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INTRODUCTION

The first description of the removal of tumor cells by needle for pathology analysis with microscope was made by Kun20 in 1847. From then on, many authors have published different methods of needle puncture of tumors in different sites of the human body11. However, the technique we know today as fine needle aspiration biopsy (FNAB) was described in details and became popular only in the 50's, in Scandinavia12, 20.

There are innumerous pathologies that may initially manifest as a cervical mass and diagnosis is not simple in many occasions, that is, it takes more than clinical aspects and imaging techniques3, 15, 17. It is exactly for neck lesions that FNAB has demonstrated its main application, since it is a simple, safe and effective method to perform differential diagnosis of such pathological processes4, 7 16.

The indications of FNAB in cervical lesions have been stricter, but today most authors advocate its practice in all patients who have undefined cervical tumors, that is, when we are not one hundred percent sure about the clinical diagnosis4, 7. Many studies have shown its great application in the pediatric population18, 19.

In the Service of Otorhinolaryngology at Hospital de Clínicas, Porto Alegre (HCPA), we have a routine practice of FNAB in cervical tumors and the purpose of the present study was to determine the diagnostic performance of biopsies made by our center.

MATERIAL AND METHOD

We conducted a retrospective study by reviewing medical charts of all patients submitted to FNAB of the cervical region at HCPA between July 1998 and December 1999. Exclusion criteria were: 1. Thyroid gland FNAB; 2. Incomplete medical charts; 3. Lack of outpatient follow-up; 4. Absence of definite diagnosis of the lesion submitted to FNAB.

Cytopathological results of FNAB were compared to the definite diagnosis of the mass submitted to punch, and the patients were divided into two groups: those that underwent tumor resection and presented pathology analysis of the piece for diagnostic comparison, which were group I. Patients in group II had definite diagnosis of punch cervical mass given by clinical evolution, other tests or biopsy performed in other sites.

TECHNIQUE

FNAB were performed according to the technique routinely used in our service, as described below.

Punches were made in the medical office, patients were seated in the Otorhinolaryngology chair. The head was turned to the side opposed to the lesion, so that the mass became palpable, and little soft tissue had to be perforated upon the introduction of the needle.

We performed skin anti-sepsis on the site with iodine alcohol. We coupled a 21 gauge needle to a 20ml syringe and introduced it in the lesion with the dominant hand, whereas we held the mass with the other hand. After the introduction of the needle, we made negative pressure by pulling the embolus and the set needle/syringe was moved some times in and out the mass so that the cells detached from the tumor could be placed inside the needle. After it, we suspended the negative pressure and, without the vacuum, the needle was removed and a small compressive dressing was placed on the punch site to avoid the formation of hematomas.

The collected material was placed on glass slides and a coverslip spread the material. We sent 4 slides to the lab: two dry slides for Romanovsky and Giemsa methods and two in ethyl alcohol at 95% for Papanicolau technique. The material was identified and immediately taken to the cytopathology lab by the patients.

Patients came back after one week to learn about the results. All collections initially classified as not satisfactory were made again, following the same technique.

RESULTS

Seventy-eight patients were initially selected and 8 were excluded (2 owing to lack of follow-up, one because of no definite diagnosis and 5 for incomplete charts). Patients submitted to thyroid FNAB were excluded from the initial selection of subjects. Out of 70 patients, 33 were in Group I (with subsequent pathology) and 37 were in Group II (without pathology analysis).

In group I, two patients (6%) had unsatisfactory results after two FNAB. Among those with satisfactory results, 87.1% (27) cases proved to be correct compared to the pathology, whereas 12.7% (4) cases had the wrong diagnosis. Among the diagnostic mistakes in the group, there was one false negative of malignant cells (cytopathology demonstrated pleomorphic adenoma and pathology resulted in well differentiated epidermoid carcinoma), another false positive for malignant cells (cytology with diagnosis of epidermoid carcinoma and pathology showed Warthin's tumor) and two cases were mistakes in type of malignant cells (both had cytopathological diagnosis of epidermoid carcinoma and pathology showed non-Hodgkin lymphoma).

In group II, 3 cases of FNAB were not satisfactory after two attempts (8%). Among the 34 patients with satisfactory FNAB for lab analysis, 30 (88.2%) had correct diagnosis and in 4 (11.8%) there were diagnostic mistakes. Out of 4 mistakes, two were false negatives for malignant cells (both had negative cytopathology and with clinical evolution, they turned out to be head and neck carcinomas) and the other two types of malignant cells (both cytopathology analyses showed epidermoid carcinoma and the definite diagnosis was non-Hodgkin lymphoma, given by biopsy in other points).

Upon the analysis of the total group of patients (70), the total unsatisfactory FNAB after two attempts was 7%. When we considered the first attempt, 18% of the cases showed unsatisfactory material for cytopathology. Among the satisfactory results, 88.6% of them were correct. Excluding the diagnoses of lymphoma, correct or not, the rate of correct diagnosis increased to 94.3%.

Upon analyzing the total number of patients submitted to FNAB in our service that resulted in correct diagnosis (that is, considering together failures of unsatisfactory material and lab mistakes), we reached the rate of 81.5%.

DISCUSSION

Fine needle aspiration biopsy was introduced in 1847 by Kun. However, its practice was not followed until the 40's and 50's, especially because of the high rates of complications described, related to exaggerated diameter of needles at the time20. As from 1950, after the description of the technique by the Scandinavian group, the technique currently considered as classical was adopted all over for investigation of neck expansive damage9, 12.

Complication rates are very low, amounting to less than 1% in some series13. FNAB has been successfully used also in pediatric applications18, 19, 20.

Considering the process since the indication of FNAB and its final cytopathology result, there are two key points that may lead to mistakes: material collection and assessment by cytopathology.

Collection mistakes are situations in which the material is considered unsatisfactory for analysis, that is, it can not be submitted to cytopathology. Such mistakes may be the result of some already defined failures. First of all, similarly to all medical procedures, the FNAB technique should be respected in order to produce good results. The literature reports seem to agree with 20ml syringes and 21 gauge needles. Cannon et al.6, in 1995, conducted a quantitative study with material aspirated by FNAB comparing 5, 10 and 20ml syringes and 21, 23 and 27 gauge needles. The best combination was the traditionally used one (20ml syringes and 21 gauge needles). It is essential to apply negative pressure during the introduction of the syringe in the mass and that it is interrupted before removing it. Any other material, such as blood, such be discarded and a new FNAB performed.

The experience of the collecting professional is also an important factor for the results of FNAB. Jandu and Webster14 compared the accuracy of FNAB performed by resident physicians and more experienced physicians and they found a statistically significant difference between the groups. The use of imaging techniques (ultrasound and computed tomography) to guide the FNAB improves the method accuracy8, 22, but they are not available in large scale. In Brazil, we indicate US-guided punch only in deep neck masses, when safety is not the same as for the procedures performed in the office.

If the collected material is satisfactory, the subsequent failures are related to the cytopathology analysis. First of all, the cytopathologist must be experienced in assessing material collected by FNAB 4, 16, 21. In addition, according to the type of tumor studied, there is more or less likelihood of correct diagnosis. Cystic lesions are more difficult to diagnose by FNAB than solid tumors7. The main diagnostic difficulty in FNAB, however, lies in lymphoproliferative lesions5, 10, because in many cases it is impossible to define the type of cells. In the series we presented, once we excluded the patients with diagnosis of lymphomas, correct or not, we increased the rate of correct diagnosis from 88.6% to 94.3%.

The percentage of unsatisfactory results described in the literature ranges from 9.2% to 12.4%3, 7, 11, 14 and our rate was 7%, within the expected parameters. Similarly, our general results of correct diagnoses with FNAB were close to the ones published by the literature in the area. Fulciniti et al.13 found 96.2% accuracy in benign lesions and 86.4% in malignant lesions, in a retrospective study of 218 FNAB. Carrol et al. assessed 78 FNAB performed and followed by surgical removal of the biopsied mass with pathology analysis, and they found accuracy of about 95%7. Mobley et al.18, in 1991, assessed 67 FNAB in children and the correct results were found in 90% of the cases. These are the studies with the highest accuracy rates; there are innumerous others with results ranging from 82% to 89% 1, 8, 11, 16.

CONCLUSION

The rate of correct cytology diagnosis of neck tumors with fine needle aspiration biopsy is high, which makes the method a useful tool for the differential diagnosis of such pathologies.

REFERENCES

1. AKHTAR, S.; HUQ, I.; FAIZ-U-DIN, M.; REYES, L. - Efficacy of fine-needle capillary biopsy in the assessment of patients with superficial lymphadenopathy. Cancer, 81(5):277-80.
2. ALVI, A.; JOHNSON, J. - The neck mass. Postg Medicine, 97(5):87-97, 1995.
3. BHATTACHARYYA, N. - Predictive factors for neoplasm and malignancy in a neck mass. Arch Otolaryngol Head Neck Surg 125:3037, 1999.
4. CAMINHA, G.; LUBIANCA NETO, J.; KUHL, G. - Punção aspirativa por agulha fina no diagnóstico de tumores de cabeça e pescoço. Rev Bras Otorrinolaringologia 62 (3):246-50, 1996.
5. CANNON, C.; RICHARDSON, L. -Value of flow cytometry in the evaluation of head and neck fine-needle lymphoid aspirates: a 3-year retrospective review of a community-based practice. Otolaryngol Head Neck Surg, 124:544-8, 2001.
6. CANNON, C.; RICHARDSON, L.; REPLOGLE, W.; HALLORAN, R. - Quantitative evaluation of fine-needle aspiration. Otolaryngol Head Neck Surg, 114(3):407-12, 1996.
7. CARROL, C.; NAZEER, U.; TIMON, C. - The accuracy of fine-needle aspiration biopsy in the diagnosis of head and neck masses. Ir J Med Sc, 167(3):149-51, 1998.
8. COLNOT, D.; NIEUWENHUIS, E.; BREKEL, M. et al. - Head and neck squamous cell carcinoma: US-guided fine-needle aspiration of sentinel lymph nodes for improved staging. Radiology, 218:289-293, 2001.
9. COSTA, S.S.; RIBEIRO, E.; ROLLIN, G. et al. - Massas cervicais. In COSTA, S.S.; CRUZ, O.; OLIVEIRA, J.Á. Otorrinolaringologia: princípios e práticas. Ed Artes Médicas, Porto Alegre. 520 - 35, 1996.
10. DASKALOPOULOU, D.; TAMIOLAKIS, D.; TSOUSIS, S. et al. - Sources of discrepancies in the diagnosis of Hodgkin's disease by fine-needle aspiration. Arch Anat cytol Path 44(4):166-73, 1996.
11. FRABLE, M.; FRABLE, W. - Thin-needle aspiration biopsy in the diagnosis of head and neck tumors. Laryngoscope, 84:1069- 76, 1974.
12. FRABLE, M.; FRABLE, W. - Fine-needle aspiration biopsy revisited. Laryngoscope, 92:1414-18, 1982.
13. FULCINITI, F.; CALIFANO, L.; ZUPI, A.; VETRANI, A. - Accuracy of fine-needle aspiration biopsy in head and neck tumors. J Oral Maxillofac Surg, 55(10):1904-7, 1997.
14. JANDU, M.; WEBSTER, K. - The role of operator experience in fine-needle aspiration cytology of head and neck masses. Int J Oral Maxillofac Surg, 28(6):441-4, 1999.
15. MAISEL, R. - When your patient complains of a neck mass. Geriatrics, 108:103-8, 1980.
16. MANDELL, D.; GENDEN, E.; BERGMAN, D. et al. - Diagnostic accuracy of fine-needle aspiration and frozen section in nodular thyroid disease. Otolaryngol Head Neck Surg, 124:531-6, 2001.
17. McGUIRT, W. - The neck mass. Medical Clin North Am, 83(1):219-234.
18. MOBLEY, D.; WAKELY, P.; FRABLE, M. - Fine-needle aspiration biopsy: application to pediatric head and neck masses. Laryngoscope 101:469-72, 1991.
19. PARK, Y. - Evaluation of neck masses in children. Am Fam Physician, 51(8):1904-12, 1995.
20. RAMADAN, H.; WAX, M.; Boyd, C. - Fine-needle aspiration of head and neck masses in children. Am J Otolaryngol, 18(6):400-4, 1997.
21. REIBEL, J. - The patient with a neck mass. Comp Ther, 23(11):737-41, 1997.
22. SACK, M.; WEBER, R.; WEINSTEIN, G. et al. - Image-guided fine-needle aspiration of the head and neck. Arch Otolaryngol Head Neck Surg, 124:1155-61, 1998.

[1] Undergraduate, Medical School, University of Pelotas - RS.
[2] Undergraduate, Medical School, University of Pelotas - RS.
[3] Resident Physician, Service of Otorhinolaryngology, Hospital de Clínicas de Porto Alegre.
[4] Joint Professor, Department of Ophthalmology and Otorhinolaryngology, Medical School, Federal University of Rio Grande do Sul.

Affiliation: Hospital de Clínicas de Porto Alegre - HCPA.

Address correspondence to: Rua Ramiro Barcelos 2350, Zona 19 / Hospital de Clínicas de Porto Alegre - 90035-003 - Tel: (55 51) 3316 8164 / 3343 9212 - E-mail: mariamagnussmith@hotmail.com

Study presented as Free paper at II Congresso Triológico - August 2001.