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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 54  |  Issue : 3  |  Page : 79-84

Effectiveness of fine needle aspiration cytology versus excisional biopsy in cervical lymphadenopathy


1 Department of General Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
2 Department of Pathology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
3 Department of Biostatistics, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission27-Jun-2020
Date of Decision17-Aug-2020
Date of Acceptance27-Oct-2020
Date of Web Publication12-Jun-2021

Correspondence Address:
Riju Ramachandran
Department of General Surgery, Amrita School of medicine, Amrita Viswavidyapeetham, Kochi 682-24, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_104_20

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  Abstract 


Background: Cervical lymphadenopathy is a common cause of referral to the surgery department. In low-resource countries, fine-needle aspiration cytology (FNAC) has been advocated as an alternative to more expensive surgical excision biopsies. Although FNAC is a simple and effective procedure in many conditions, its sensitivity and specificity still remains a question.
The primary aim of our study was to evaluate the sensitivity and specificity of FNAC of head-and-neck lymph nodes using histopathology as the gold standard.
Methods: All patients clinically diagnosed with cervical lymphadenopathy were included in the study, and they underwent FNAC followed by surgical excision and histopathology. The results were tabulated and analyzed using IBM SPSS V.20.0 software. To test the statistical significance between benign and malignant groups, Chi-square test was used, and the difference in FNAC and histopathology were analyzed using McNemar's test.
Results: The mean age group in our study of 86 patients was 45.20 ± 18.20 years with equal sex distribution. Among 23 male patients with age above 45 years, 15 patients (65.2%) had malignancy in the lymph node. Level V lymph nodes were most commonly involved (n = 31 [36%]), of which 13 were diagnosed as malignancy and 10 as tuberculosis (TB). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value of FNAC in comparison to histopathology for diagnosis of malignancy were found to be 79.4%, 98.1%, 96.4%, and 87.9%, respectively, and for TB was 77.8%, 87.5%, 87.5%, and 77.8%, respectively.
Conclusion: FNAC of head-and-neck lymph nodes has comparable sensitivity and specificity with histopathological examination. It has a very high (96.4%) PPV in detecting malignancy and 100% for detecting metastatic disease in cervical lymph nodes. In patients with suspected lymphoproliferative disorder and in patients above 45 years of age, open biopsy is recommended. For younger patients and in level V cervical lymphadenopathy, irrespective of age, FNAC should be the first invasive diagnostic tool of choice.

Keywords: Cervical lymphadenopathy, excision, fine-needle aspiration cytology, surgery


How to cite this article:
Pillai AV, Ramachandran R, Borkar PV, Bhaskaran R. Effectiveness of fine needle aspiration cytology versus excisional biopsy in cervical lymphadenopathy. Formos J Surg 2021;54:79-84

How to cite this URL:
Pillai AV, Ramachandran R, Borkar PV, Bhaskaran R. Effectiveness of fine needle aspiration cytology versus excisional biopsy in cervical lymphadenopathy. Formos J Surg [serial online] 2021 [cited 2021 Jul 24];54:79-84. Available from: https://www.e-fjs.org/text.asp?2021/54/3/79/318210




  Introduction Top


Lymphadenopathy is categorized by abnormalities in the size and character of the lymph nodes and may be primary or secondary. The head-and-neck lymph nodes are grouped and neck dissections are classified based on recommendations of the Committee for Head-and-Neck Surgery and Oncology of the American Academy of Otolaryngology.[1] Cervical lymphadenopathy can be due to diverse causes including infections like tuberculosis(TB) and human immunodeficieny virus, lymphoma , metastasis and autoimmune disease.[2] Fine-needle aspiration cytology (FNAC) has become an integral part of the initial diagnosis and management of patients with lymphadenopathy. It provides for an early availability of results, ease of procedure to the physician, and minimal trauma with fewer complications to the patients.[3],[4] While in many centers an excision biopsy is considered as the gold standard in diagnosis, it has the disadvantage of the need for anesthesia as well as longer reporting times.[5] Compared to open biopsy, results are much quicker with FNAC.[4]

In our institution, we found that there was a disparity between various departments regarding indication for and requirement of FNAC versus excision biopsy when referring the patient to us for cervical node biopsy. In many instances, we found that patients requiring a simple FNAC were sent to us for excision biopsy without an FNAC being done. In some instances, the reverse also has happened. This study was aimed at finding out the definitive indication of FNAC versus excision biopsy in a given patient with cervical lymphadenopathy.


  Materials and Methods Top


The study was conducted in our institution, a tertiary referral center, between May 2016 and September 2018. Approval for the study was obtained from the Institutional Review Board and Ethics Committee (Dissertation review/MD/MS/2016/21). All patients presenting to our institution with a finding of cervical lymphadenopathy for evaluation were enrolled. These patients were either admitted under general surgery or had been referred to us for the requirement of lymph node biopsy as a mode of evaluation from other departments irrespective of primary diagnosis.

Our primary objective was to evaluate the sensitivity and specificity of FNAC of cervical lymph nodes versus excisional or open biopsy. The secondary objective was to evaluate clinical indications for an excisional lymph node biopsy.

A detailed clinical history was obtained and examination was carried out. Details of age, sex, site, and size of enlarged lymph nodes were noted. A detailed, informed consent was taken from all of the patients.

Aspiration of the lymph node was done under aseptic precautions using a 22–23G needle and a 10 ml syringe. Following the aspiration, the adequacy and nature of the aspirated material were assessed and were confirmed by the cytologist. Several smears were prepared. Smears were immediately fixed by air drying and in 100% alcohol and examined under a microscope after adequate staining by a cytologist. The slides were examined to determine the cytomorphological features which included adequacy, cellularity, the arrangement of cells, and nuclear as well as cytoplasmic features. The background of all slides was noted for the presence of necrosis and granuloma formation as well as for the type of inflammatory cells.

Lymph node excision biopsy was done in all the patients, and the specimen was subjected to histopathological examination. The procedure was done under local or general anesthesia as per the fitness or preference of the patient. In all patients, excision was done between 7 and 14 days after the FNAC due to logistical issues such as patient fitness and theater availability. The cytopathological diagnosis was then compared with the histopathological results of the same excised nodes. In cases of any discrepancy in the results, histopathological results were considered the gold standard for treatment purposes.

Based on the sensitivity of FNAC with respect to histopathology observed in an earlier publication by Arakeri and Gandhi and with 95% confidence and 10% precision, the minimum sample size was 86.[6]

Statistical analysis was performed using IBM SPSS statistics for windows, version 20.0 (IBM Corp., Armonk, NY, USA). Categorical variables are expressed using frequency and percentage and numerical variables using mean and standard deviation. Statistical significance of comparison of various factors between benign and malignant groups was done using the Chi-square test. Statistical significance of the difference in FNAC and histopathology results was tested using McNemar's test. P < 0.05 was considered as statistically significant. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were also calculated.


  Results Top


We had 86 patients included in the study with an equal sex distribution. The mean age of the study population was 45.20 ± 18.20 (14–83 years). Since the people in the age group <45 years are considered young and 45–65 are considered middle age, we used 45 as a cutoff for statistical correlation.[7] Out of 43 patients aged <45 years, 31 patients were found to have a benign disease, and in patients aged above 45 years, 22 patients (51%) were diagnosed with malignancy [Table 1]. Among the 23 male patients with age above 45 years, 15 patients were found to have a malignancy in lymph node [Table 1]. The result showed borderline statistical significance (P = 0.069). [Table 2] shows the sensitivity and specificity of FNAC in detection of malignancy separately for each age group. The accuracy of FNAC to diagnose malignancy is higher in younger age groups (11–30 years) with 100% and lowest in the age group of 61–70 years with an accuracy of 75%. However, P value is not significant in any age group.
Table 1: Association of age and sex with malignancy

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Table 2: Comparison of fine-needle aspiration findings with histopathology findings according to different age groups

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Malignancy was detected in 28 patients using FNAC and confirmed by histopathology in 27 (96.4%). We had 16 cases cytologically diagnosed as metastasis, and all 16 (100%) were confirmed by histopathological examination giving a 100% diagnostic accuracy for diagnosis of metastatic disease. The sensitivity, specificity, PPV, NPV, and accuracy were 79.4%, 98.1%, 96.4%, 87.9%, and 90.7%, respectively [Table 3]. Similarly, in 16 patients detected to have TB on FNAC, 14 (77.8%) were confirmed on histopathology. The sensitivity, specificity, PPV, NPV, and accuracy were 77.8%, 87.5%, 87.5%%, 77.8%, and 82.3%, respectively [Table 4].
Table 3: Correlation of fine-needle aspiration cytology and histopathology for malignancy

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Table 4: Correlation of fine-needle aspiration cytology and histopathology for tuberculosis

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We had 19 patients with a confirmed diagnosis of various types of lymphomas on excision biopsy. However, when their FNAC results were seen, we found that 11 patients were reported as lymphoproliferative disease, 4 had hyperplasia, reactive change was reported in 2, and one case each of atypical cells and necrotizing inflammation. The actual type and classification of lymphoma were possible only with histopathology.

There were 31 patients with level V lymph node enlargement in our series. In this group, 13 patients were diagnosed with malignancy and 10 patients were found to have TB. [Table 5] shows the distribution of the risk of malignancy with each level of lymph node station.
Table 5: Distribution of level of the lymph node with the risk of malignancy

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  Discussion Top


Lymphadenopathy is a part of the spectrum of various serious illnesses such as TB, metastatic cancer, lymphoma, or reactive lymphoid hyperplasia. An excision followed by histopathology is considered as the gold standard in diagnosis. The disadvantages of excision biopsy include the need for anesthesia as well as longer reporting times. However, a FNAC provides an early, less painful, lower-cost preliminary examination in the investigation of lymphadenopathy with minimal discomfort to the patient.[8] FNAC can also be done as an outpatient procedure without the need for anesthesia.

Core-needle biopsy (CNB) in the cervical region has a higher risk of damage to adjacent structures such as the carotid artery and vagus nerve. Ultrasound-guided CNB can be done to achieve better precision. However, CNB cannot be done for lesions ≤1 cm and nodes that are abutting the carotid sheath. Hence, CNB was not considered in our series.[9]

Malignancy was found in 28 of our patients. This was confirmed in 27 (96.4%) after histopathology. Hence, we have a sensitivity, specificity, PPV, and NPV of 79.4%, 98.1%, 96.4%, and 87.9%, respectively, for FNAC in our series. This compares well with other series on the topic [Table 6]. The sensitivity of FNAC in our series was found to be lower in comparison to reported sensitivity in the other studies.[10],[11],[12] This could have been due to the fewer false-negative results of malignancy in most other studies.
Table 6: Efficacy of fine-needle aspiration cytology in malignancy

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TB, once thought to be under control, is now undergoing a resurgence globally. This dramatic increase in the number of cases is due to a growing number of drug-resistant strains.[13] In our series, 16 patients were detected to have TB on FNAC and were confirmed by histopathology in 14 (77.8%) of these patients. This gives FNAC a sensitivity, specificity, PPV, NPV, and accuracy of 77.8%, 87.5%, 87.5%, 77.8%, and 82.3%, respectively, in our series. The frequency of TB positivity in FNAC smears in various studies ranges from 70% to 100%.[14],[15],[16] [Table 7] shows a comparison of similar results from other series. Few patients were diagnosed with granulomatous lymphadenitis and could not be proved by FNAC to be TB due to the absence of caseation necrosis or acid-fast bacilli in the FNAC sample. We had a lower PPV as compared to other series due to this factor. This was easily made out in the histopathology of the nodes.
Table 7: Efficacy of fine-needle aspiration cytology in tuberculosis

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The diagnosis of metastatic disease on FNAC in our series had a 100% correlation with later histopathology. This result validates the effectiveness of FNAC. The report of our findings compares with most investigators who reported more than 90% accuracy rate.[17] Hafez and Tahoun reported 100% diagnostic accuracy for diagnosis of metastatic carcinoma to the lymph nodes by FNAC, which were similar to our results.[18]

In our study, it was detected that among the 23 male patients with age above 45 years, 15 patients (65.2%) were found to have a malignancy in the lymph node. This indicates that male patients above the age of 45 years need an excision biopsy more often as they have higher chances of having a malignancy. Similarly, Hafez and Tahoun[18] in their study of 157 patients noticed that metastatic cases (77.4%) were seen most often over the age of 45 years.

Female patients with age more than 45 years were found to have mostly benign (65%) disease. FNAC being less expensive and easier may be used as the primary tool of diagnosis in an elderly female with cervical lymph node enlargement since the risk of malignancy is lower.

On further detailed evaluation of the levels of lymph nodes and the etiology of lymph node enlargement [Table 5], it was found that 13 of the 31 cases of level V lymphadenopathy had malignancy. In patients aged above 45 years, 10 patients out of the 13 had a malignant disease. There were 10 cases of TB detected in level V lymph nodes. In a significant number of these patients, the diagnosis was missed on FNAC and was picked up in excision biopsy (29%). When there is a clinical suspicion of malignancy or TB in patients aged above 45 years with level V lymph node enlargement, a definite lymph node excision biopsy is warranted.

Lymphoproliferative disorders usually present with a wide range of symptoms and signs. They commonly present with fever or discrete rubbery lymph nodes and occasionally with symptoms related to the organ system affected. A high index of suspicion is required by the clinician in diagnosing this condition. Suspicion is based on their clinical presentation, the involvement of other nodes, and classical B symptoms with weight loss and loss of appetite. FNAC and excision of the lymph node will give a definite histological diagnosis.

Nineteen patients were detected to have lymphoma on excision biopsy which was considered to be the gold standard. However, we could detect only 11 lymphomas in FNAC. The sensitivity of FNAC to correctly identify the subtype of lymphoma is poor. Various studies quote 0%–68% sensitivity for FNAC to correctly identify the subtype of lymphoma.[19],[20] Excision biopsy in combination with immunohistochemistry is very specific for categorizing the subtype of lymphoma. A review of multiple related articles by Health Quality Ontario cited the sensitivity of FNAC in patients with excision biopsy-proven lymphoma to range from 25% to 95%.[21]

Young patients aged below 45 years had higher chances of benign enlargement of lymph nodes (72.1%). This indicates that in young patients with cervical lymphadenopathy, FNAC is a very good initial diagnostic tool. Whereas, reactive changes were less common in patients aged more than 45 years. Similar findings were noted in a study conducted by Hafez and Tahoun.[18] They have reported that reactive lymphoid hyperplasia was seen most often under the age of 40 years.

Limitation of the study

Our study included 86 patients, divided equally into two groups, below and above 45 years of age, as a part of thesis research for 2 years. A larger number and longer duration of study would have yielded a better result.


  Conclusion Top


FNAC of cervical lymph nodes has comparable sensitivity and specificity with histopathological examination. FNAC of cervical lymph nodes has a 96.4% PPV in detecting a malignancy and can detect metastasis with 100% accuracy. In the case of suspected lymphoproliferative disorders, an open biopsy is inevitable to establish a proper classification. An excision biopsy is recommended as the modality of choice in the diagnosis of cervical lymphadenopathy for male patients above 45 years of age. In patients with level V cervical lymphadenopathy, irrespective of age, an FNAC should be the first invasive diagnostic tool of choice as TB is more common in this lymph node station. In younger patients, an FNAC could be recommended as the initial diagnostic tool. In elderly patients with clinical suspicion, an excision biopsy would be more informative.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kumar H, Chandanwale SS, Gore CR, Buch AC, Satav VH, Pagaro PM. Role of fine needle aspiration cytology in assessment of cervical lymphadenopathy. Med J Dr DY Patil Univ 2013;6:400.  Back to cited text no. 14
    
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Karimi-Yazdi A, Motiee-Langroudi M, Saedi B, Ensani F, Amali A, Memari F, et al. Diagnostic value of fine-needle aspiration in head and neck lymphoma: A cross-sectional study. Indian J Otolaryngol Head Neck Surg 2014;66:277-80.  Back to cited text no. 19
    
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21.



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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