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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 28  |  Issue : 2  |  Page : 112-116

Computed tomography guided percutaneous transthoracic fine needle aspiration cytology of pulmonary mass lesions: Two years cross sectional study of 61 cases


Department of Pathology, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication18-Sep-2014

Correspondence Address:
Dr. Ratan Konjengbam
Department of Pathology, Regional Institute of Medical Sciences, Imphal - 975 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.141098

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  Abstract 

Background and Objective: A vast spectrum of pathological lesions like neoplastic, inflammatory, congenital and various miscellaneous lesions may present as lung masses. With computed tomography (CT) guidance it is possible to perform a biopsy on almost any portion of lung with high degree of safety and minimal morbidity avoiding more invasive techniques. The objective of present study was to evaluate the diagnostic utility of CT-guided fine needle aspiration cytology (FNAC) in pulmonary mass lesions and to compare with previous similar studies. Materials and Methods: Sixty-one patients presented with undiagnosed pulmonary mass lesions underwent CT-guided FNAC for a period of 18 months. The lesions were localized by CT scan and after the needle tip was confirmed to be in the desired location, aspirations were performed. Smears were fixed with 95% ethyl alcohol stained for Papanicolaou stain and air dried smears were routinely stained with giemsa. Cell blocks were prepared from aspirated materials. Data were analyzed using Epi Info™ version 7. Results: Out of 61 one cases, 56 (91.80%) cases were adequate for evaluation. Considering cell block diagnosis as the standard, sensitivity, specificity, positive predictive value and negative predictive value and diagnostic accuracy of CT-guided FNAC of pulmonary malignant lesions were 95.5%, 84.6%, 94.3%, 91.3% and 91.6% respectively (P < 0.0000096). The mean age of presentation was 65.75 years with male to female ratio of 1.44:1. Squamous cell carcinoma was the most common malignant lesion (35.0%). Hemoptysis and transient pleuritic chest pain were some complications encountered. Conclusion: CT-guided FNAC is simple, safe and has a high sensitivity and diagnostic accuracy with only a few complications.

Keywords: CT-guided, Cytology, Lung masses, Squamous cell carcinoma


How to cite this article:
Konjengbam R, Singh NB, Gatphoh SG. Computed tomography guided percutaneous transthoracic fine needle aspiration cytology of pulmonary mass lesions: Two years cross sectional study of 61 cases. J Med Soc 2014;28:112-6

How to cite this URL:
Konjengbam R, Singh NB, Gatphoh SG. Computed tomography guided percutaneous transthoracic fine needle aspiration cytology of pulmonary mass lesions: Two years cross sectional study of 61 cases. J Med Soc [serial online] 2014 [cited 2019 Aug 22];28:112-6. Available from: http://www.jmedsoc.org/text.asp?2014/28/2/112/141098


  Introduction Top


Computed tomography (CT)-guided fine needle aspiration cytology (FNAC) of suspicious intrathoracic lesions is widely accepted and is a simple diagnostic technique. With CT guidance it is possible to perform a biopsy on almost any portion of chest with high degree of safety and minimal morbidity because of ability to plan a needle path such that the major blood vessel are avoided. [1] It has become the first line diagnostic procedure in diagnosing lung malignancies and confirming metastasis. [2],[3],[4] CT guided FNAC is safe and has high sensitivity and specificity with a high diagnostic accuracy with minimally invasive procedure with a few acceptable complications. [5],[6],[7],[8],[9],[10],[11],[12],[13] However, sensitivity of the technique in the diagnosis of the malignant pulmonary neoplasms and small pulmonary nodules varies according to both size and needle length path. [14],[15],[16] Pneumothrax, hemorrhage, hemoptysis and chest pain are some common complications of the technique and only a few require active management. [17],[18] Severe emphysema, insufficient lung capacity, bleeding diathesis international normalized ratio (INR) >1.5/platelets <50,000/mm 3 , inability to hold breath, uncontrolled cough, positive pressure ventilation, pulmonary arterial hypertension, hydatid cyst, arteriovenous malformation/aneurysm and uncooperative patients are some of the contraindications of the technique.

The purpose of our study is to evaluate diagnostic utility of CT-guided FNAC in pulmonary mass lesions and to compare with previous similar studies.


  Materials and Methods Top


It is cross sectional hospital-based study conducted in the cytology section, department of Pathology, Regional Institute of Medical Sciences, Imphal, Manipur, India for a period of 18 months starting from January 2010 in collaboration with the department of Radiodiagnosis, RIMS, Imphal. All the patients presented with undiagnosed pulmonary mass lesions from both out-patient department and in-patient department are included in the study. Those patients who cannot hold their breaths or patients having severe obstructive pulmonary disease, pulmonary artery hypertension, uncontrolled cough, bleeding disorders, bullous emphysema, suspected hydatid disease, arteriovenous malformation and dyspnea at rest were excluded from the study. Already diagnosed cases in follow-up study were also excluded from the study. Recruitment into the study were done after the approval from the Institutional Ethical Committee. Written informed consent were taken from every case. The detailed history of the patient regarding age, sex, duration of the lesion detected by imaging and signs and symptoms of the patient and all other relevant investigations will be recorded. The provisional diagnoses given by radiological studies were also recorded. A full coagulation profile, hemoglobin level, platelet count and cross matching of blood were made available before the FNAC. CT guided FNAC were conducted after explaining the risks and benefits of the procedure. 22 gauze spinal needles were used for the aspirations. Patients were placed in supine, prone or lateral decubitus position depending upon the location of the lesions and safe approach of the needle placement. The lesions were localized by CT scan using contiguous 5-10 mm collimated images of the area of interest to map the path and length of the needle to center of the lesion. The skin entry sites were marked with pen using the laser light from the CT gantry. The aspiration needle was advanced into the lesions during suspended respiration. After the needle tip was confirmed to be in the desired location by taking limited CT cuts, aspiration was performed. From the aspirated material, smears were made and fixed with 95% ethyl alcohol stained for Papanicolaou (PAP) stain and air dried smears were routinely stained with Giemsa. Other special stains were also done whenever required. Two to three smears were stained by the Diff Quik method to assess presence of the materials. If adequate materials were not present, repeat aspirations were done. From the aspirated materials remained in the needle, cell blocks were made whenever possible. Aspirated materials were subjected to cytological examination and reported into 3 groups as:

  1. Positive for malignancy (PFM) when cytology showed diagnostically malignant cells.
  2. Suspicious for malignancy (SFM) when cytology showed atypical cells with no definite evidences of malignancy or too less cells to give a definite opinion.
  3. Negative for malignancy (NFM) when cytology did not reveal malignant cells or atypical cells but show only benign cells or nonspecific inflammatory cells.


SFM cases were considered as malignant lesions for statistical analysis. Lung lesions are reported as small cell lung carcinoma (SCLC), non-small cell lung carcinoma (NSCLC), metastatic lesions when malignant cells were not consistent with the morphological features of lung carcinoma, and benign lesions. NSCLCs cases were further sub-classified as squamous cell carcinoma (SCC), adenocarcinoma (ADC), and undifferentiated large cell carcinoma (Undiff. LCC) according to cytomorphology of malignant cells. After the procedure, the patient were placed in a puncture side down position and advised not to cough and talk for one hour of observation. Expiratory chest X-rays at erect posture were taken at 1 hour to detect any complications for cases with suspected peumothorax. Recruitment into the study was done after the approval from the Institutional Ethical Committee, RIMS. Written informed consents were taken from each and every case. Data were analyzed using Epi Info™ version 7.


  Results Top


A total of sixty one cases underwent CT-guided FNAC out of which 5 aspirates (8.20%) were inadequate for evaluation. Three of these five cases, second aspirate contain only benign respiratory epithelial cells and remaining two cases, second aspirates yielded only blood. Re-aspiration advised but patients lost to follow-up. Fifty six aspirates (91.80%) were adequate for evaluation. Thirty two cases (52.46%) are on right side and 29 (47.54%) on left side. As per the lobe wise involvement, upper lobes are affected the most, left upper lobe (20;32.79%) being more than right upper lobe (15;24.59%). Age ranged from 45-84 years with overall mean age of presentation was 65.75 year (SD ± 10 year). Maximum number of cases for both males and females were seen in age groups of 61-70 years. 36 cases (59.02%) were males and 25 cases (40.98%) female with a male to female ratio of 1.44:1. Details of patient demographic features and other patient characteristics are shown in [Table 1].
Table 1: Demographic and patient characteristics of the study

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Cytological examination revealed 38 cases (67.9%) positive for malignancy (PFM), 2 cases (3.5%) SFM and 16 cases (28.6%) cases NFM and further classified as SCLC (12%), NSCLC (55%), malignant metastatic lesion (2%) and benign lesion (28%) [Figure 1]. A total of 35 cell blocks (CB) were prepared from the aspirated materials. The two SFM cases, after CB study, were found to be one case each of SCLC and ADC.
Figure 1: Cytological diagnosis of various lung lesions SCLC: Small Cell lung carcinoma, NSCLC: Non-Small cell lung carcinoma: SFM: Suspicious for malignancy

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Of total 40 malignant lesions, 32 cases (80%) were NSCLC, 7 cases (17.5%) SCLC while one case (2.5%) was malignant metastatic lesion. Among NSCLC, SCC [Figure 2] and ADC [Figure 3] constituted 14 (35.0%; 14/40) and 13 (32.5%; 13/40) respectively while five cases (12.5%; 5/40) were Undiff. LCC. Malignant metastatic lesion was a case of breast carcinoma (invasive ductal carcinoma, not otherwise specified) involving left lower lobe of 51year female. Among the males, SCC was the most frequent diagnosis (10/23;43.5%) followed by ADC (9/23;39.1%) whereas among the female most frequent diagnosis was small cell carcinoma (5/17; 29.4%) followed by ADC and SCC (each 4/17; 23.5%). There were 12(12/16;75%) cases of non-specific inflammatory lesions (NSILs) comprising of five cases of acute inflammatory lesions, 7 cases of chronic inflammatory lesions and four cases (4/16;25%) of granulomatous tuberculous lesions. NSILs were found maximum in fifth decade (50%) while tuberculous lesions found in sixth and seventh decades (each 50%). Age and sex distribution of malignant lesion is shown in [Table 2].
Figure 2: (a) Photomicrograph of cytological fi ndings of SCC with extensive necrosis and keratin debris from 51 year old female; Giemsa; ×1000. (b) Photomicrograph of Cell Block study showing features of SCC; H & E; ×1000

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Figure 3: Photomicrograph from 78 year old female ADC case showing highly cellular smears with fl at monolayer sheets; Giemsa, ×1000

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Table 2: Age and sex distribution of malignant cytological diagnosis

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Considering cell block diagnosis as the standard, sensitivity, specificity, positive predictive value and negative predictive value and diagnostic accuracy of CT-guided FNAC of pulmonary malignant lesions were 95.5%, 84.6%, 94.3%, 91.6%, and 91.4% respectively (P < 0.0000096) [Table 3].
Table 3: Association of cytological diagnoses and cell block diagnoses

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We had no case of pneumothorax. Hemoptysis (1.6%) and transient pleuritic chest pain (4.9%) were some complications encountered during the procedure. None of cases required active management. No fatalities were experienced in our study.


  Discussion Top


Lung cancer is currently the most frequently diagnosed major cancer and the most common cause of cancer mortality in males worldwide. [19],[20] There are many diagnostic approach to a case presented with lung mass. CT-guided FNAC of suspicious pulmonary lesions is widely accepted and is a simple diagnostic technique. Because of high diagnostic accuracy of CT-guided FNAC with minimally invasive, this procedure avoids more invasive and expensive diagnostic tests.

The reported diagnostic accuracy in the literature ranged from 64-97%. [11],[16] The present study had diagnostic accuracy of 91.4% (P < 0.000009). This finding is comparable with the result reported by Jaya Shanker E et al. [2] (>91%) and Li H et al. [16] (96%). We also had high sensitivity of 95.5% and sensitivity of 84.6%. Similar to our finding, Li H et al. [16] reported sensitivity of 94% but they reported 100% sensitivity.

Maximum number of cases were seen in the age-group of 61-70year (Mean ± SD, 65.75 ± 10 year). This is comparable with JayaShanker E et al. [2] and Santambrogio L et al. [21] Benign lesions were most commonly seen in fifth and sixth decades while malignant lesions in sixth and seventh decades.

Males were predominant for both malignant (23/40; 57.5%) and benign (9/16; 56.3%) lesions of the lung with a male to female ratio of 1.44:1. This finding is comparable as reported by other authors. [2],[9],[11],[13]

In our study, maximum cases were malignant (71.4%) with primary cases being 97.5%. SCC was the most common malignant lesion (35.0%) followed by ADC (32.0%). These findings are similar to those reported by JayaShanker E et al.[2] and Madan M et al. [9] However JP Singh et al. [11] found equal number cases for both squamous cell carcinoma and ADC. We found small cell carcinoma constituting 17.5% of all malignant lesions. This finding is comparable with result reported by Parajuli S et al. [12] (14.9%). In contrast to our finding, JayaShanker E et al. [2] reported only 3% of small cell carcinoma. We found only one case of metastatic lesion (2.5%; metastatic breast carcinoma). This finding is comparable with result reported by Parajuli S et al. [12] (4.9%). However Jaya Shanker E et al. [2] (6%) and JP Singh et al. [11] (44.4%) reported higher number of metastases. Among the males, SCC was the most frequent diagnosis (43.5%) followed by ADC (39.1%) whereas among the female most frequent diagnosis was small cell carcinoma (29.4%) followed by ADC and SCC (23.5%). Madan M et al. [9] also reported SCC most common among the males but they found ADC most common among the female. This difference may be due to regional and genetic differences among the study population and difference in smoking habit.

We found 16 cases of benign lesions. Four cases were tuberculous lesions (25%) and remaining cases were NSIL (75%). As per tuberculous lesions, our finding is comparable with Li H et al. [16] (25%) but NSILs were found to be higher in our study in comparison to other similar studies. This difference may be due to clumping of abscesses and cases of pneumonia together under this heading in our study.

We found overall low rate of complications may be likely due to use of smaller size needle (aspiration with 22 G), less number of multiple punctures and pneumothorax precautions like discouraging the patient not talk and cough, puncture site down positions.


  Conclusions Top


We concluded that CT-guided FNAC is simple, safe and has a high sensitivity and diagnostic accuracy in our series. It is a useful diagnostic tool for evaluation of lung mass lesions with a few acceptable complications like hemoptysis and transient pleuritic chest pain. None of cases required active management.

 
  References Top

1.Mark FG, Kenneth RT, Stuart ML. Percutaneous biopsy of the lung, mediastinum, and pleura. In: Mathew AM, Kieran PJ, Kenneth RT, Anthony CV, Christoph LZ, editors. Image-Guided Interventions. 1 st ed., Vol 2. Saunders: Elsevier Ltd; 2008. p. 1628-32.  Back to cited text no. 1
    
2.JayaShankar E, Pavani B, Chandra E, Reddy R, Srinivas M, Shah A. CT guided percutaneous thoracic: FNAC in lung and mediastinum. J Cytol Histol 2010;1:107-10.  Back to cited text no. 2
    
3.Svante RO, Gregory FS, Darrel W. Fine needle aspiration cytology. 4 th ed. Churchill Livingstone: Elsevier Ltd; 2005. p. 1-8.  Back to cited text no. 3
    
4.Shah S, Shukla K, Patel D. Role of fine needle aspiration cytology in the diagnosis of lung tumours - a study of 100 cases. Indian J Pathol Microbiol 2007;50:56-8.  Back to cited text no. 4
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6.Syed A, Shabab M, Uddin A. Computed tomography guided fine needle aspiration cytology of lung lesions: A study of 162 cases. J Chittagong Med Coll Teach Assoc. 2009;20:50-2.  Back to cited text no. 6
    
7.Bandyopadhyay A, Laha R, Das TK, Sen S, Mangal S, Mitra PK. CT guided fine needle aspiration cytology of thoracic mass lesions: A prospective study of immediate cytological evaluation. Indian J Pathol Microbiol 2007;50:51-5.  Back to cited text no. 7
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8.Shaheen MZ, Sardar K, Murtaza HG, Safdar SS, Hafeez A, Mushtaq MA, et al. CT guided trans-thoracic fine needle aspiration/biopsy of mediastinal and hilar mass lesions. Indian J Pathol Microbiol 2010;16:4-13.  Back to cited text no. 8
    
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13.Prashant, Ramachandra C, Pattbhiraman, Raghuram, Satya V, Attili S. Feasibility, safety, and efficacy of the CT guided fine needle aspiration cytology of lung lesions. Indian J Med Paediatr Oncol 2007;28:16-25.  Back to cited text no. 13
    
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