FINE NEEDLE ASPIRATION CYTOLOGY VERSUS …...6. Som PM, Silvers AR, Urken ML. Surveillance CT and...
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4 4 2 0 1 2 3 4 5 no.of patients no.of patients FINE NEEDLE ASPIRATION CYTOLOGY VERSUS DIRECT LARYNGOSCOPIC BIOPSY IN SUSPICIOUS LARYNGO-PHARYNGEAL MASSES Lakshminarasimman Parasuraman*, C hirom Amit Singh*, Suresh Chandra Sharma*, Alok Thakar*, V. Iyer#, Ashu Seith Bhalla^ Departments of *Otolaryngology Head & Neck Surgery,#Pathology, ^Radiology All India Institute of Medical Sciences, New Delhi, India Introduction Transcutaneous fine-needle aspiration biopsy (FNAB) is the method of choice for many palpable head and neck masses. 1-4 More useful when real-time ultrasound (US) or computed tomography (CT) are used to guide sampling 5-7. Gold standard for diagnosis of endolaryngeal lesions is microlaryngoscopic biopsy under general anaesthesia. In large tumours: Risk of breathing difficulties In severe cases, protective tracheotomy may be required 8. Aim To evaluate the feasibility and performance of ultrasound-guided transcutaneous FNAC of suspicious laryngo-hypopharyngeal masses & compare it with the biopsy reports. Methodology Informed written consent. Evaluation: History, Clinical examination, Examination by rigid telescope or fiberoptic laryngoscopy, Nodal status & metastatic work up, Computed tomography (contrast), platelet count, pro thrombin time (PT). Ultrasound screening scan. Test procedure Ultrasound scanning is performed using high frequency linear transducer probe. The tumour is visualized as an irregular hypo echoic mass. While continuing to visualize the mass, a 21-gauge needle attached to a syringe is passed into the mass. Approach for USG aspiration: Supraglottic lesions: through the thyrohyoid membrane Subglottic lesions: through the cricothyroid ligament Hypopharyngeal lesions: lateral to the free edge of the thyroid cartilage. The needle will be repeatedly thrust into the tumour until a drop of blood is seen in the hub of the needle. The suction is released, and the needle is withdrawn. The specimen obtained is transferred to glass slide, stained with Papanicolaou & Giemsa stain and examined under microscope. Patient will be under observation for 4 hours. Gold standard test: Direct laryngoscopy Next day - Direct laryngoscopy for biopsy & assessment of disease extent in operating theatre. specimens obtained by FNAC & biopsy - examined by pathologists. Computed tomography section demonstrating mass lesion in a patient with suspected squamous cell carcinoma of the larynx. Cytopathologic examination showing cell groups with nuclear hyperchromasia and thin cytoplasm, suggesting squamous cell carcinoma (Papanicolaou stain, ×40). Cytopathologic examination showing cell groups withnuclear hyperchromasia and thin cytoplasm, suggesting squamous cell carcinoma (Giemsa stain, ×40). Total no. of patients-10 Age distribution Sex TYPE OF LESION No. FNAC REPORT DIRECT LARYNGOSCOPY BIOPSY REPORT 1 12Y205-SQUAMOUS CELL CARCINOMA 1239660-MDSCC 2 13Y241-POORLY DIFFERENTIATED CA 13599-MDSCC 3 12Y207-SQUAMOUS CELL CARCINOMA 1239218-MDSCC 4 13Y662-SQUAMOUS CELL CARCINOMA 13600-NEGATIVE 5 13y652-SQUAMOUS CELL CARCINOMA 1236787-NEGATIVE 13934- NEGATIVE. 6 13Y736-ATYPICAL SQUAMOUS CELLS 1239221-MDSCC 7 13y1080-POORLY DIFFERENTIATED CARCINOMA 13785-MDSCC 8 13y2438-SQUAMOUS CELL CARCINOMA 132427-SCC 9 IN ADEQUATE SAMPLE MDSCC 10 13y2333-SQUAMOUS CELL CARCINOMA 133834-MDSCC INCONCLUSIVE REPORT: FNAC TYPE OF LESION STAGE-TNM REPORT SUPRAGLOTTIC CARCINOMA STAGE 3 ATYPICAL CELLS LARYNGO – HYPOPHARYNGEAL CARCINOMA STAGE 4 B IN ADEQUATE SAMPLE. DIRECT LARYNGOSCOPY BIOPSY: TYPE OF LESION STAGE-TNM REPORT RECURRENT TRANS- GLOTTIC CARCINOMA STAGE-4A NEGATIVE TRANS-GLOTTIC CARCINOMA STAGE-4B NEGATIVE DISCUSSION Direct laryngoscopic biopsy reported negative for malignancy in 2 patients of which one patient had recurrent trans glottic lesion & other had sub mucosal infiltrating transglottic lesion. But Usg guided -FNAC reported positive for squamous cell carcinoma in these 2 patients. 2 patients had negative FNAC of which one patient with supraglottic carcinoma(stage-3) & other with laryngo hypopharyngeal carcinoma (stage -4B). (Reason: Atypical cells/In-adequate sample). Positivity rate of 80%(8/10). LIMITATION: Less number of patients. Not useful in early stage disease. Needs experienced radiologists & pathologists CONCLUSION Although Direct laryngoscopy biopsy remains the gold standard technique, ultrasound guided FNAC can be used to diagnose advanced laryngo hypopharyngeal lesions. Availability of ultrasonography in primary health centres may help to diagnose these lesions at community level at an early stage for proper referral. Since patients are referred to higher Centre for management, this procedure can be used as preliminary investigation for tissue diagnosis. out-patient procedure. simple, safe, cost effective. particularly useful for patients contraindicated for general anaesthesia/inoperable due to advanced disease or those with a risk of tracheotomy due to intubation difficulties. BIBLIOGRAPHY 1. Fulciniti F, Califano L, Zupi A, Vetrani A. Accuracy of fine needle aspiration biopsy in head and neck tumors. J Oral Maxillofac Surg. 1997;55:1094–1097. 2. Jandu M, Webster K. The role of operator experience in fine needle aspiration cytology of head and neck masses. Int J Oral Maxillofacial Surg. 1999;28:441–444. 3. Dedivitis RA, De Carvalho MB, Rapoport A. Transcutaneous fine needle aspiration biopsy of the preepiglottic space. Acta Cytol. 2000;44:158–162. 4. Amedee RG, Dhurandhar NR. Fine-needle aspiration biopsy. Laryngoscope. 2001;111:1551–1557. 5. Abemayor E, Ljung BM, Ward PH, et al. CT-directed fine needle aspiration biopsies of masses in the head and neck. Laryngoscope. 1985;95:1382–1386. 6. Som PM, Silvers AR, Urken ML. Surveillance CT and the prompt use of CT-guided fine-needle aspiration in patients with head and neck cancer who have undergone surgery. AJR Am J Reontgenol. 1999;173:1505–1508. 7. DelGaudio JM, Dillard DG, Albritton FD, Hudgins P, Wallace VC, Lewis MM. Computed tomography-guided needle biopsy of head and neck lesions. Arch Otolaryngol Head Neck Surg. 2000;126:366–370. 8. Brouwer J, Bodar EJ, De Bree R, et al. Detecting recurrent laryngeal carcinoma after radiotherapy: room for improvement. Eur Arch Otorhinolaryngol. 2004;261:417–422 9. Ansarin M, De Fiori E, Preda L, Maffini F, Bruschini R, Calabrese L, Jereczek- Fossa BA, Chiesa F, Bellomi M (2007) Ultrasound-guided transcutaneous tru-cut biopsies to diagnose laryngopharyngeal masses. A pilot study. Cancer 109:2268– 2272. Massively calcified thyroid cartilage,Superficial cT1-T2 disease, Refusal for informed consent Highly vascular lesions/A-V malformations Inaccessible to usg e.g.. Shadowed by calcified cartilage. INCLUSION CRITERIA: Patients with suspected laryngo-pharyngeal disease, bulky endolaryngeal mass. EXCLUSION CRITERIA: Supraglottic Lesion Transglottic Lesion Laryngo hypopharyngeal Lesion
Transcript of FINE NEEDLE ASPIRATION CYTOLOGY VERSUS …...6. Som PM, Silvers AR, Urken ML. Surveillance CT and...
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FINE NEEDLE ASPIRATION CYTOLOGY VERSUS DIRECT LARYNGOSCOPIC BIOPSY IN SUSPICIOUS LARYNGO-PHARYNGEAL MASSES
Lakshminarasimman Parasuraman*, Chirom Amit Singh*, Suresh Chandra Sharma*, Alok Thakar*, V. Iyer#, Ashu Seith Bhalla^
Departments of *Otolaryngology Head & Neck Surgery,#Pathology, ^Radiology
All India Institute of Medical Sciences, New Delhi, India
IntroductionTranscutaneous fine-needle aspiration biopsy (FNAB) is the method of choice for many palpable head and neck masses. 1-4
More useful when real-time ultrasound (US) or computed tomography (CT) are used to guide sampling 5-7.
Gold standard for diagnosis of endolaryngeal lesions is microlaryngoscopic biopsy under general anaesthesia.
In large tumours:
Risk of breathing difficulties
In severe cases, protective tracheotomy may be required 8.
Aim To evaluate the feasibility and performance of ultrasound-guided transcutaneous FNAC of suspicious laryngo-hypopharyngeal masses & compare it with the biopsy reports.
Methodology Informed written consent.
Evaluation:
History, Clinical examination,
Examination by rigid telescope or fiberoptic
laryngoscopy,
Nodal status & metastatic work up,
Computed tomography (contrast), platelet count, pro
thrombin time (PT).
Ultrasound screening scan.
Test procedure
Ultrasound scanning is performed using high frequency linear transducer probe. The tumour is visualized as an irregular hypo echoic mass. While continuing to visualize the mass, a 21-gauge needle attached to a syringe is passed into the mass.
Approach for USG aspiration:
Supraglottic lesions:
through the thyrohyoid membrane
Subglottic lesions:
through the cricothyroid ligament
Hypopharyngeal lesions:
lateral to the free edge of the thyroid cartilage.
The needle will be repeatedly thrust into the tumour until a drop of blood is seen in the hub of the needle. The suction is released, and the needle is withdrawn. The specimen obtained is transferred to glass slide, stained with Papanicolaou & Giemsa stain and examined under microscope.
Patient will be under observation for 4 hours.
Gold standard test: Direct laryngoscopy
Next day - Direct laryngoscopy for biopsy &
assessment of disease extent in operating theatre.
specimens obtained by FNAC & biopsy - examined by
pathologists.
Computed tomography section demonstrating mass lesion in a patient with suspected squamous cell
carcinoma of the larynx.
Cytopathologic examination showing cell groups with nuclear hyperchromasia and thin cytoplasm,
suggesting squamous cell carcinoma (Papanicolaou stain, ×40).
Cytopathologic examination showing cell groups withnuclear hyperchromasia and thin cytoplasm,
suggesting squamous cell carcinoma (Giemsa stain, ×40).
Total no. of patients-10
Age distribution
Sex
TYPE OF LESION
No. FNAC REPORT DIRECT LARYNGOSCOPY BIOPSY REPORT
1 12Y205-SQUAMOUS CELL CARCINOMA 1239660-MDSCC2 13Y241-POORLY DIFFERENTIATED CA 13599-MDSCC3 12Y207-SQUAMOUS CELL CARCINOMA 1239218-MDSCC4 13Y662-SQUAMOUS CELL CARCINOMA 13600-NEGATIVE 5 13y652-SQUAMOUS CELL CARCINOMA 1236787-NEGATIVE 13934-
NEGATIVE.6 13Y736-ATYPICAL SQUAMOUS CELLS 1239221-MDSCC7 13y1080-POORLY DIFFERENTIATED
CARCINOMA 13785-MDSCC8 13y2438-SQUAMOUS CELL CARCINOMA 132427-SCC9 IN ADEQUATE SAMPLE MDSCC10 13y2333-SQUAMOUS CELL CARCINOMA 133834-MDSCC
INCONCLUSIVE REPORT: FNAC
TYPE OF LESION STAGE-TNM REPORT
SUPRAGLOTTIC CARCINOMA
STAGE 3 ATYPICAL CELLS
LARYNGO –HYPOPHARYNGEAL CARCINOMA
STAGE 4 B IN ADEQUATE SAMPLE.
DIRECT LARYNGOSCOPY BIOPSY:
TYPE OF LESION STAGE-TNM REPORT
RECURRENT TRANS-GLOTTIC
CARCINOMA
STAGE-4A NEGATIVE
TRANS-GLOTTIC CARCINOMA
STAGE-4B NEGATIVE
DISCUSSION
Direct laryngoscopic biopsy reported negative for malignancy in 2 patients of which one patient had recurrent trans glottic lesion & other had sub mucosal infiltrating transglottic lesion.
But Usg guided -FNAC reported positive for squamous cell carcinoma in these 2 patients.
2 patients had negative FNAC of which one patient with supraglottic carcinoma(stage-3) & other with laryngohypopharyngeal carcinoma (stage -4B). (Reason: Atypical cells/In-adequate sample).
Positivity rate of 80%(8/10).
LIMITATION:
Less number of patients.
Not useful in early stage disease.
Needs experienced radiologists & pathologists
CONCLUSION
Although Direct laryngoscopy biopsy remains the gold
standard technique, ultrasound guided FNAC can be
used to diagnose advanced laryngo hypopharyngeal
lesions.
Availability of ultrasonography in primary health
centres may help to diagnose these lesions at
community level at an early stage for proper referral.
Since patients are referred to higher Centre for
management, this procedure can be used as
preliminary investigation for tissue diagnosis.
out-patient procedure.
simple, safe, cost effective.
particularly useful for patients contraindicated for
general anaesthesia/inoperable due to advanced
disease or those with a risk of tracheotomy due to
intubation difficulties.
BIBLIOGRAPHY1. Fulciniti F, Califano L, Zupi A, Vetrani A. Accuracy of fine needle aspiration biopsy
in head and neck tumors. J Oral Maxillofac Surg. 1997;55:1094–1097.2. Jandu M, Webster K. The role of operator experience in fine needle aspiration
cytology of head and neck masses. Int J Oral Maxillofacial Surg. 1999;28:441–444.3. Dedivitis RA, De Carvalho MB, Rapoport A. Transcutaneous fine needle aspiration
biopsy of the preepiglottic space. Acta Cytol. 2000;44:158–162.4. Amedee RG, Dhurandhar NR. Fine-needle aspiration biopsy. Laryngoscope.
2001;111:1551–1557. 5. Abemayor E, Ljung BM, Ward PH, et al. CT-directed fine needle aspiration
biopsies of masses in the head and neck. Laryngoscope. 1985;95:1382–1386.6. Som PM, Silvers AR, Urken ML. Surveillance CT and the prompt use of CT-guided
fine-needle aspiration in patients with head and neck cancer who have undergone surgery. AJR Am J Reontgenol. 1999;173:1505–1508.
7. DelGaudio JM, Dillard DG, Albritton FD, Hudgins P, Wallace VC, Lewis MM. Computed tomography-guided needle biopsy of head and neck lesions. Arch Otolaryngol Head Neck Surg. 2000;126:366–370.
8. Brouwer J, Bodar EJ, De Bree R, et al. Detecting recurrent laryngeal carcinoma after radiotherapy: room for improvement. Eur Arch Otorhinolaryngol. 2004;261:417–422
9. Ansarin M, De Fiori E, Preda L, Maffini F, Bruschini R, Calabrese L, Jereczek-Fossa BA, Chiesa F, Bellomi M (2007) Ultrasound-guided transcutaneous tru-cut biopsies to diagnose laryngopharyngeal masses. A pilot study. Cancer 109:2268–2272.
Massively calcified thyroid cartilage,Superficial cT1-T2
disease,
Refusal for informed consent
Highly vascular lesions/A-V malformations
Inaccessible to usg e.g.. Shadowed by calcified
cartilage.
INCLUSION CRITERIA:Patients with suspected laryngo-pharyngeal disease, bulky endolaryngeal mass.
EXCLUSION CRITERIA:
Supraglottic Lesion Transglottic Lesion Laryngo hypopharyngeal Lesion
