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Role of cytological examination in head neck masses

FNAC is the ideal procedure for assessment of individuals with a cervical mass. It differentiates the mass into inflammatory or a neoplastic and if the latter; suggests necessity of a subsequent meticulous search for a primary malignant condition in the upper part of the aerodigestive tract or elsewhere, prior to obtaining a tissue diagnosis from the cervical mass. Moreover, it suggests the most cost-effective plan to further evaluate and plan treatment of the patient.


INTRODUCTION
FNAC is the ideal procedure for assessment of individuals with a cervical mass. It differentiates the mass into inflammatory or a neoplastic and if the latter; suggests necessity of a subsequent meticulous search for a primary malignant condition in the upper part of the aerodigestive tract or elsewhere, prior to obtaining a tissue diagnosis from the cervical mass. Moreover, it suggests the most cost-effective plan to further evaluate and plan treatment of the patient.
Aim of the study was to assess the reliability of fine needle aspiration cytology in affording correct diagnosis in morbid head and neck masses and to work out the incidence of false negative, false positive and accuracy of fine needle aspiration was recorded.
A FNAC of the masses was carried out in all the patients and a cytological diagnosis was made. Out of the 106 aspiration biopsies, 89 aspirations were performed from lymph nodes, 7 from salivary glands, 7 were fine needle aspirates from masses, arising from oropharynx and oral cavity and one from ear canal. Out of 106 patients, excision biopsy following fine needle cytology was carried out in 38 patients.
Inclusion criteria included salivary gland swellings, cystic neck masses and intra oral tumors. Exclusion criteria excluded thyroid swellings and ulcerated masses.
All statistical calculations were done using the statistical package of social sciences (SPSS) 17 version statistical program for Microsoft windows (SPSS Inc. Released 2008. SPSS statistic for windows, version 17.0, Chicago). Ethical approval of the study was taken from the institutional ethics committee.

RESULTS
There were 61 males and 45 females. Youngest was a male child of one-year age and the oldest a 76-year-old male with a cervical metastatic lymph node. 57 (53.8%) patients belonged to the rural areas while 49 (46.8%) belonged to the urban areas.  The primary presenting symptom was swelling in the head and neck region. Though many patients presented with associated symptoms.
The duration of head and neck masses at the time of presentation in this series ranged from less than one month to more than one year. Maximum patients presented with duration of swelling ranging from one month to 6 months (65%) followed by duration of less than one month in 36 patients (15%).
In most of the cases, there was nothing significant in their past history. Two patients had received anti tubercular treatment in the past but reports were not available. Anemia in the form of pallor was present in 38 patients. Three patients had marked cachexia at the time of presentation. Axillary lymphadenopathy was noted in 6 patients while 2 patients had enlarged nodes in the inguinal region. Hepato-splenomegaly was noted in 5 patients. The maximum (65.1%) cases of cervical lymphadenopathy had involvement of the jugular chain of lymph nodes. In all 11 (12.4%) cases, enlarged nodes were seen at more than one site submandibular nodes were involved in 15 (16.9%) patients and supraclavicular lymph nodes in 4 (4.5%) patients. In 1 (1.1%) patient, sub mental lymph node was involved.  47 out of 106 patients had hemoglobin below 10 gm/dl while 59 patients had hemoglobin concentration above 10 gm/dl total leucocyte count (TLC) was found to be in the normal range of 4000-11000 mm 3 in 94 cases. It was elevated above 11000 in 12 patients. Erythrocyte sedimentation rate (ESR) was elevated in 54 patients in which it ranged from 20 to 45 mm in the 1 hour. X-ray chest undertaken in all showed 4 patients with features of old healed tuberculosis and 2 with active lesion. In 9 the radiograph indicated chronic bronchitis.
Skiagram of regions other than the chest were done in selected cases wherever indicated. These revealed increased soft tissue shadow of nasopharynx in two cases, increase in the soft tissue shadow of laryngopharynx in 4 cases and in one case barium swallow of esophagus showed irregularity and narrowing in the upper end of esophagus.
FNAC was done in all 106 cases. The results of aspiration biopsy are shown in the following tables:  Pleomorphic adenoma of salivary gland was diagnosed on the cytological findings of epithelial cells of uniform shape and size, having oval or round nucleus and homogeneous cytoplasm arranged in acini or clumps with variable amounts of intercellular fibrillar mucus in the background. Some smears revealed collagen fibers and myoepithelial cells. In patients with chronic sialadenitis, the smears revealed numerous polymorphonuclear leukocytes and lymphocytes dispersed and in clumps with a few degenerated epithelial cells.
Cytological examination of 2 cystic swellings showed benign cystic lesion in one and dermoid cyst in the other.
Comparison between cytological and histopathological diagnosis: Out of 106 cases studied, 38 patients were operated either for surgical excision of the head and neck mass or for obtaining incisional biopsy for histopathological examination. These included 5 patients of lymphadenopathy, 7 patients with salivary gland swellings, 6 patients with oropharyngeal and oral cavity masses, one from ear canal, two cystic swellings and 17 cases from primary. In all these patients, the results of cytological diagnosis were compared with those of histopathology. Out of a total number of 30 cases of metastatic lymphadenopathy diagnosed on cytology, 11 (36.6%) cases had secondaries from larynx, 4 (13.4%) cases from hypo pharynx, 11 (36.6%) cases from oropharynx and oral cavity and three (10.0%) cases from nasopharynx. In one (3.4%) case, the primary could be detected.
Cytological correlation for salivary glands: Out of 7 cases studied, surgical excision and histological examination was done in 7 cases. The overall accuracy of cytological diagnosis in salivary gland lesions was 100%.
Out of 27 histopathologically proven cases of malignancy, 24 cases (88.9%) were correctly diagnosed on fine needle aspiration biopsy. Of the remaining 3 cases, the aspiration smears were unsatisfactory for examination in 1 case while 2 cases were diagnosed as reactive hyperplasia.

DISCUSSION
In the present study of 106 subjects 89 had cervical lymphadenopathy, 7 were salivary glands, 2 cystic lesions, 3 masses in the oral cavity, 4 in the oropharynx and one in the ear canal. All the patients were subjected to fine needle aspiration biopsy of the mass at the time of initial evaluation.
Open surgical biopsy and histopathological examination was performed in 38 patients subsequently and the results of cytological and histological examination were compared in different groups to find the accuracy of fine needle aspiration biopsy in these cases. The purpose of this study was to evaluate 106 patients with head and neck masses by FNAC.
89 patients with cervical lymphadenopathy were studied involving sub mental lymph nodes in one case, submandibular lymph nodes in 15 cases, jugular chain in 58 cases, supraclavicular in 4 cases and multiple in 11 cases. 50 cases (56.2%) were reported as tubercular, 30 cases (33.7%) were reported as malignant and 3 cases (3.4%) were reported as non-Hodgkin lymphoma. Cytology was inconclusive in 6 cases (6.7%) out of which histopathology was done in 5 cases, 2 cases were reported as tubercular and 3 as malignant deposits. One case did not turn up for follow up.
Cases which were diagnosed as tubercular on cytology were not subjected to biopsy and histopathological examination. They were put on anti-tubercular-therapy and follow-up.
Out of the 27 proven cases of metastatic carcinoma, 24 (88.88%) cases were diagnosed correctly on cytological examination. This is in close conformity with the observations made by Bloch, Engzell et al, and Frable who have reported an accuracy of 87%, 90% and 92.2% respectively for the diagnosis of metastatic carcinoma on FNAC. [1][2][3] Out of 7 cases with salivary gland masses, 3 were diagnosed as pleomorphic adenoma and 4 as sialadenitis.
All the seven cases were subjected to histopathological examination and accuracy was found to be l00%. This is in accordance with the observations made by Mavec  FNAC can be undertaken in the outpatient clinics with minimal trauma and has the advantage of early differentiation of benign from malignant pathology thereby dictating the planned therapeutic modality. It can be both diagnostic and therapeutic in cystic swellings.

CONCLUSION
In the present study it was noted that interpretation of smears was erroneous in the presence of necrotic material and overlap of smear patterns thereby the need to repeat FNAC as in 6.6% subjects. 3 were false negatives and 3 were inconclusive. It is concluded that properly executed FNAC is of greater value in surgical practice.