Computed tomography-guided fine-needle aspiration biopsy
Departments
of Anatomic
Pathology and Radiology, A.C. Camargo Hospital
Antonio Prudente Foundation
- São Paulo, Brazil
T h e th e ra p e u tic a n d p ro g n o s tic e v a lu a tio n o f m a lig n a n t n e o p la s ia s d e p e n d s la rg e ly u p o n a p re c is e m o rp h o lo g ic d ia g n o s is . S e v e ra l p a p e rs h a v e fo c u s e d o n th e im p o rta n c e o f fin e -n e e d le a s p ira tio n u n d e r c o m p u te d to m o g ra p h y g u id a n c e in th e d ia g n o s is o f u n re s e c ta b le n e o p la s m s a n d in th e in v e s tig a tio n o f m e ta s ta s e s . T h e o b je c tiv e o f th is s tu d y is to e v a lu a te th e d ia g n o s tic a c c u ra c y , th e s e n s itiv ity , a n d th e n e g a tiv e p re d ic tiv e v a lu e o b ta in e d w ith th e te c h n iq u e . F in e -n e e d le a s p ira tio n c y to lo g y (F N A C ) w a s p e rfo rm e d o n 2 0 7 p a tie n ts , w ith a to ta l o f 2 1 0 c a s e s , fro m 1 9 9 1 to 1 9 9 4 , u n d e r c o m p u te d to m o g ra p h y (C T ) g u id a n c e . T h e re w e re 1 2 8 (6 1 .8 p e rc e n t) m a le s a n d 7 9 (3 8 .2 p e rc e n t) fe m a le s w ith a m e a n a g e o f 4 1 y e a rs (ra n g e 1 to 9 1 y e a rs ). L u n g a n d Iiv e r w e re th e m o s t fre q u e n t a n a to m ic s ite s . T h e a n a ly s is 'o f th is m a te ria l d is c lo s e d 4 1 c a s e s w ith c y to lo g ic a l d ia g n o s is o f n e g a tiv e fo r m a lig n a n c y (1 9 .5 2 p e rc e n t), a n d in 1 3 1 (6 2 .3 8 p e rc e n t), th e d ia g n o s is w a s p o s itiv e . It w a s p o s s ib le to d e fin e th e c y to lo g ic lin e a g e in 5 4 p e rc e n t o f th e c a s e s . T h e d ia g n o s is in 1 4 (6 .6 7 p e rc e n t) c a s e s w a s s u s p ic io u s fo r m a lig n a n c y , a n d in 2 4 (1 1 .4 3 p e rc e n t) c a s e s th e m a te ria l w a s in s u ffic ie n t fo r th e c y to lo g ic d ia g n o s is . O f th e 2 1 0 c a s e s , 1 0 6 s h o w e d h is to lo g ic a l d ia g n o s is a n d / o r c lin ic a i fo llo w -u p . F o rty -s e v e n (4 4 .3 p e rc e n t) h a d h is to lo g ic a l d ia g n o s is b e fo re th e F N A C a n d 5 0 c a s e s (5 6 .7 p e rc e n t) h is to lo g ic a l d ia g n o s is a fte r th e p ro c e d u re . T h e c o m p a ris o n b e tw e e n c y to lo g i-c a l a n d h is to lo g ii-c a l d ia g n o s is s h o w e d a s e n s ib ility o f 8 0 .4 p e ri-c e n t, s p e i-c ifii-c ity o f 1 0 0 p e ri-c e n t, p o s itiv e p re d ii-c tiv e v a lu e o f 1 0 0 p e ri-c e n t a n d n e g a tiv e o f 1 6 .7 p e rc e n t. T h e e ffic ie n c y o f th e te s t w a s 8 1 .1 p e rc e n t. T h is s tu d y s h o w e d th a t F N A C , u n d e r c o m p u te d to m o g ra p h y g u id a n c e , is a s e n s itiv e a n d s p e c ific te c h n iq u e fo r th e d ia g n o s is o f d e e p -s e a te d le s io n s .
U N IT E R M S : B io p s y -n e e d le , c y to lo g ic a l te c h n iq u e s , c y to d ia g n o s is , fin e -n e e d le a s p ira tio n .
IN T R O D U C T IO N
F
lnethodine-needle aspiration biopsy (FNAB) is an outpatientused for the evaluation of palpable m asses.The assessm ent of deep-seated, non-palpable lesions
requires im aging m ethods, com puted tom ography (CT)
in particular. FNAB application is im portant for the
diagnosis of advanced and unresectable neoplasias as
available results have confirm ed the effe,ctiveness and
safety of this technique,3 which is indicated for the
investigation of benign or m alignant, prim ary or m etastatic
neoplasias. A precise m orphologic diagnosis is essential
A d d re s s fo r c o rre s p o n d e n c e : G ild a d a C u n h a S a n to s
R u a Ita p e v a , 5 0 0 C o n j. 7 A - B e la V is ta S ã o P a u lo /S P - B ra s il- C E P 0 1 3 3 2 -0 0 0
for the planning of treatm ent and the prognosis of
m alignant neoplasias. Several reports have em phasized the
high specificity and sensitivity of CT-guided aspirative
cytology.2.9.,o
The present report presents the results obtained with
CT-guided FNAB and com pares them to those obtained
by histology of biopsy m aterial and surgical specitnens,
and in term s of the clinicaI follow-up of the patients in
order to establish the diagnostic accuracy of the m ethod.
M A T E R IA L A N O M E T H O O S
W e studied 2 1 0 CT-guided aspirative biopsies carried
out at A.C. Cam argo Hospital from June 1 9 9 1 to June
S A N T O S , G .C .; M O R IN I, S .R .; G R A N E R O , L .C .S . e t a I. - C o m p u te d to m o g ra p h y -g u id e d fin e -n e e d le a s p ira tio n b io p s y
R E S U L T S
T a b le 2
D is trib u tio n o f F N A B b y a n a to m ic s ite s T h e 2 1 0 a s p ir a tiv e b io p s ie s w e r e p e r f o n n e d o n 2 0 7
p a tie n ts , 1 2 8 m a le s ( 6 1 .8 p e r c e n t) a n d 7 9 f e ln a le s ( 3 8 .2
p e r c e n t) . P a tie n t a g e r a n g e d f r o ln 1 to 9 I y e a r s ( I n e a n 4 I
y e a r s ) , w ith a I a r g e r n u m b e r o f c a s e s s itu a te d in th e s e v e n th
d e c a d e o f lif e ( T a b le 1 ) . T h e p r o c e d u r e s w e r e p e r f o n n e d
f r o m J u ly 1 9 9 I to J u n e 1 9 9 4 . T a b le 2
snows
th e ir d is tr ib lltio nb y y e a r . T h e b io p s ie s w e r e o b ta in e d f r o ln d if f e r e n t I o c a tio n s ,
w ith th e lu n g a n d I iv e r b e in g th e I n o s t f r e q u e n t ( F ig s . I , 2
a n d 3 ) . T a b le 2 s h o w s th e ir d is tr ib u tio n b y 1 0 c a tio n . 1 3 4 4
1 9 9 4 . A lI c a s e s w e r e s u b m itte d to th e c la s s ic a l F N A B
te c h n iq u eÓ
u s in g a F r a n z e n ty p e c y to a s p ir a tio n g u n c o u p le d
to a 1 0 ln l d is p o s a b le s y r in g e w ith . a d is p o s a b le n e e d le
c o m ln o n ly u s e d f o r s p in a l a n e s th e s ia , 0 .7 m m in o u te r
d ia ln e te r ( 2 2 G ) . T h e p r o c e d u r e s w e r e c a r r ie d o u t u n d e r
th e g u id a n .c e o f a to m o g r a p h y a p p a r a tu s ( C T M A X ,
G e n e r a l E le c tr ic ) .
T h e S ln e a r s w e r e f ix e d in 9 5 p e r c e n t a lc o h o l a n d
s ta in e d b y th e P a p a n ic o la o u a n d H & E te c h n iq u e s . A ir
-d r ie -d s lid e s w e r e th e n s u b m itte d to G ie m s a s ta in in g . I n
s o m e c a s e s , p a r t o f th e m a te r ia l o b ta in e d w a s f ix e d in .1O
p e r c e n t f o r m a lin a n d e m b e d d e d in p a r a f f in f o r th e
p r e p a r a tio n o f a c e ll b lo c k , a n d th e s lid e s w e r e s ta in e d b y
th e H & E te c h n iq u e .
T h e p o s itiv e a n d n e g a tiv e c y to lo g ic d ia g n o s e s w e r e
c o n s id e r e d to b e tr u e o r f a ls e in r e la tio n to th e
h is to p a th o lo g ic d ia g n o s e s a n d c lin ic a I f o lI o w - u p o f th e
p a tie n ts . O n th e b a s is o f th e s e d a ta , s ta tis tic a l in d ic e s o f
c lin ic a l- I a b o r a to r y im p o r ta n c e w e r e c a lc u la te d , s u c h a s
s p e c if ic ity , s e n s itiv ity , p o s itiv e a n d n e g a tiv e p r e d ic tiv e
v a lu e , a n d e f f ic ie n c y ." x C a s e s w ith a s u s p ic io u s o r
in c o n c lu s iv e c y to lo g ic d ia g n o s is , a n d c a s e s w ith n o
h is to p a th o lo g ic e x a m in a tio n ', w e r e e x c lu d e d f r o ln th e
s ta tis tic a l a n a ly s is .
T h e p a tie n ts w e r e d iv id e d in to c a s e s w ith a
h is to p a th o lo g ic d ia g n o s is o b ta in e d b e f o r e th e a s p ir a tiv e
b io p s y , a n d c a s e s w ith a n a n a to m o p a th o lo g ic r e p o r t a n d /
o r c lin ic a I f o llo w - u p a f te r th e c y to lo g ic e x a m in a tio n .
L o e a tio n
L u n g L ive r M e d ia stin u m A d re n a l g la n d C h e st w a ll P e lvie ' e a vity O rb it
A b d o m in a l e a vity K id n e y
S p in e P a n e re a s O th e rs T o ta l
F re q u e n e y
N (% )
1 1 0 (5 2 .4 )
2 3 (1 1 .0 )
1 6 1 1
09
07
07
0 606
0 4 0 308
2 1 0 (1 0 0 )
T a b le 1
P a tie n t d is trib u tio n b y a g e ra n g e in 2 0 7 p a tie n ts s u b m itte d to F N A .
A g e ra n g e
0 -1 0 1 1 -2 0 2 1 -3 0 3 1 -4 0 4 1 -5 0 5 1 -6 0 6 1 -7 0 7 1 -8 0 > 8 0 T o ta l:
F re q u e n e y
N (% )
7 (3 .4 )
5 (2 .4 )
5 (2 .4 )
1 5 (7 .3 )
2 3 (1 1 .1 )
4 2 (2 0 .3 )
6 7 (3 2 .4 )
3 4 (1 6 .4 )
9 (4 .3 )
2 0 7 1 0 0%
T h e d ia g n o s is f o r th e p r e s e n c e o f n e o p la s tic c e lls w a s n e g a tiv e in 4 1 c a s e s ( 1 9 .5 2 p e r c e n t) a n d p o s itiv e in
1 3 1 ( 6 2 .3 8 p e r c e n t) . T h e d ia g n o s is o f th e c e lllin e a g e w a s p o s s ib le in 5 4 p e r c e n t o f th e la tte r c a s e s . A s lls p ic io u s
d ia g n o s is ( a ty p ic a l c e lls ) w a s ln a d e in 1 4 c a s e s ( 6 .6 7
p e r c e n t) , a n d in 2 4 c a s e s ( 1 1 .4 3 p e r c e n t) th e I n a te r ia I w a s c o n s id e r e d in s u f f ic ie n t. O f th e 2 0 7 p a tie n ts s tlld ie d , 1 0 6
h a d a n a n a to m o p a th o lo g ic e x a ln in a tio n a n d /o r c lin ic a I f o llo w - u p . A d ia g n o s is p r e c e d in g th e a s p ir a tiv e b io p s y w a s a v a ila b le in 4 7 c a s e s ( 4 4 .3 'p e r c e n t) , a n d a h is to p a th o lo g ic
e x a m in a tio n f o lI o w in g th e b io p s y w a s o b ta in e d in 5 0 c a s e s ( 5 6 .7 p e r c e n t) .
C o m p a r is o n o f th e c y to lo g ic a n d h is to p a th o lo g ic d ia g n o s e s r e v e a le d 8 2 c a s e s o f tr u e - p o s itiv e r e s u lts ( 7 7 .3 p e r c e n t) , 4 c a s e s w ith tr u e - n e g a tiv e r e s u lts ' ( 3 .8 p e r c e n t) , n o f a ls e - p o s itiv e c a s e , a n d 2 0 c a s e s w ,ith f a ls e - n e g a tiv e
r e s u lts ( 1 8 .9 p e r c e n t) ( T a b le 3 ) . T h e te s t s h o w e d 8 0 .4
F ig u re 1 - A x ia l ta m a g ra p h y s e c tia n a f th e liv e r s h o w in g th e p a s itia n a f th e n e e d le in a n a d u la r le s io n .
A C = A n a to m o p a th o lo g ic a n d /o r c lin ic a i d ia g n o s is .
L a te r A C P re v io u s A C T o ta l
(N ) (N )
4 4 3 8 8 2 (7 7 .3 % )
4 O 4 (3 .8 % )
O O O
1 1 9 2 0 (1 8 .9 % )
5 9 4 7 1 0 6
su rg e ry .2 T h e m e th o d p e rm its a p re c ise In o rp h o lo g ic
d ia g n o sis, re d u c in g th e n e e d fo r d ia g n o stic th o ra c o to ln ie s
in 3 1 -3 5 p e rc e n t o f c a se s.7
.12 F N A B o ffe rs se v e ra l
a d v a n ta g e s o v e r o th e r d ia g n o stic In e th o d s, e sp e c ia lly in
th o ra c ic le sio n s: it is ra p id , d o e s n o t re q u ire g e n e ra l
a n e sth e sia o r p ro lo n g e d h o sp ita liz a tio n , a n d is le ss c o stly
a n d 1 1 1 0 reto Ie ra b Ie to p a tie n ts c o m p a re d to su rg e ry O I'
m e d ia stin o sc o p y .1 5
In c a se s o f h e p a tic Ie sio n s, th e In a jo r a d v a n ta g e o f
F N A B c o m p a re d to sta n d a rd -n e e d le b io p sy is its h ig h e r
su c c e ss ra te in d e te c tin g m a lig n a n t n e o p la sia s. T h e
d isc re p a n c y b e tw e e n th e se tw o ln e th o d s w ith re sp e c t to
tu m o r d e te c tio n is re Ia te d to th e re Ia tiv e ly a tra u ln a tic n a tu re
.o fF N A B , w h ic h p e rm its ln u ltip le p u n c tu re s o fth e Je sio n ,
w h e re a s th e n u m b e r o f p ro c e d u re s (o r a tte ln p ts) w ith a
T a b le 3
P o s itiv e a n d n e g a tiv e c y to lo g ic c a s e s c o n s id e re d tru e o r fa ls e a fte r c o rre la tio n w ith th e a n a to m o c lin ic a l d ia g n o s is
D ia g n o s is
T o ta l T ru e p o s itiv e
T ru e n e g a tiv e
F a ls e p o s itiv e
F a ls e n e g a tiv e
D IS C U S S IO N
p e rc e n t se n sltlv lty , 1 0 0 p e rc e n t sp e c ific ity ,
I0 0 p e rc e n ~ p o sitiv e p re d ic tiv e v a Iu e , 1 6 .7
p e rc e n t n e g a tiv e p re d ic tiv e v a lu e , a n d 8 1 .1
p e rc e n t e ffic ie n c y (T a b Ie 4 ).
T h e p re se n t stu d y sh o w e d th a t C T
-g u id e d F N A B is a se n sitiv e a n d h ig h Iy
sp e c ific te c h n iq u e fo r th e d ia g n o sis o f d e e p
-se a te d le sio n s, w ith re su Its siln ila r to th o se
o b ta in e d in p re v io u s in v e stig a tio n s.2 .9 T h e m e th o d h a s
p ro v e d to b e re p ro d u c ib Ie a t se v e ra I m e d ic a I c e n te rs a n d
is b e in g a p p Iie d fo r th e d ia g n o sis o f n e o p la sia s, e sp e c ia lly
u n re se c ta b Ie le sio n s o r le sio n s o f d iffic u It su rg ic a I a c c e ss,
a n d fo r th e c o n firm a tio n o f m e ta sta se s. A n a Iy sis o f th e
re su lts re v e a le d th a t a p p ro x im a te ly 4 4 p e rc e n t o f p a tie n ts
w ith a n a n a to ln o p a th o Io g ic e x a m in a tio n (4 7 c a se s)
p re se n te d a p re v io u s d ia g n o sis, w ith F N A B b e in g u se d to
e v a Iu a te m e ta sta se s.
B e c a u se o f th e in h e re n t c h a ra c te ristic s o f F N A B ,
w h ic h u se s sln a lI-g a u g e n e e d Ie s (2 2G ), th e m e th o d is sa fe ,
w ith o u t th e risk s o f m o re in v a siv e m e th o d s. F u rth e rm o re ,
it p e n n its th e u se o f a p p ro p ria te tre a tm e n t b y o ffe rin g a
p re c ise ty p in g o f th e n e o p la sia s in a sig n ific a n t n u m b e r o f
c a se s, w ith th e c o n se q u e n t a v o id a n c e o f risk y m a jo r
S A N T O S , G .C .; M O R IN I, S .R .; G R A N E R O , L .C .S . e t a I. - C o m p u te d to m o g ra p h y -g u id e d fin e -n e e d le a s p ira tio n b io p s y
1346
Figure 2 -A x ia l to m o g ra p h y s e c tio n o f th e c h e s t w ith a p a tie n t in v e n tra l d e c u b itu s . N o te th e d is ta i e n d o f th e n e e d le p o s itio n e d in s id e a n o d u la r le s io n o f th e lu n g .
(% ) (% )
S e n s itiv ity 8 0 .0 8 0 .8 8 0 .4
S p e c ific ity 1 0 0 .0 1 0 0 .0 * 1 0 0 .0
(+ ) P re d ic tiv e v a lu e 1 0 0 .0 1 0 0 .0 * 1 0 0 .0
(-) P re d ic tiv e v a lu e 2 6 .6 1 6 .7
E ffic ie n c y 8 1 .3 8 0 .8 8 1 .1
* C o n s id e re d to b e 1 0 0%
b e c a u s e th e re w e re n o fa ls e -p o s itiv e re s u lts * * N o t c a lc u la te d .
T o ta l P re v io u s A C
L a te r A C
in c re a s e s w ith re p e a te d p ro c e d u re s .1 4
A m o n g th e fa c to rs
re s p o n s ib le fo r fa ls e -n e g a tiv e re s u lts a re p e ritu lT IO ra l
in fa re tio n , in fIa m m a tio n a n d fib ro s is .2 A lo w in d e x o f
fa ls e -n e g a ti v e d ia g n o s e s h a s b e e n c o n s id e re d to b e th e
re s u lt o f in te n s e c o o p e ra tio n a n d c o m m u n ic a tio n b e tw e e n
p a th o lo g is t a n d ra d io lo g is t, w ith a n e g a tiv e re s u lt b e in g
c o n s id e re d d e fin itiv e fo r th o s e c a s e s in w h ic h th e
m o rp h o lo g ic a n d ra d io .Io g ic a s p e c ts in d ic a te a b e n ig n
p ro c e s s .2
S e n s itiv ity a n d s p e c ific ity w e re w ith in th e ra n g e
re p o rte d fo r a s p ira tiv e b io p s ie s o f th o ra c ic le s io n s , i.e .,
7 1 to 1 0 0 p e rc e n t a n d 9 5 to 1 0 0 p e rc e n t, re s p e c
-tiv e ly .2 .5 .7 .1 0 .lóT h e re s u lts re v e a le d th a t th e re w a s n o
d iffe re n c e in s e n s itiv ity , s p e c ific ity o r e ffic ie n c y b e tw e e n
Table 4
Indices of the diagnostic performance of fine-needle
aspirative cytology
In d ic e s th ic k n e e d le is lim ite d b y th e p o te n tia l
o c c u rre n c e o f s e v e re c O lT Ip lic a tio n s . 1 3
T h e fre q u e n c y o f in s u ffic ie n t m a te ria l
(1 1 .4 3 p e rc e n t) w a s s im ila r to th a t o b ta in e d
in o th e r s tu d ie s .2 .9
In th e c a s e o f s u p e rfic ia l
p a lp a b le le s io n s o f.e a s ie r a c c e s s , th e in d e x
o f u n s a tis fa c to ry m a te ria l, w h ic h in c lu d e s
. in s u ffic ie n t s a m p le s , s a m p le s th a t a re n o t
re p re s e n ta tiv e o f th e o rg a n a n d s a m p le s
re p re s e n te d b y b lo o d e le m e n ts , is v a ria b le .
T h e in d e x fo r m a m m a ry le s io n s ra n g e s
fro m 3 to 3 6 p e rc e n t, a n d th e in d e x fo r
th y ro id le s io n s ra n g e s fro m 8 to 1 8 p e rc e n t (4 ). T h e p ro p o rtio n o f u n s a tis fa c to ry
a s p ira te s d e c re a s e s w ith in c re a s in g
e x p e rie n c e w ith th e p ro c e d u re o n th e p a rt o f th e o p e ra to r.4
It h a s b e e n s u g g e s te d th a t h o n e s t c o m m u n ic a tio n w ith
c lin ic ia n s a b o u t th e q u a lity o f th e c y to lo g ic c o n trib u tio n
to th e p a tie n t m a n a g e m e n t a n d its lim ita tio n s c o u ld re d u c e
th e n u m b e r o f fa ls e -p o s itiv e re s u lts .11
A lth o u g h s o m e
le s io n s a re d iffic u lt to in te rp re t b o th in te rm s o f
d is c rilT Iin a tin g m a lig n a n c y a n d in te rm s o f h is to g e n e tic
c h a ra c te riz a tio n , n o fa ls e -p o s itiv e c a s e s o c c u rre d in th e
p re s e n t s tu d y , e x p la in in g th e h ig h s p e c ific ity d e te e te d .
T h e p e rc e n ta g e o f fa ls e -n e g a tiv e re s u lts w a s 1 8 .8 6
p e rc e n t. T h u s , a n e g a tiv e re s u lt d o e s n o t e x c lu d e th e
p re s e n c e o f a m a lig n a n t n e o p la s ia a n d th e e x a m in a tio n
s h o u ld b e re p e a te d . In th e p re s e n t s e rie s , n o n e w a s p ira tiv e
b io p s ie s w e re ta k e n . H o w e v e r, it is k n o w n th a t p o s itiv ity
Figure 3 -D e ta il o f F ig u r e 2 , s h o w in g th e n e e d le p o s itio n e d in s id e th e n o d u la r le s io n .
cases with an anatomoclinical
diagnosis
preceding
or
following the biopsy.
Sensitivity,
specificity
and predictive
value depend
on lnany factors in addition to the presence or absence of
disease.
xThe predictive
value of a test depends on the
prevalence
of a given disease.
xIn the present study, the
negative predictive value, VP (-) was low. This is explained
by the fact that the study was carried out at a cancer hospital
that receives cases screened at general hospitaIs and private
offices, with a high prevalence ofthis disease. Thus, there
is a reduction
in the nUlnber of true-negative
results, a
variable
that directly
affects
the VP (-) values.
The
calculation of specificity was not impaired only because
there were no false-positive results in this study. However,
the high prevalence
of cancer in this population
(96.2),
and the positive predictive value of 100 percent indicate
that a patient with a positive result has a high probability
(certainty) of really having cancer.
The results obtained in this study, using CT-guiclecl
FNAB, in anatolnic parts of the body when t.he access is
difficult,
recommend
the use of this proceclure
as an
efficient and safe lnethod for the diagnosis of Inalignancy.
S A N T O S , G .C .; M O R IN I, S .R .; G R A N E R O , L .C .S . e t a I. - C o m p u te d to m o g r a p h y - g u id e d fin e - n e e d le a s p ir a tio r i b io p s y
1 3 4 8
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