J Oral Maxillofac 48:702-706.

Surg

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Fine-Needle Aspiration

Biopsy:

An Analysis of 89 Head and Neck Cases JAY C. PLATT, DDS,* DARRELL DAVIDSON, MD, PtiD,t CHARLES L. NELSON, DDS,$ AND EDWARD WEISBERGER,

MD§

In a recent 2-year period, 89 fine-needle aspiration biopsies (FNAB) were performed on head and neck lesions in 81 patients from 6 to 97 years of age. Eighty-four of the FNABs were considered diagnostic. Thirty of the aspirates were diagnosed as benign whereas 54 were diagnosed as malignant. Three specimens were suspicious for malignancy, and 2 specimens were considered nondiagnostic. The most common malignant diagnosis was squamous cell carcinoma, which involved 32 of the specimens. The most common benign diagnosis was pleomorphic adenoma. Subsequent surgical biopsy specimens were available in 45 of the patients, Of these, 41 were consistent with the FNAB diagnosis, whereas 4 were not.

Aspiration biopsy is actually an old technique. Kun,’ who may well be the father of this technique, reported needle recovery of tumor cells for microscopic examination in 1847. Greig and Gray,’ in 1904, demonstrated the presence of tryponosomal organisms in lymph nodes using aspiration. The slow, early development of the needle aspiration biopsy may be due to rapid improvements in surgical technology and improvements in the microtome between 1850 and 1900 that made alternative methods of tissue analysis more attractive. By the 1930s Martin and Ellis3,4 and Stewart’ published large series of aspiration biopsies showing excellent diagnostic accuracy. In the 1950s Franzen et al6 and others at the Karolinska Institute developed the technique known today as fine-needle aspiration bi-

* Chief Resident, Department of Oral and Maxillofacial Surgery, Indiana University Medical Center, Indianapolis. t Assistant Professor of Pathology, Section of Cytopathology, Indiana University Medical School, Indianapolis. $ Associate Professor of Oral and Maxillofacial Surgery, Indiana University School of Dentistry, Indianapolis. 8 Associate Professor of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis. Address correspondence and reprint requests to Dr Platt: Department of Oral and Maxillofacial Surgery, Indiana University School of Dentistry, 1121 W Michigan St, Indianapolis, IN 46202. 0 1990 geons

American

Association

0278-2391/90/4807-0007$3.00/O

of Oral

and Maxillofacial

Sur-

opsy (FNAB) using needles sized 20 gauge or smaller. The recent American resurgence of interest in FNAB brought many United States physicians to Sweden to learn this technique in the 1960s and 1970s. The usefulness, safety, and accuracy of FNAB has been proved repeatedly.‘-l3 FNAB has gained wide acceptance in many medical specialties; however, the field of oral and maxillofacial surgery seems to have neglected its use. The convenience and rapid diagnosis of FNAB should recommend it to oral and maxillofacial surgeons as well as to other specialists. The fundamental indication for FNAB is a mass lesion, either palpable or visible by radiologic imaging. l4 A variation of this fundamental indication frequently encountered in the present study was to verify recurrence of a previously treated neoplasm. In addition, FNAB can be used to confirm a suspected malignancy, to differentiate benign from malignant conditions, to document malignancy for inoperable patients, to evaluate metastasis or extent of malignant disease, to diagnose multiple tumors or enlarged lymph nodes, and to identify infectious organisms and obtain material for cultures. Diagnosis of the mass requires retrieval of an adequate cellular sample carefully prepared to preserve structural detail. The specimen should be interpreted by one familiar both with the identification of cells in smears and with the relevant diagnostic possibilities based on clinical information.

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PLATT ET AL

Materials and Methods In a recent 2-year period, 89 FNABs were performed on head and neck lesions at the Indiana University Medical Center. These were done primarily in outpatient clinics, and occasionally in the operating room for rapid diagnosis. When excised tissue from the area of FNAB was available, the histologic sections were reviewed and correlated with the diagnosis by the aspiration biopsy. Complications from the aspiration were sought by asking the patient about symptoms related to the FNAB during the procedure and when the patient was told the diagnosis. Many patients were also reexamined when definitive therapy was instituted. The technique used to obtain aspirations in this study was as follows (Fig 1). After minimal skin preparation, local anesthesia was obtained. A 23- to 25-gauge needle was attached to a lo-mL disposable syringe containing 1 to 2 mL of air. The needle was introduced into the mass, which was immobilized

by the opposite hand. Negative pressure was applied to the syringe and several sharp, quick strokes were made with the needle. These passes were made at different angles to sample representative areas of the mass. Before removing the needle, the negative pressure was released to keep the specimen in the needle when it was withdrawn from the skin. The specimen was then expressed onto a glass slide. A second glass slide was used to spread the aspirate in the same manner as a blood smear. One slide was immediately immersed in 95% ethanol fixative and the other was allowed to air dry. The alcohol-fixed slide was stained with Papanicoulau’s stain, the other with a Wright stain (D&Quick, Scientific Products, McGaw Park, IL). The specimen was then ready for examination by the pathologist. Results The 89 aspirates were performed on 81 patients. Thyroid fine-needle aspirations were excluded from

FIGURE 1. A, The mass is located and immobilized. B, The needle is introduced into the mass at different angles and C, aspiration is accomplished. D, After being expressed onto a slide, the specimen is fixed and ready for examination by the pathologist.

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ASPIRATION

this series of patients who ranged in age from 6 to 97 years. The population consisted of 54 males and 27 females. All biopsies were obtained from the head and neck region, with the most common site being the neck, followed by the submandibular and parotid salivary gland regions (Table 1). The aspirates were placed into one of four diagnostic categories: benign, malignant, suspicious for malignancy, and nondiagnostic. Thirty of the aspirants (34%) were diagnosed as benign, 54 were malignant (61%), 3 (3%) were suspicious for malignancy, and 2 (2%) were nondiagnostic. The most common diagnosis was squamous cell carcinoma (36%), followed by lymphoma (9%), adenocarcinoma (5%), and pleomorphic adenoma (5%) (Tables 2 and 3). Of the 81 patients, 57 (70%) had a history of malignancy, whereas the remaining 24 did not. Seven of the malignant aspirates provided an initial diagnosis, whereas the remaining 47 diagnosed recurrence or metastatic disease. Surgical biopsy specimens were available for 45 (56%) of the patients. Of these, 41 (91%) were consistent with the FNAB diagnosis while 4 (9%) disagreed. Two of the disagreements had a benign diagnosis for both the FNAB and the surgical specimen. In a third case, both the FNAB and the surgical biopsy showed a small round cell malignant neoplasm. The FNAB was diagnosed as recurrent disease, whereas electron microscopy of the surgical biopsy showed a new primary small cell neoplasm, rhabdomyosarcoma. In the fourth disagreement, a diagnosis of adenocarcinoma was made by FNAB, whereas the surgical specimen showed malignant fibrous histiocytoma. Of the three FNABs that were considered suspicious for, but not diagnostic of, malignancy two were subsequently proven malignant by surgical specimen. The third case was in a patient with Table 1.

Table 2.

BIOPSY: 89 HEAD AND NECK CASES

Malignant Diagnoses

No. of

Diagnosis

Cases

Squamous cell carcinoma Adenocarcinoma Lymphoma (non-Hodgkin ‘s) Carcinoma (NOS) Hodgkin’s disease Malignant melanoma Basal cell carcinoma Embryonal carcinoma Merkel cell carcinoma Retinoblastoma Synovial sarcoma

30 5 5 4 3 2 1 1 1 1 1

Total

54

known previous malignant disease and the patient was treated nonsurgically for a recurrent malignancy without further biopsy confirmation. In this case two aspirates were called nondiagnostic due to lack of cellularity. There were no complications found upon review of the 89 head and neck aspirations . Discussion

The accuracy of FNAB is rarely below 80% and false-positive reports are almost nonexistent. Sismanis et a1,7 in their series of head and neck aspirations, reported an overall concurrence rate between cytologic and histologic findings in benign and malignant tumors of 82.2%. This included a false-negative rate of 5.6% and no false-positive results. Cohen et al” compared FNAB with frozen section for salivary gland tumors and reported that 85% of 40 lesions were completely and accurately diagnosed. A 94.5% overall accuracy rate was reTable 3.

Sites of FNABs

Benign Diagnoses Diagnosis

No. of Cases 5 5 3 3 2 2 2 2 1 1 1 1 1 1

Site

No. of Cases

Neck Submandibular Parotid Preauricular Postauricular Mandible scalp Submental Cheek Face Oropharynx Tongue

45 16 13 3 2 2 2 2 1 1 1 1

Pleomorphic adenoma Sialadenitis Lipoma Inflammation Benign salivary gland Fibrous connective tissue Monomorphic adenoma Reactive node Fat, muscle Lymphangioma Neuroma Oncocytoma Reactive muscle (torticollis) Warthin’s tumor

Total

89

Total

30

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PLATT ET AL

Table 4. Comparing Accuracy Rates oi FNAB Series

Frable and Frable” Chu and Hoyei6 Frable” Young et al8 Engzell et a!” Meyers et al” O’Dwyer et alI9 Thompson et al*’

No. in Series

Overall Accuracy (%I

567

98

86 195 513 257

Specificity (%)

Sensitivity (%)

99.3

97.9

96.0 95.9 94.5

100 100 97.1

96 95.9 91.5

93.3

100

93.4

78

90

100

90

341

90

94

73

33

8.5

97

88

ported by Young et al* in their series of more than 500 FNAB on head and neck lesions. Frable and Frablet3 reported a histologic specificity of 98%, with a false-positive rate of 0.7% and a falsenegative rate of 2.1% in their series of 567 thinneedle biopsies of head and neck lesions. Scher et al,” in their report on FNAB in the oral cavity, orophraynx, and nasopharynx, reported a positive predictive value of 100% for patients with and without prior history of head and neck malignancy. Generally, when sparsely cellular or poorly preserved specimens are excluded, the accuracy is greater. If the FNAB provides inconclusive samples, then the patient should be considered for open surgical biopsy. Table 4 reviews several large reports in the literature in regard to accuracy rate. With the use of a very fine needle (23-25 gauge), FNAB has been found safe and remarkably free of complications. Safety and simplicity have become the hallmarks of this procedure. Sismanis et al’ reported no complications in their series of 101 patients. They noted that bleeding is easily controlled and usually stops within a few seconds. In Frable and Frable’s13 series of 567 head and neck lesion aspirations, one small hematoma was reported following aspiration of a submaxillary node. Raju et al9 cited no complications in a series of 52 palpable head and neck masses and noted that this technique can be performed safely in children without having to restrain the child. Fine needles cause so little discomfort that local anesthesia is generally not used. The concern that FNAB may cause implantation of malignant cells along the needle tract should not be dismissed lightly. However, a search of the literature reveals only three such cases despite many

reports involving thousands of uncomplicated cases. Ferruci et al” reported the seeding of a poorly differentiated inoperable pancreatic carcinoma 3 months after aspiration of the tumor with a 22-gauge needle. Most documented cases of needle tract seeding involve needles larger than 20 gauge. 22-25 Smith et a12’j reported the cutaneous seeding of a pancreatic cancer by “skinny needle” biopsy; however, they did not report the size of the needle used. Sinner and Zajicek2’ reported one case of 20-gauge needle tract tumor implantation in 5,300 cases of FNAB for malignant tumors. The implanted tumor was an inoperable squamous cell carcinoma which had already involved the chest wall. FNAB diagnosis is usually more rapid than surgical biopsy diagnosis because there is not tissue embedding and sectioning required. Rapid staining of some slides permits a preliminary diagnosis within a few minutes for many lesions.‘” Rapid diagnosis not only allows for more efficient treatment planning, but also helps to alleviate patient anxiety. A traditional hematoxylin-eosin section may take 2 to 7 days before completion. Frable and Frable13 also have stated that they consider the technique essentially painless because of the narrow diameter of the needle. Another advantage of this technique is its simplicity and low cost, requiring only equipment readily available in most outpatient clinics. The entire cost of essential materials for an aspiration biopsy is less than $1. Total cost to the patient can be as little as the surgeon’s clinic appointment fee and the pathologist’s cytologic diagnosis fee. Open biopsy still requires operating room scheduling and personnel, regional or general anesthesia, possible hospitalization, and a return clinic appointment for wound check and suture removal. When the FNAB diagnosis is benign and there is no need for excisional biopsy and hospitalization, savings to the patient can be as much as $2,000.28 If patients must travel long distances to the surgeon’s office, then reduction in number of visits is an added benefit of FNAB. The FNAB technique is repeatable and a resample can be taken easily if the initial pass is inadequate or if additional material is needed for special tests, such as culture. It can be safely performed in pregnant and high-risk patients. The patient can be either supine or sitting. Aspiration specimens also can be taken for special staining or electron microscopy. FNAB leaves no scar. However, it should be stressed that FNAB of a cervical lymph node, when positive for a malignant disease such as squamous cell carcinoma, should not prevent the clinician from a diligent search for the primary lesion using

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FINE-NEEDLE

thorough physical examination of the head and neck as well as other diagnostic studies. References 1. Kun M: A new instrument

2. 3. 4. 5. 6.

7. 8. 9. 10. 11.

12.

13.

for the diagnosis of tumors. Monthly J Med Sci 7:853, 1847 Grieg E, Gray A: Note on the lymphatic glands in sleeping sickness. Lancet 1:1590, 1904 Martin H, Ellis E: Biopsy by needle puncture and aspiration. Ann Surg 62:169, 1930 Martin H, Ellis E: Aspiration biopsy. Surg Gynecol Obstet 59578, 1943 Stewart FW: The diagnosis of tumors by aspiration. Am J Path01 9:801, 1933 Franzen S, Giertz G, Zajicek J: Cytologic diagnosis of prostatic tumors by transrectal aspiration biopsy. Br J Urol 32:193, 1960 Sismanis A, Strong MS, Merriman J: Fine needle aspiration biopsy diagnosis of neck masses. Otolaryngol Clin North Am 13:421, 1980 Young JE, Archibald SD, Shier K: Needle aspiration cytologic biopsy in head and neck masses. Am J Surg 142:484, 1981 Raju G, Kakar P, Das D, et al: Role of tine needle aspiration in head and neck tumors. Laryngol Otol 102:248, 1988 Frable W: Thin-needle aspiration biopsy: A personal experience with 469 cases. Am J Clin Pathol 63:168, 1976 Cohen M, Ljung BM, Boles R: Salivary gland tumors: Fine needle aspiration vs frozen-section diagnosis. Arch Otolaryngol Head Neck Surg 112:867, 1986 Frable W, Frable M: Thin-needle aspiration biopsy in the diagnosis of head and neck tumors. Laryngoscope 84: 1069, 1974 Frable W, Frable M: Thin-needle aspiration biopsy, the diagnosis of head and neck tumors revisited. Cancer 43: 1541,1979

J Oral Maxillofac 48:706-707.

ASPIRATION:

A DISCUSSION

14. Frable W: Fine-needle aspiration biopsy: A review. Human Path01 14:9, 1983 15. Scher RL, Petronella EO, Levine PA, et al: Role of fine needle aspiration in the diagnosis of lesions of the oral cavity, oropharynx and nasopharynx. Cancer 62:2602, 1988 16. Chu E, Hoye R: The clinician and the cytopathologist evaluate the need for line needle aspiration cytology. Acta Cytol 17:413, 1973 17. Engzell V, Jakobsson P, Sigurdson A, et ah Aspiration biopsy of metastatic carcinoma in lymph nodes of the neck. Acta Otolaryngol72:138, 1971 18. Meyers 0, Oregon E, Templer T, et al: Aspiration cytology for diagnosis of head and neck masses. Otolaryngology 86:650, 1978 19. O’Dwyer P, Farrar W, James A, et al: Needle aspiration biopsy of major salivary gland tumors. Cancer 57:554, 1986 20. Thompson J, Andreassen J, Bargsbo C: Fine needle aspiration biopsy of tumors of the head and neck. J Laryngol Otol 87:1211, 1973 21. Ferrucci J, Wiltenberg J, Margolies M, et al: Malignant seeding of the tract after thin-needle aspiration biopsy. Radiology 130:345, 1979 22. Reincke J: Zwei falle von kresbsimfung in punctionskanalen bei carcinomatoses peritonitis. Virchows Arch 51:319. 1870 23. Dolley FS, Jones JD: Lobectomy and pneumectomy for lung sunnuration and malignancv. Lancet 59: 162, 1939 24. Dutra-FR, Geruci LL: Needle biopsy of the ‘lung. JAMA 155:21, 1954 25. Wolarsky H, Lischner MW: Needle track implantation of tumor after percutaneous lung biopsy. Ann Intern Med 71:359, 1969 26. Smith FP, MacDonald JS, Schein PS, et al: Cutaneous seeding of pancreatic cancer by skinny-needle aspiration biopsy. Arch Intern Med 140:855, 1989 27. Sinner N, Zajicek J: Implantation metastasis after percutaneous needle aspiration biopsy. Acta Radio1 Diagn 17:473, 1976 28. Frable M, Frable W: Fine-needle aspiration biopsy revisited. Laryngoscope 92:1414, 1982

Surg

1990

Discussion Fine-Needle Aspiration: An Analysis of 89 Head and Neck Cases James

C. Burns, DDS, PhD

Medical College of Virginia School of Dentistry, Richmond

The authors have exposed the attributes of tine-needle aspiration biopsy and stated that “the field of oral and maxillofacial surgery seems to have neglected its use.” Assuming this to be true, there can be only two reasons for this neglect: 1) it is unintentional (reversible with proper knowledge and education); or, the converse, 2) it is intentional. While I strongly favor broader use of this excellent technique, allow me to offer some cautionary comments. A major area of concern is sampling error. The technique is exacting in that proper placement of the needle,

amount of suction, and timing of the suction are critical. The aperture of the needle should sample only the lesion itself, no adjacent “normal” tissue. If the lesion is not homogenous (eg, pleomorphic adenoma, War-thin’s tumor, areas of massive necrosis intermixed with viable tumor, etc), numerous samplings are required to capture the true essence of the lesion. The amount of suction also is very important. During insertion and withdrawal of the needle into and out of the lesion, it should be zero, whereas the amount of suction while the needle’s aperture is within the lesion should vary from minimal to maximal so as to produce a “pumping” action. Too much suction can cause the sample to be aspirated into the syringe rather than only the needle, causing real difficulty in expressing the material onto a glass slide. Positive pressure should be applied only while expressing the sample onto the slide, and then only after disconnecting the syringe from the needle, filling it with air, and reconnecting it to the needle. Through-

Fine-needle aspiration biopsy: an analysis of 89 head and neck cases.

In a recent 2-year period, 89 fine-needle aspiration biopsies (FNAB) were performed on head and neck lesions in 81 patients from 6 to 97 years of age...
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