8/18/2019 47592-59403-1-PB

1/7

FINE NEEDLE ASPIRATION CYTOLOGY IN TUMOUR DIAGNOSIS

D. E Obaseki (MBBS, MWACP, FMCPath)Consultant Histopathologist, Department of Histopathology, University of BeninTeaching Hospital, Benin City, Nigeria

Correspondence:Dr. D. E. ObasekiDepartment of HistopathologyUniversity of Benin teaching hospitalBenin City Nigeria

INTRODUCTIONFine needle aspiration cytology (FNAC), a technique for obtainingcellular material for cytologicalexamination and diagnosis using a 21-gauge or smaller needle, is performed

using a 5, 10, or 20ml syringe eitherfreehand or using special syringeholders. It allows a minimally invasive,rapid diagnosis of tissue samples butdoes not preserve its histologicalarchitecture.  Although exfoliative cytology (i.e. Papsmear) is universally accepted andused in Nigeria, aspiration cytologyhas yet to be widely accepted as amethod of microscopic diagnosis.These two techniques differ in theiraim. Exfoliative cytology is usedprimarily to detect precancerous andcancerous conditions that are not yetclinically apparent, aspiration cytologyis used to determine the nature ofclinically detectable tumours.The advantages of FNAC areinnumerable and these include costeffectiveness, rapid reporting andbedside diagnosis, minimal physicaland psychological discomfort,

elimination of a two-stage procedurefor diagnosis and treatment, activeparticipation of the patient in treatmentplanning, and serving as a therapeuticprocedure for evacuation of cysticlesions1,2  Unfortunately this techniqueis under-utilised in most centres inNigeria, even when most of them haveinadequate theatre facilities, limited

operating time, and a heavy patientload culminating in long waiting lists foroperative procedures such as openbreast biopsies. This results in delay indefinitive diagnosis of lesions andinstitution of appropriate early

management, thus leading toincreased morbidity and mortality ratesin these patients3. Yet this rathersimple and inexpensive diagnostictechnique has been in use in otherparts of the world since the 1920s-eighty years ago!THE ORIGINS OF FNACThe earliest report of a needletechnique being employed to obtainmaterial for microscopy was by Kun in1847 who described a “new instrumentfor the diagnosis of tumours”. Therefollowed sporadic reports of thistechnique, championed mostly byclinicians including Leydon who in1883 used needle aspiration to obtaincells to isolate pneumonicmicroorganisms and Greig and Graywho in1904 diagnosedtrypanosomiasis in cervical lymphnode aspirates from patients withsleeping sickness in Uganda4,. Their

findings were reported by a captainBruce (later of Brucellosis fame) in aBritish Medical Journal memorandumin 1904. Afterwards there were otherreports of a similar technique topuncture and diagnose lymph nodesinfected by Leishmaniasis andsecondary syphilis5.

8/18/2019 47592-59403-1-PB

2/7

In the mid-1920s there were attemptsin New York and Chicago to employlarge needle (1.2-3.0mm) aspiration fora variety of sites ranging throughlymph nodes, prostate and breast butover time the dimension of 1mm or

less has come to be accepted as thedefinition of ‘thin’ or ‘fine’5,6. A detailed and systematic study onFNAC was carried out in the late1920s by Hayes Martin, a head andneck surgeon and James Ewing, thechief pathologist at the New YorkMemorial Hospital. Their experiencecomprising 2500 tumours annually wasdocumented by Fred Stewart (aHistopathologist) who then enunciatedthe fundamental principles regarding

the philosophy of aspiration biopsy andemphasized the need for close clinicaland pathological co-operation.However, full confidence in theprocedure was never achieved andthis period coincided with a fiercecontroversy both in Great Britain andthe USA over the reliability and risks ofopen biopsy in surgical practice, whichclinicians feared would increase therisk of tumour spread. However, astheir fears were laid to rest, thepopularity of needle aspiration wanedto such an extent that by the 1960s thetechnique was all but obsolete in theUSA7,8.Interest in the procedure wasresurrected by Europeans in the mid1950s. In contrast to Martin andStewart who used thicker calibre (18gauge) needles, the European workerspopularized the technique employingthin needles (22 gauge and higher)

with an external diameter of 0.6mm orless. This is the technique knowntoday as the fine needle aspiration(FNA) cytology. Developments inStockholm Karolinska RadiumhemmetHospital in Sweden were of utmostand fundamental importance. Here,workers such as Sixten, Franzen,Sordenstrom, and Torsten Lowhagen

in collaboration with Joseph Zajicekapplied the requisite scientific rigour todefine precise diagnostic criteria in avariety of conditions. The sheervolume, histopathological correlation,follow-up information, coupled with

superbly illustrated publicationsprovided an ethos within the medicalprofession to allow the technique freereign. Their practice invented a novelspecialty of ‘clinical cytologist’ whowould examine the patient, aspiratethe lesion, prepare and read the slideand arrange subsequent onwardreferral. They thus provided a modelfor FNA services for the rest of theworld such that it is now part of allsophisticated pathology

departments.5,6

INDICATIONS/USESThanks to radiological guidance, thereis practically no organ or structure thatis now beyond the reach of the FNACneedle. Masses of deep intra-abdominal organs like the pancreas,kidneys, Para-aortic lymph nodes andalso lung tumours are all subject toFNA cytodiagnosis.Without image guidance, FNACs ofsuperficial masses of the breast,superficial lymph nodes, thyroid gland,salivary glands and cutaneousswellings are done.The technique can be

•  Diagnostic or  

•  Therapeutic e.g. evacuation ofbenign breast cysts 

The major indication for FNA relates todiagnosis of either primary malignancyor metastatic disease. As a diagnostic

tool for evaluating potentially malignantconditions FNAC has the followingindications

•  Initial evaluation beforetreatment and in prognostication

•  Evaluation of recurrencefollowing therapy

•  Evaluation of metastasis

8/18/2019 47592-59403-1-PB

3/7

8/18/2019 47592-59403-1-PB

4/7

8/18/2019 47592-59403-1-PB

5/7

FNAC IN UBTH

The popularity of FNAC in UBTH hasbeen on the increase since theprocedure was introduced to thehospital in the early 2000s. But it wasbeen used rather sparingly as attested

to by the fact that for the whole of theyear 2003 only 5 FNACs wereperformed (all for breast masses).Most of which were for cases that wereobviously clinically malignant. Thesurgeons were in these cases, formedico-legal reasons, looking forpathological justification to performtherapeutic surgery without necessarilysubjecting the patient to two surgeries.The reasons for this initial apathy aremanifold but were mostly centred on

the reliability of the test result, theadded cost implication to the patientsand the timeliness of the result. Aftersome of these fears and reservationswere allayed, the procedure hasgained currency among surgeons inUBTH to the extent that in the year2005 the number of FNAC done forbreast masses alone had risen to 103.

This has led to the setting up of adedicated FNAC clinic in thedepartment of pathology. In addition tobreast lumps, other sites frequentlyaspirated in the clinic includessuperficial lymph node enlargement,

thyroid gland masses and salivarygland masses.In breast aspirates, where the mostexperience has been acquired over thepast 3-4 years, we have been able todemonstrate that our results are mostreliable. In the period between January2005 and March 2006 absolute andcomplete sensitivity of 84.6% and97.4% respectively were achieved.The specificity was 64%, positivepredictive value for malignancies was

100%, and there was an inadequaterate of 19.4%.15 These results are comparable to thoseobtained from other centres in Nigeriaand abroad and well above theminimum standard of practicerecommended by the National HealthService Breast Screening Programme(NHSBSP) guidelines of the UnitedKingdom.

Photomicr ograph of a malignant breast smear done at the FNAC clinic in UBTH. (Haematoxyl in & Eosin X40).

8/18/2019 47592-59403-1-PB

6/7

In conclusion, it should be said that FNAtechnique is simple but not banal. Itrequires a certain manual dexterity inthe same way as surgical proceduresdo. Though it has now been established

as the first line investigation of masslesions wherever they occur in the body,it will continue to flourish only if used

 judiciously with realistic approach ofwhat is achievable kept in view andclear communication between clinicianand cytopathologist maintained. 

REFERENCES1. Fletcher SW, Black W, Harris R,

Rimer BK, Shapiro S. Report of

international workshop onscreening for breast cancer. JNatl Cancer Inst. 1993; 85:1644-1656.

2. Vargas HI, Masood S,Implementation of a minimallyinvasive breast biopsy program incountries with limited resources.Breast J 2003;9 (Suppl 2):S81-85.

3. Thomas JO, Amanguno AU, Adeyi OA, Adesina AO. Fineneedle aspiration in themanagement of palpable massesin Ibadan: Impact on the cast ofcare. Cytopathology 1999;10:206-210.

4. Webb AJ. Early microscopy:history of fine needle aspiration(FNA) with particular reference togoitres. Cytopatology 2001; 12:1-7.

5. Frable WJ. Needle aspirationbiopsy: past, presnt and future.Hum Pathol 1989; 20:504-517.

6. Ansari NA, Derias NW. Fineneedle aspiration cytology. J ClinPathol 1997; 50:541-543.

7. Stewart FW. The diagnosis of

tumour by aspiration. Am JPathol 1933; 9: 801-812.

8. Martin HE, Ellis EB. Biopsy byneedle puncture and aspiration.

 Ann Surg 1930; 92:169-181.

9. Orell SR. Pitfalls in fine needleaspiration cytology. Cytopatology2003; 14:173-182.

10. Stevenson J, James AS,Johnston MA, Anderson IW.Pneumothorax after fine needleaspiration of the breast. BMJ1991; 303:924.

11. Howat A, Coghill S. Normalbreast cytology and breastscreening In: Gray W, Mckee GT(eds). Diagnostic cytopathology.Churchill livingstone, Philadelphia2003: 237-255.

12. Thunnissen FBJM, Kroese AH, Ambergen AW et al. Whichcytological criteria are the mostdiscriminative to distinguishcarcinoma, lymphoma, and softtissue sarcoma? A probabilisticapproach. Diag Cytopathol 1997;17: 333-338.

13. Non-operative diagnosisSubgroup of NationalCoordinating Group for BreastScreening Pathology. Guidelinesfor Non-operative DiagnosticProcedures and Reporting BreastCancer Screening. Sheffield,NHS Cancer screening

8/18/2019 47592-59403-1-PB

7/7

programme, 2001 (NHSBSP NO.50)

14. Lamb J, Anderson TJ. Influenceof cancer histology on the

success of fine needle aspirationcytology of the breast. J ClinPathol 1989; 42:733-735

15. Obaseki DE, Olu-Eddo AN,Ogunbiyi JO. The diagnosticaccuracy of fine needle aspirationof palpable breast masses in

Benin City, Nigeria. WAJM(submitted).