellings in the thyroid gland, salivary gland, and lymph nodes. Preoperative aspiration cytology can be practiced on almost any anatomic region evident visually. The goal of FNAC is to yield diagnosis by causing minimum tissue trauma and producing quick results. Fine needle aspiration cytology (FNAC) of oral and maxillofacial region has not been widely utilized for diagnosis due to diversity of lesion types, heterogeneity of cell populations and difficulties in reaching and aspirating these lesions. Aim: The purpose of the current study was to evaluate the diagnostic accuracy, sensitivity, and specificity of Fine needle aspiration cytology (FNAC) in tumors and tumor-like conditions in the oral and maxillofacial region. Materials and method: The study was conducted on 62 patients of both sexes and all age groups, with clinically diagnosed tumors and tumor-like conditions of oral and maxillofacial region, with the oro-facial swellings. A comparison between cytological and histological diagnosis was done wherever biopsy material was available. Results: In present study of 62 cases excluding 3 cases with unsatisfactory smear, The Diagnostic accuracy was 88.13%, Sensitivity 97.05%, Specificity 90.47%, Positive predictive value 94.28% and, Negative predictive value 95%. Conclusion: FNAC is a minimally invasive, highly accurate and cost-effective procedure for the assessment of patients with oromaxillofacial lesions. The present study illustrates the role of FNAC in the diagnosis of a variety of benign as well as malignant lesions of the oral cavity and oropharynx. The deeply situated oral / oropharyngeal lesions are difficult to aspirate, still FNAC is highly accurate especially for the malignant lesions which can be of great help in early planning of the definitive course of management. However, specific cytological diagnosis may be difficult to make in the absence of characteristic architectural patterns.

Transcript of 3 FINE NEEDLE ASPIRATION NEEDLE ASPIRATION.pdf · INTRODUCTION : Fine needle aspiration cytology...

Page 1: 3 FINE NEEDLE ASPIRATION NEEDLE ASPIRATION.pdf · INTRODUCTION : Fine needle aspiration cytology (FNAC) is a well established diagnostic tool for the lesions of the head and neck

Journal of Dental Sciences

University

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 03

University J Dent Scie 2017; No. 3, Vol. 1

Research Article1 2 3 4 5 Amrita Raj ,Amit Pandey , Ankita Raj , Gauri Mishra , Abhinav Misra , Saket Nigam

1. Reader, Department of Oral and Maxillofacial Pathology, Rama Dental College, Hospital & Research Centre, Kanpur. 2. Reader, Department of Periodontology and Oral Implantology, Rama Dental College, Hospital & Research Centre, Kanpur.3. Reader, Department of Oral and Maxillofacial Surgery, Rama Dental College, Hospital & Research Centre, Kanpur.4. Associate Professor, Department of Dentistry. Government Medical College Jalaun, Orai. 5. Associate Professor, Department of Dentistry. Government Medical College, Kannauj. 6. Associate Professor, Department of Radiodiagnosis, Rama Medical College, Mandhana, Kanpur.

INTRODUCTION : Fine needle aspiration cytology

(FNAC) is a well established diagnostic tool for the lesions of

the head and neck region, especially for swellings in the

thyroid gland, salivary gland, and lymph nodes. Preoperative

aspiration cytology can be practiced on almost any anatomic

region evident visually. [1] The goal of FNAC is to yield

diagnosis by causing minimum tissue trauma and producing

quick results. It can obviate the need for surgery in non-

neoplastic conditions or inflammatory lesions and metastatic

tumors. Its low cost, minimal morbidity, rapid turn around

time and relatively high sensitivity and specificity makes it a

useful method of evaluating suspicious masses in outpatient

and hospital setting.

FINE NEEDLE ASPIRATION CYTOLOGY IN OROFACIAL SWELLINGS- A USEFUL TOOL

Keywords-

Source of support : Nil

Conflict of interest: None

Fine needle aspiration

cytology, FNAC,

Oropharyngeal Lesions,

Diagnostic Accuracy,

Oro-facial Swellings.

ABSTRACT: Fine needle aspiration cytology (FNAC) is a well established diagnostic tool for

the lesions of the head and neck region, especially for swellings in the thyroid gland, salivary

gland, and lymph nodes. Preoperative aspiration cytology can be practiced on almost any

anatomic region evident visually. The goal of FNAC is to yield diagnosis by causing minimum

tissue trauma and producing quick results. Fine needle aspiration cytology (FNAC) of oral and

maxillofacial region has not been widely utilized for diagnosis due to diversity of lesion types,

heterogeneity of cell populations and difficulties in reaching and aspirating these lesions.

Aim: The purpose of the current study was to evaluate the diagnostic accuracy, sensitivity, and specificity of Fine needle aspiration cytology (FNAC) in tumors and tumor-like conditions in the oral and maxillofacial region.

Materials and method: The study was conducted on 62 patients of both sexes and all age groups, with clinically diagnosed tumors and tumor-like conditions of oral and maxillofacial region, with the oro-facial swellings. A comparison between cytological and histological diagnosis was done wherever biopsy material was available.

Results: In present study of 62 cases excluding 3 cases with unsatisfactory smear, The Diagnostic accuracy was 88.13%, Sensitivity 97.05%, Specificity 90.47%, Positive predictive value 94.28% and, Negative predictive value 95%.

Conclusion: FNAC is a minimally invasive, highly accurate and cost-effective procedure for the assessment of patients with oromaxillofacial lesions. The present study illustrates the role of FNAC in the diagnosis of a variety of benign as well as malignant lesions of the oral cavity and oropharynx. The deeply situated oral / oropharyngeal lesions are difficult to aspirate, still FNAC is highly accurate especially for the malignant lesions which can be of great help in early planning of the definitive course of management. However, specific cytological diagnosis may be difficult to make in the absence of characteristic architectural patterns.

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FNAC of oral and maxillofacial region has not been widely utilized for diagnosis due to diversity of lesion types, heterogeneity of cell populations and difficulties in reaching and aspirating these lesions. [2] The purpose of the current study was to evaluate its diagnostic accuracy, sensitivity, and specificity in tumors and tumor-like conditions in the oral and maxillofacial region.

MATERIAL AND METHODS

The study was conducted on 62 patients of both sexes of all

age groups, with clinically diagnosed tumors and tumor-like

conditions of oral and maxillofacial region, with the oro-

facial swellings. The patients were selected from the indoor

and outdoor department of Rama Dental College, Hospital

and Research Center, Kanpur, Rama Medical College,

Kanpur, J.K.Cancer Institute, Kanpur.

The FNAC was performed using 21–25 G needle and a 20-ml

syringe with or without local anesthetic, as and when

required. The lesional site was swabbed, using povidine-

iodine solution and ethyl alcohol (spirit). The needle was

inserted into the lesion and aspirate from different portions of

the mass lesion was collected by altering the direction of the

needle inside the mass and by giving multiple passes. The

aspirated material so obtained was smeared onto glass slide

[75x25mm]. Air-dried smears were stained with May-

Grünwald Geimsa (MGG) stain and smears fixed in 95%

ethanol were stained with hematoxylin and eosin (H& E) /

Papanicolaou (PAP) stains. Special stains like Ziehl-Neelsen

and periodic acid-Schiff (PAS) were performed in accordance

with the type of lesion and requirement. Cytopathological

diagnosis was made and correlated with histopathological

diagnosis wherever biopsy was possible. Complete

requisition form was filled, mentioning the clinical details.

Procedure-related minor complications in the form of

prolonged bleeding were noted in a few of the patients;

however, no major complications were seen.

RESULTS AND OBSERVATIONS

Fine needle aspiration was performed on 62 patients (Table 1, Graph 1), out of which, a definite positive diagnosis of malignant or benign lesion was given in 57 cases (91.93%). Histopathological correlation was possible in 44 cases. Out of these 57 cases, 37(59.67%) were proved to be malignant and 20(32.25%) were benign on biopsy. On cytology, two cases were signed out as suspicious for malignancy and three cases were unsatisfactory because of inadequate material for which tissue was not available.

TABLE 1: Showing categorization of total orofacial

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Category Reported Cases

n (%)

Benign 20 (32.25)

Malignant 37 (59.67)

Suspicious 02 (3.3)

Inadequate 03 (4.83)

Total 62 (100)

aspirations performed.

GRAPH 1: Showing categorization of total orofacial

aspirations performed

On considering various sites (Table 2), a total of 54 cases

were reported from within oral cavity, of which 16 were

benign and 33 turned out to be malignant. Two out of three

cases from lymph node area were benign. Three cases were

reported from salivary glands of which 1 was malignant and

from the tonsillar area, 2 cases were reported both being

carcinomas.

TABLE 2: Showing Cyto-diagnosis of various lesions

/sites

On comparing the cytodiagnosis with histopathology (Table

3), Squamous cell carcinoma was reported on cytodiagnosis

in twenty eight patients which was histopathologically

confirmed in twenty seven cases, whereas in one case only

benign necrotic tissue was seen. Giant cell lesion was reported

in three patients which were confirmed by histopathology as

giant cell granulomas. Adenoid cystic carcinoma of minor

salivary glands was reported in three patients which was

histopathologically confirmed in two patients whereas one

turned out to be adenoma. Eight cases were reported as

odontogenic lesions of which three were reported as

ameloblastoma, three as OKC, one as radicular cyst and one

as benign inflammatory tissue on histopathology. Five cases

were reported as benign inflammatory tissues of which one

was histopathologically confirmed as malignant carcinoma.

Sr No Site ofFNAC

Total no. of cases

Benign Malignant Suspicious Inadequate

1 Oral cavity 54 16 33 02 03 2 Lymph node 03 02 01 00 00

3 Salivary gland

03 02 01 00 00

4 Tonsillar region

02 00 02 00 00

5 Total n (%) 62 20 (32.25)

37 (59.67) 02 (3.3) 02 (4.83)

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One case was reported as melanoma which was confirmed

histopathologically as malignant melanoma. In major

salivary glands, a total of three cases were encountered of

which two were benign and one was malignant. Benign cases

were confirmed histopathologically but for the malignant

lesion, the histopathology was not available. From the

tonsillar area two cases were reported both cytologically as

malignant lesion which was confirmed by histopathology.

One metastatic lymphnode was reported and confirmed by

histopathology.

TABLE 3: Showing distributions of cases according to site

and corealation of FNAC with histopathological findings.

On comparing the results of fine needle aspiration cytology to

histopathologically confirmed cases in various sites (Table 4),

of total sixty two patients, fifty seven patients were diagnosed

of which fifty two were confirmed by histopathology. Two

cases were false positive which were given as carcinomas on

cytodiagnosis but turned out to be benign on histopathology.

Sr no Nature of lesion No of cases diagnosed by FNAC

Histological Diagnosis

No of cases confirmed by histology

Oral cavity 1 Squamous cell

carcinoma 28 Squamous cell

carcinoma 27 01

Benign necrotic inflammation

2 Giant cell lesion 03 Giant cellgranuloma

03

3 Adenoid cystic carcinoma of minor salivary glands

03 Adenoma 01 02

Adenoid cystic carcinoma

4 Acute inflammatory lesion

05 Acute inflammatory lesions

04 01

Squamous cell carcinoma

5 Odontogenic lesion 08 Ameloblastoma 03 03 01 01

Odontogenic Keratocyst Radicular cyst

Benign inflammatory tissue

6 Melanoma 01 Melanoma 01

7 Sarcoma 01 Histology not available

01

8 Suspicious 02 Histology not available

02

9 Inconclusive 02 Histology not available

02

Lymphnodes 1 Metastatic (Squamous

cell) carcinoma 01 Confirmed 01

2 Tubercular lymphadenitis 02 Confirmed 02

Tonsillar region

1 Tonsillar carcinoma 02 Carcinoma 02

Salivary glands 1 Pleomorphic adenoma 01 Confirmed 01

2 Pleomorphic adenoma ex-carcinoma

01 Histology not available

01

3 Sialadenitis 01 Confirmed 01

TABLE 4: Showing overall results of FNAC at different

sites

Tables show a comparison between benign and malignant

cases given on FNA with their respective histological

diagnoses.

TABLE 5: Showing diagnostic accuracy of FNAC at

different sites.

On comparing the overall accuracy rate (Table 5), 88.23%

accuracy rate was seen in the oral cavity and 66.66% in the

salivary glands where as in l the other sites the rate was 100%,

which may be due to the small sample size. The sensitivity in

the oral cavity was 96.77% whereas in all the other sited it was

99.3% and the specificity was seen to be 93.75% in the oral

cavity and 66.66% in salivary gland whereas 100% in other

two sites.

Table 6: Overall diagnostic accuracy of FNAC of

Orofacial swellings.

Of the total sixty two aspirations done (Table 6), diagnosis by

FNAC was possible in fifty seven cases, of which fifty two

were confirmed by histopathology. Nineteen cases were

Sr no Site & nature of lesions

Total no of cases

No of cases diagnosed by FNAC

No of cases confirmed by histology

Unsatisfactory /Inconclusive

False positive

False negative

Suspicious

1 Oral cavity

· Benign · Malignant

54 49 16 33

45 15 30

03 01 01 02

2 Lymph node

· Benign · Malignant

03 03 02 01

03 02 01

-- -- --

3 Salivary gland

· Benign · Malignant

03 03 02 01

02 02 00

-- 01 --

4 Tonsillar region

· Benign · Malignant

02 02 00 02

02 00 02

-- -- --

5 Total 62 57 52 03 02 01 02

Sr no

Site of aspiration

No of cases confirmed by histology

Overall accuracy TP+TN/(total cases)x100

Sensitivity TP/(TP+FN)x100

Specificity TN/(TN+FP)x100

1. Oral cavity 45 88.23 96.77 93.75

2. Lymph node

03 100 99.3 100

3. Salivary gland

02 66.66 99.3 66.66

4. Tonsillar region

02 100 100 100

Sr No Diagnostic accuracy Total no.

1 Total No. of aspirations done 62

2 Total No. of cases diagnosed by FNAC 57

3 Histological correlation possible in 52

4 Total No. of true negative cases 19

5 Total No. of true positive cases 33

6 Total No. of false positive cases 02

7 Total No. of false negative cases 01

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lesions, is available but only few reports, however, explore the

potential of Fine needle aspiration cytology for the diagnosis of intraoral and lesions of maxillofacial region.[4] The

various cytological target areas of orofacial lesions include

cheeks and lips, jaws, intraoral mucosa, tonsils and tongue,

salivary glands and lymph nodes. On considering various

sites, of total 62 cases, 54 were encountered within the oral

cavity, and a diagnosis by FNAC was made on 49 cases, of

which 16 were benign and 33 were malignant.

ASPIRATION OF LYMPH NODES:

Lymph nodes are commonly aspirated masses in head and

neck region. They are important component of peripheral and

secondary lymphoreticular tissue, react to various

pathological stimuli, resulting in their enlargement, which

may be considerable, sometimes. Aspiration from lymph

nodes requires no radiological guidance and can be very

useful in diagnosing metastatic carcinomas, extent and

recurrence of lymphomas, inflammatory conditions like

tuberculosis, non specific lymphadenitis, and in providing

material for culture and other studies.

The group with the best diagnostic accuracy on

cytohistological correlation was carcinoma metastatic to the

lymphnodes (100%). Schour and Qiu in [5] 1972 reported the

accuracy of 97% in carcinoma metastatic to lymphnodes.

They constitute one of the commonest indications for FNAC

and in this cytological diagnosis can be easily obtained. Along

with the malignancy, the nature and the site of the primary can

also be given in most of the cases.

Results of tubercular lymphadenitis as per Gupta et al [6] in

1991 shows the accuracy of 76.78% however, definitive

diagnosis is difficult in cases where Langhan's giant cells and

epitheloid cells are not seen in the smears. Also they may

contain only casseous material or pus. Our results showed

100% accuracy but that may be due to less number of cases

encountered. The cytological smear revealed the presence of

langhan's giant cells. (Fig-01)

FIG 01: FNAC smear of tubercular lymphadenitis showing

identified as True Negative and thirty three as True Positive.

Two cases were False Positive and one was False Negative.

TABLE 7: Showing validity of FNAC in Orofacial

swellings.

Accordingly, the overall diagnostic sensitivity, specificity,

positive predictive value, and negative predictive value of

FNAC of orofacial swellings (Table 7) was found to be

97.05%, 90.47%, 94.28%, 95% respectively and the overall

accuracy was found to be 88.13%.

DISCUSSION

Fine needle aspiration cytology as practiced today, is an

interpretative art with histopathology as its scientific base. Its

practice is quite different from that of either exfoliative

cytology or surgical pathology. Unlike histopathology where

tissue pattern, cell morphology, intercellular products and

inter cellular matrix are preserved, in cytology it is mainly the

cell morphology which is preserved.

The fundamental indication for FNAC is a lesional mass that is palpable or visible by a radiological imaging method. This technique may also assist in establishing a specific diagnosis for radiolucent lesions of the jaw. The thinning or destruction of cortical bone permits the use of thin needles to aspirate such abnormalities.[2]

Fine needle aspiration cytology was performed on sixty two patients with various palpable lesions in the orofacial region. Fifty seven (96%) aspirations were considered to be satisfactory of which 20(32.25%) were benign and 37(59.67%) were diagnosed as malignant, three were considered inadequate as were hypocellular and two cases were considered suspicious for malignancy but aspirate consisted of only blood.

In present study of 62 cases excluding 3 cases with unsatisfactory smear, the Diagnostic accuracy was 88.13%, Sensitivity 97.05%, Specificity 90.47%, Positive predictive value 94.28% and, Negative predictive value 95.0%. On comparing the results of the present series with other workers it can be said that the result of this study compare favorably with those published in literature and are fairly accurate.

FNAC of head and neck region was pioneered by Martin in

the early 1930s. [3] A relatively large volume of literature,

documenting the effectiveness of Fine needle aspiration

cytology for diagnosis of head and neck and salivary gland

Measure of validity Results (%)

Sensitivity 97.05

Specificity 90.47

Overall accuracy 88.13

Positive predictive value 94.28

Negative predictive value 95.00

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lymphocytes, foamy macrophage, plasma cells and one area

of the smear shows one langhan's giant cell.

Cytology of non-Hodgkins lymphoma can be confused with

reactive hyperplasias and may not be a suitable tool in

forming the diagnosis as stated by Frable [7] in 1979. The

exclusion or confirmation of malignant lymphoma is of

practical importance and may obviate in surgical excision.

ASPIRATION OF ORAL CAVITY, PHARYNX AND

JAWS:

The target areas of orofacial regions are cheeks and lips, jaws,

mucosa (masticatory mucosa, lining mucosa and specialized

mucosa of tongue), tonsils, salivary glands, and lymph nodes.

The data from the population based cancer registries in India

shows the malignant tumors of Lips, Oral Cavity, and Pharynx

are the most common group of cancers. Squamous Cell

Carcinoma is the most common oral malignant neoplasm as

also found in this study 45.16% in total 62 cases of this region,

and the most common site was found to be cheeks and angle of

the mouth. Cytological smears revealed the presence of

atypical cells and later histopathological diagnosis confirmed

squamous cell carcinoma.

Orofacial lesions are readily accessible to FNAC and the

proximity of tissues of various types and wide range of

primary and metastatic neoplasm are responsible for this site

being the most interesting in Fine needle aspiration diagnosis.

The confirmation of the metastatic spread to lymph nodes can

be amongst the easiest of diagnosis variation in the

appearance of even common type of primary neoplasm like

salivary gland tumors makes this a challenging and difficult

area.

Cheeks, lips and face:

There are many cystic, infective and neoplastic conditions of

this region which are easily diagnosed by FNAC. Benign

lesion like dermoid cyst, epidermal cyst to neoplasm like

hemangiomas and malignant lesions like basal cell

carcinoma, lymphomas, squamous cell carcinoma and rarely

melanomas are encountered in this area and can be easily

diagnosed by FNAC.

Feldman et al [8] in 1983 discussed FNAC in squamous cell

carcinoma of head and neck, and problem of differentiating it

cytologically from congenital cyst and other cysts having

squamous lining epithelium. Kiran Alam [9] in 2009, studied

efficacy of Fine needle aspiration cytology of head and neck

masses, where aspiration was done in 74 patients and their

cytohistological correlation were done. The sensitivity and

specificity of FNAC in pediatric head and neck masses was

found to be 95.65 and 93.3% respectively.

Squamous cell carcinoma as also found in this study 45.16%

in total 62 cases of this region, and the most common site was

found to be cheeks and angle of mouth. Of twenty eight cases

that were reported as squamous cell carcinoma on FNAC,

twenty seven were confirmed on histopathology. The smear

show dysplastic cells (fig- 2A, 2B & 2C). The squamous cell

carcinoma of this area is usually associated with secondaries

in lymphnodes, submental, submandibular or cervical group.

In many cases patient present with cervical lymphadenopathy

showing metastasis with hidden primary which may be

usually found in pharyngeal and laryngeal area. In such cases

FNAC can be of great help.

FIG 02A: Pap stained smear of SCC, showing

dedifferentiated cells

FIG 02B (i & ii): Giemsa stained smear showing atypical

squamous cells showing hyperchromatism, nuclear and

cellular pleomorphism and atypical mitosis, confirmed by

histopathology

FIG 02C: H&E stained smear showing dysplastic cells

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the aspirates as stated by Gunhan et al[12] in 1993.

According to Mathew [13] in 1997, the odontogenic tumors

like ameloblastomas can be correctly diagnosed by FNAC.

He defined and elaborated the cytomorphological features of

primary and metastatic ameloblastoma on fine needle

aspiration and to discuss the differential diagnosis with

closely related entities. He found hypocellular smears with

occasional basaloid cells having peripheral palisading. He

characteristically found two cell populations, consisting of

small hyperchromatic basaloid cells and large cells with more

open chromatin. Mesenchymal cells with more elongated

nuclei and ample, clear cytoplasm were also noted. Malignant

cases showed prominent cytologic pleomorphism, cellular

crowding and high mitotic/ karyorrhectic index. He

concluded that with proper radiological evidence, the

cytological features of primary and metastatic ameloblastoma

are unique. Diagnostic problems may arise when these lesions

are pleomorphic and frankly malignant, especially at the

metastatic sites such as lungs.

Gausia Rahim[14] also found FNAC as a valuable tool in initial diagnosis for primary ameloblastoma where the smears depicted basaloid epithelial cells in sheets and clusters with scanty, poorly defined cytoplasm, elongated nuclei, finely distributed chromatin and inconspicuous nucleoli in ameloblastoma. Smears showed showed fragments depicting nests and cords of cells in a fibroblastic stroma. The cell groups showed peripheral palisading and stellate reticulum in the centre although no nuclear atypia or mitotic figures were evident. FNAC is not usually the first diagnostic method in these lesions, as incisional biopsy is easily and rapidly carried out. Nevertheless, the cytological study can be very useful in cases of metastatic disease or in the follow up of possible recurrences.[15,16] Also a prior cytological diagnosis ensures adequate excision with uninvolved margins which definitely prevents recurrence.

However, in our study of 08 cases of odontogenic tumors we

could only find inflammatory cells in the aspirate with few

basaloid cells. Of these 08 cases, 03 cases were diagnosed as

ameloblastoma, 03 as keratocystic odontogenic tumor, 01 as

radicular cyst and 01 as inflammatory tissue. Although tumor

typing of odontogenic tumors was not possible through

FNAC in our study, it can be used as tool to rule out

malignancy.

Salivary glands

A lot of work has been done on FNAC of salivary glands in the

past with varying results. FNAC forms a useful tool in

diagnosing intrinsic salivary gland lesions and to differentiate

Fig 03: FNAC smear showing atypical melanocytes with

anisocytosis, anisonucleosis.

JAWS

Lytic lesions of the jaw are readily accessible to FNAC with

radiographic control. Giant cell granulomas produce spindle

cells and multinucleated giant cells. Hemosederin is present

in Brown tumor of parathyroid that also yields multinucleated

giant cells. In our study three cases were reported as giant cell

lesion on FNAC were confirmed as giant cell granulomas on

histopahology.

Aspirates of cystic bone lesions yield more material than firm

lesions do. However, it is reported that, the diagnosis of

aspirates from cystic lesions may be difficult and less specific

than the FNAC diagnosis of solid lesions due to the paucity of

specific lesional cells and also chances for superimposed

infection. A diagnosis of 'benign cystic lesion' is justified in

many instances. [10] Ramzy et al[11] in 1985 presented their work on radiolucent

lesions of the jaws, making diagnosis in most of the lesions by

fine needle biopsy. Omar Gunhan [12] in 1993 did FNAC

various cystic, inflammatory and neoplastic lesions of jaws

and found their results specific in 92% of malignant and 97%

of benign lesions.

Melanoma, a malignant neoplasm of melanocytic origin, has

low rate of occurrence in the oral cavity with the incidence

being less than 1%. It has aggressive nature and high rate of

metastasis. Biopsy is contraindicated due to the

aggressiveness and rapid spread. We found a case with

extensive involvement of palate and maxillary attached

gingival. The FNAC smear showed malignant cells with

pigment, and the metastatic lymph nodes were positive for

malignant cells (Figure 03).

Odontogenic cyst contains anucleated and superficial

squamous cells. Odontogenic tumors like ameloblastoma

yield basaloid cells in sheets and keratinized squamous cells.

Cytologically, varying proportions of inflammatory cells,

histiocytes, clusters of mature squamous cells, columnar or

cuboidal cells, keratin lamellae and cyst fluid can be seen in

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salivary gland from non salivary gland masses. Pleomorphic

adenoma is the commonest of all salivary gland tumors.[17]

The aspirates reveals fibrillary chondromyxoid ground

substance and epithelial cells, single and in poorly cohesive

clusters and sheets. Cells have regular ovoid nucleus with

bland nuclear chromatin and well defined cytoplasm.

Orell[18] in 1995 discussed the difficulties in interpretation of

FNAC of salivary glands. He described hyaline stromal

globules resembling those characteristic of adenoid cystic

carcinoma or beaded hyaline stroma in pleomorphic

adenoma. Epithelial cells showing nuclear enlargement,

abnormal nuclear chromatin, nucleolar prominence,

epihthelial cells in a fibromyxoid stroma raise a suspicion of

carcinoma arising in pleomorphic adenoma.

Coexpression of glial fibrillary acid proteins, keratin and

vimentin is a unique feature useful in diagnosis of

pleomorphic adenoma in FNAC smears. [19]

Mucoepidermoid carcinoma has a bimorphic glandular and

squamous structure. Acinic cell carcinoma smears contain

abundant cellular material against a clean background. The

cells appear cohesive and very well differentiated with

granular cytoplasm and medium sized nuclei with little

evidence of pleomorphism.[20] Minor salivary gland tumors

in the oral cavity account for about 15% of all salivary gland

tumors. PLGA is seen almost exclusively in the minor

salivary glands. Gibbons et al[21] described this tumor as

having architectural diversity but cytological uniformity. Two

cases of PLGA were misdiagnosed as ACC and PA in their

study initially. It is important to differentiate PLGA from

more aggressive tumors like ACC. Differentiation of PA from

ACC may pose problems at times in cytology. Cerulli 2004

[22] studied 24 patients with pleomorphic adenoma and

adenoid cystic carcinoma of minor salivary glands of palate,

and found definitive histopathologic results in 22 of 24 cases.

We reported three cases in the major salivary gland of which

one was reported as pleomorphic adenoma, one as sialdenitis

and one as ex carcinoma pleomorphic adenoma.

Histopathology could not be done for ex carcinoma

pleomorphic adenoma while the other two were confirmed by

histopathology. The overall diagnostic accuracy in this group

was found to be 66.66% but the sample size was small in our

study. Three cases were found intraorally and were reported as

malignant adenoid cystic carcinoma. However, only two were

confirmed as adenoid cystic carcinomas.

A variety of non-neoplastic and neoplastic lesions can involve the oral and oropharyngeal cavity and these are common lesions encountered in clinical practice. FNAC can prove to

be helpful in the diagnosis of clinically non-characteristic lesions. The first aim of FNAC is to detect if the lesion is malignant or benign. Also the specific diagnoses of the lesions by examining their cellular properties on the cytological specimen can be done and it practically has no contraindications.

The FNAC is a non-traumatic and a cost-effective procedure and can provide a simple and safer alternative to open biopsy with a low morbidity rate. The technique does not require much equipment. In the present study, there were not any complications related with FNAC. FNAC materials also p e r m i t t h e s u p p l e m e n t a r y s t u d i e s s u c h a s immunohistochemistry, electron microscopy, morphometric studies for diagnosis of specific typing of lesions. [23]

CONCLUSION

The present study illustrates the role of FNAC in the diagnosis of a variety of benign as well as malignant lesions of the oral cavity and oropharynx. Information on the biological behaviour of a lesion in the preoperative period is very important and FNAC forms a good starting point for the diagnosis. The deeply situated oral/oropharyngeal lesions are sometimes difficult to aspirate. FNAC is highly accurate for the malignant lesions which can be of great help in early planning of the definitive course of management. However, specific cytological diagnosis may be difficult to make in the absence of characteristic architectural patterns. Diagnosis of aspirates from cystic lesions may be less specific as compared to solid lesions due to paucity of specific lesional cells and also there can be superimposed infection. Based on overall results and rarity of false positive FNAC results in our study, we support the use of Fine needle aspiration cytology in diagnosing lesions of oral and maxillofacial region.

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