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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 5  |  Page : 486-497  

Role of ultrasonography and fine-needle aspiration cytology in the evaluation of neck masses


1 Department of ENT and Head Neck Surgery, J.L.N. Hospital and Research Centre, Bhilai, Chhattisgarh, India
2 Department of Radiodiagnosis, J.L.N. Hospital and Research Centre, Bhilai, Chhattisgarh, India

Date of Submission16-Jul-2019
Date of Decision03-Mar-2020
Date of Acceptance03-Dec-2019
Date of Web Publication7-Sep-2020

Correspondence Address:
Gaveshani Mantri
Department of ENT and Head Neck Surgery, J.L.N. Hospital and Research Centre, Bhilai - 490 009, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_206_19

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  Abstract 


Objective: The objective of the study is to study the efficacy of ultrasonography (USG) and fine- needle aspiration cytology (FNAC) in the evaluation of neck masses and differentiating between cystic, inflammatory, benign, and malignant neck masses with a histopathological correlation. Study Design: Prospective study and observational study. Setting: J. L. N. Hospital and Research Centre, Bhilai (C. G). Study Period: June 1, 2016–May 30, 2017. Materials and Methods: Sonographically, neck masses were evaluated final diagnosis was made on the basis of FNAC and histopathology of excised specimens. Finally, the USG findings were correlated with FNAC report and histopathology reports (wherever possible) to evaluate their sensitivity, specificity, and accuracy by statistical methods. Results: Most of the cases clustered between 31 and 60 years of age group. Among all patients, males outnumbered the females with the M:F ratio 1.5:1. Hyperechoic and anechoic lesions suggested benign pathology, whereas chances of malignancy were highest with hypoechoic lesions. As diagnosed by USG, the majority was benign lesion (36.4%), followed by inflammatory neck masses (27.08%), then cystic neck masses (20.83%) and least was malignant masses (15.63%). FNAC impression diagnosed benign mass (32.29%), inflammatory mass (26.04%), cystic mass (19.79%), and malignant mass (15.63%). The diagnostic accuracy of USG, FNAC, and Histopathological Examination (HPE) was comparable as P ≤ 0.05 for inflammatory, cystic, benign, and malignant neck masses. Conclusion: High-resolution grayscale ultrasound can differentiate inflammatory, cystic, benign and malignant neck masses. FNAC can be considered highly efficacious in distinguishing benign and malignant neck masses. A team work between a cytopathologist, radiologist, and clinician maximizes the diagnostic utility of USG and FNAC.

Keywords: Benign and malignant, cystic, fine-needle aspiration cytology, inflammatory, ultrasonography


How to cite this article:
Mantri G, Jaiswal AA, Pal RK, Sharma N. Role of ultrasonography and fine-needle aspiration cytology in the evaluation of neck masses. Med J DY Patil Vidyapeeth 2020;13:486-97

How to cite this URL:
Mantri G, Jaiswal AA, Pal RK, Sharma N. Role of ultrasonography and fine-needle aspiration cytology in the evaluation of neck masses. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Oct 24];13:486-97. Available from: https://www.mjdrdypv.org/text.asp?2020/13/5/486/294349




  Introduction Top


Neck masses form a wide pathologic spectrum. These lesions, because of their superficial location, are easily accessible but complicated by the fact that structures of multiple organ systems are in such proximity in the neck, there is often a diagnostic dilemma. A palpable neck mass is a commonly encountered clinical problem. Although there are overlapping features, differentiation between the lesions can usually be made on specific imaging findings and relevant clinical information. Various disease processes may affect head and neck regions which present clinically as masses. The masses can be broadly classified[1] as inflammatory, cystic, benign or malignant in nature. In the evaluation of such masses, a detailed case history and clinical examination are the most important and mandatory steps, but in some cases, such as chronic inflammation, abscess formation, deep-seated or infected cystic lesions and neoplasms, clinical examination, and palpation do not provide complete assessment of the exact origin and nature of the masses; such cases require radiological imaging and fine-needle aspiration cytology (FNAC).

Ultrasonography (USG) has several advantages as it is harmless, uses no ionizing radiation, widely available, easy to use, noninvasive, inexpensive, and unaffected by metal artefacts such as dental restorations. It can be performed in mass population without any preparation. Ultrasound causes no health problems and may be repeated as often as necessary. Ultrasound is capable of differentiating cystic from solid lesions and is also helpful in diagnosing malignant versus benign masses. It is helpful in delineating the presence of multiple lymph nodes and the course of resolution of infectious diseases. It is used in cases of oral carcinoma to observe the presence of regional lymph node metastasis. Ultrasound is also helpful in detecting sialolithiasis and in the diagnosis of conditions involving the salivary gland.

FNAC offers a simple method of diagnosing a wide range of neck masses, and accurate cytological analysis plays a major role in planning for surgery. Its aim is to provide a diagnosis agreeing as closely as possible with that of histological examination in a very short time, thus enabling the surgeon to take an early decision regarding the mode of treatment. It can be performed as an outpatient procedure. The procedure is acceptable to most of the patients. There is no need for anesthesia and speedy results are available. It is safe, minimally invasive and cost-effective diagnostic tool. There is no evidence suggesting that the tumor spreads through the skin track created by the hypodermic needle. Therefore, to get a final diagnosis, clinical examination must be supplemented with various investigative procedures, which in turn can help evidence-based treatment and record-keeping in litigation cases.

In the present study, an attempt has been made to evaluate the efficacy of USG and FNAC in the process of arriving at the diagnosis of masses in the neck region. In this research study, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the tests were calculated in inflammatory, cystic, benign, and malignant masses.


  Materials and Methods Top


  • Study area: Patients with neck masses attending the ENT OPD in JLN Hospital, Bhilai, Sector 9, Chhattisgarh.
  • Study Design: “A prospective study, a diagnostic accuracy study
  • Study period: June 1, 2016–May 30, 2017 (1 year)
  • Estimated sample size: Seventy-three patients which is our minimum sample size for our study, but to increase the power of our study, we took it as 100. Taking SN = 95% from the reference study, the sample size was calculated using the following formula.


Sample size N = Z^2 ((SN (1-SN))/E^2)/P from sensitivity

Sample size N = Z2 (SP (1-SP))/(1-P) from specificity E2

SN-sensitivity, SP-specificity

E = precision, usually 5%, i.e. 0.05

Z = constant 1.96, Z value for 5% confidence level

Hence, by substituting values in the above formula, we were getting sample size N = 73

Hence, our minimum sample size for our study for was 73, but to increase the power of our study, we took it as 100.

Inclusion criteria

Patients with complaints of neck masses, attending the department of ENT irrespective of age and sex, and patients willing to take part and give written informed consent after the details of the study were explained to them.

Exclusion criteria

Patients with prior history of neck surgeries, with neck masses post-trauma, with mandibular or bony lesions, with apical chest lesions extending into the neck or very extensive neck masses, with vascular neck masses and patients diagnosed earlier with neck masses, i.e., before the study period and now follow-up case during the study.

Methodology

All patients presenting with neck masses were examined clinically after taking a detailed history. Basic hematological and other relevant investigations were carried out as per requirements followed by USG of the neck. USG was done in supine position with neck hyperextended using 3.5 MHZ convex and 5 MHZ linear probes and Transverse, longitudinal, multiple angled, and oblique projections were taken. Sonographically, neck masses were evaluated for size, location, echotexture, margins, presence of halo, calcification, vascularity, nodules, associated cervical lymphadenopathy, and consistency (solid, cystic, or mixed).

These patients were further evaluated for FNAC. Under all aseptic precautions, aspiration was performed using a disposable 5/10 ml syringe with a 23G needle. A minimum of two passes of the needle were performed on each lesion. FNAC was performed without ultrasound guidance by different cytologists. FNA smears were stained with PAP, MGG, and special stains whenever required. The final diagnosis was made on the basis of FNAC and histopathology of excised specimens (whenever indicated).

Finally, the USG findings were correlated with FNAC report and histopathology reports (wherever possible) to evaluate their sensitivity, specificity and accuracy by statistical methods.

Ethical clearance to conduct the research was sought and obtained from Ethical Review Committee and followed the national ethical guideline.

The study was conducted in patients presenting with a complaint of neck masses, attending ENT department irrespective of age group and sex, during the study, and willing to undergo USG neck, FNAC of neck masses and surgery (as per the disease).

Written informed consent was taken from the patient or guardian/relatives before the procedure of USG and FNAC. All the subjects were interviewed, examined, and investigated as per the predesigned proforma. Patients were investigated under aseptic precautions and proper positioning of the patient. Care was taken not to get into any sort of conflict of interest in the community.

The patient and the concerned doctor were informed about the evaluation of the procedure as soon as the procedure was done.

Statistical analysis

Statistical analysis was performed using a computer Statistical Package for Social Sciences (SPSS) program Version 16.0 (international Business Machines (IBM) Corporation. HQ Armonk, New York). Results were presented as frequency and percentage.

The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy along with 95% confidence intervals of these values of USG and FNAC in the evaluation of neck masses were evaluated using categorical tables.


  Observation and Results Top


Age distribution

Majority of the patients were in 31–60 years age group, and the youngest was 6 months old, and the eldest was 88 years old. The mean age was 43 years old [Figure 1].
Figure 1: Distribution of age group in study population

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Sex distribution

Males were commonly affected than the females in the ratio of 1.5:1. In thyroid lesions (35 cases), 23 cases (65.71%) were female and 12 cases (52.1%) were male [Figure 2].
Figure 2: Distribution of sex in study population

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Distribution of cases according to the site

The most common site for neck swelling was anterior midline (51%) followed by submandibular region (15%), anterolateral (13%), posterior triangle (11%), and angle of mandible and submental region (5%) each [Figure 3].
Figure 3: Distribution of neck swellings according to the site in study population

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Ultrasonography characteristics distribution: Distribution of boundaries in different neck masses

Of 15 cases of malignant neck masses, 10 cases (66.6%) had ill-defined boundaries and 5 cases (33%) had well-defined boundaries [Table 1].
Table 1: Distribution of boundaries in different neck masses

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Distribution of echogenicity in different neck masses

In 38 cases of benign neck masses, we found 16 cases (42.1%) were hyperechoic, 10 cases (26.3%) were hypoechoic, 5 cases (13.1%) were isoechoic, 4 cases (10.5%) were mixed echoic, and 3 cases (7.8%) were anechoic. However, in 15 cases of malignant neck masses, 10 cases (66.66%) were hypoechoic, 3 cases (20%) were mixed echoic, and 1 case (6.66%) was anechoic and isoechoic each and none of the cases had hyperechoic echotexture [Table 2].
Table 2: Distribution of echogenicity in different neck masses

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Distribution of consistency in different neck masses

In 27 cases of inflammatory neck masses, 26 cases (96.2%) were of mixed consistency and 1 case (3.7%) was cystic in nature. However, in 20 cases of cystic mass, 20 cases (100%) were cystic in nature [Table 3].
Table 3: Distribution of consistency of different neck masses

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Distribution of calcification in different neck masses

In 38 cases of benign masses, 23 cases (60.5%) had no calcification and calcification in 15 cases (39.4%). In 15 cases of malignant neck masses, 8 cases (53.3%) had no calcification and 7 cases (46.6%) had calcification [Table 4].
Table 4: Distribution of calcification of different neck masses

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Distribution of lymph node involvement in different neck masses

Of 27 cases of inflammatory neck masses, 16 cases (59.2%) had no lymph node involvement and 11 (40.7%) cases had lymph node involvement. However, in 20 cases of cystic mass, none had lymph node involvement. Of 38 cases of benign masses, 36 cases (94.7%) had no lymph node involvement and 2 cases (5.2%) had lymph node involvement. In 15 cases of malignant neck masses, 8 cases (53.4%) had no lymph node involvement whereas lymph node involvement was seen in 7 cases (46.6%) [Table 5].
Table 5: Distribution of lymph node involvement in different neck masses

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Fine-needle aspiration cytology impression

Diagnosis of different neck masses according to the fine-needle aspiration cytology impression

Of 25 cases of inflammatory neck masses, 19 cases (76%) were due to the involvement of lymph node and rest 6 (24%) were of salivary gland involvement. Twenty cases of cystic masses were included in miscellaneous group comprising of thyroglossal cysts (45%), branchial cysts (20%), sebaceous cyst (20%), laryngocoele (10%), and cystic hygroma (5%). Of 38 cases of benign masses, 22 cases (57.8%) due to thyroid involvement, 5 cases (13.1%) of lipoma, 2 cases (5.2%) were of salivary gland tumor, and 2 cases (5.2%) of neurogenic tumor, i.e., vagal schwannoma. Five cases of follicular neoplasm were categorized under neoplastic neck mass. Fifteen cases of malignant neck masses were seen in which 7 cases (46.6%) were metastatic lymph node, 7 cases were malignant thyroid enlargement (46.6%), and 1 case (6.6%) of malignant submandibular gland enlargement. Four cases were categorized under nondiagnostic, out of which 3 were inadequate sample of thyroid gland enlargement and 1 case of lymph node had hemorrhagic background with inconclusive diagnosis.

Diagnosis of thyroid lesions according to Bethesda system

Of total 35 cases of thyroid, FNAC revealed 18 cases (51.42%) as benign (Bethesda category II) which comprises colloid/nodular goiter and 6 cases (17.14%) were reported as suspicious of malignancy-(Bethesda category V), 4 cases (11.42%) were reported as follicular neoplasm (Bethesda category IV), 3 cases (8.57%) were reported as nondiagnostic (Bethesda category I), 2 cases (5.71%) as malignant (Bethesda category VI), and 2 cases (5.71%) were reported as follicular lesion of undetermined significance (FLUS)–(Bethesda category III) [Table 6].
Table 6: Diagnosis of thyroid lesions according to Bethesda system

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Comparison of fine-needle aspiration cytology, ultrasonography and HPE in the diagnosis of different neck masses

The diagnostic accuracy of FNAC, USG, and HPE were comparable as P ≥ 0.05 for inflammatory, cystic, benign, and malignant neck masses as shown in [Table 7].
Table 7: Comparison of fine-needle aspiration cytology, ultrasonographic, and histopathological examination in the diagnosis of different neck masses

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Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ultrasonography and fine-needle aspiration cytology diagnosis

In our study, USG diagnosis of inflammatory neck masses had a sensitivity of 75% (66.51%–83.48%), specificity of 98.55% and accuracy of the test was 96.1% whereas the FNAC diagnosis of inflammatory neck masses had a sensitivity of 87.5% (81.02%–93.98%), specificity of 100% and accuracy of the test was 93.5% (88.67%–98.33%).

USG diagnosis of cystic neck masses had a sensitivity of 100%, specificity of 98.28%, and accuracy of the test was 98.7% whereas FNAC diagnosis of cystic masses had a sensitivity, specificity and accuracy of the test of 100%.

USG diagnosis of benign neck masses had a sensitivity of 97.14%, specificity of 97.62% and accuracy of the test was 97.4% whereas FNAC diagnosis of benign swellings had a sensitivity of 85.71% (81%–94%), specificity of 100% and accuracy of the test was 93.5% (98.3%–88.7%).

USG diagnosis of malignant neck masses had a sensitivity of 80% (72.46%–87.8%), specificity of 95.16% and accuracy of the test was 92.2% (86.95%–97.45%) whereas FNAC diagnosis of malignant swellings had a sensitivity of 100%, specificity of 98.9%, and accuracy of the test was 98.7%.


  Discussion Top


In the present study, the age of representation, ranged from 6 months old to 88 years old, with most of the cases clustered between 31 and 60 years. The mean age of our study was 43 years. Amatya et al.[2] in their similar study, found age presentation ranged from 9 to 82 years with a mean age of 40 years. In their study, the most common age group was 31–40 years. Rathod et al.[3] conducted a study on 200 patients with head and neck lesions and found the age of presentation ranged from 1 to 70 years with the most common age group was 21–30 years.

Among 100 patients, 61were male (61%) and 39 were female (39%), with male:female ratio of 1.5:1. Amatya et al.[2] conducted a similar study on 1229 cases and found male: female ratio of 1:1.4. In the study by Jasani et al.,[4] 54% were male and 46% were female with male: female ratio of 1.2:1.

In the present study, the most common clinical diagnosis was thyroid enlargement constituting 35% of all cases, which was comparable with the studies of Amatya et al.[2] In our study, we found benign neck masses (36.46%) then inflammatory neck masses (27.08%) as the most common USG findings followed by cystic masses (20.83%) and finally malignant masses (15.63%).

The frequency of occurrence of diseases of head and neck, in our study, is close to Sardar et al.[5] [Table 8].
Table 8: Comparison of disease-wise distribution of masses of our study with other studies with reference to ultrasonographic findings

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In our study, most of the inflammatory swellings had relatively well-defined boundaries, hypoechoic echo intensity, and homogeneous ultrasound architecture of lesion. The posterior echoes appeared enhanced and ultrasound characteristics of tissues were cystic or mixed in nature. Our findings were consistent with findings given by Sivarajasingam et al.[6] and Baurmash[7] who stated that in cases of abscesses, USG showed a reduction of echo intensity and deep “underlying cystic change.” Three cases of parotid abscess had mixed echoic areas and one case of submandibular sialadenitis had isoechoic areas and the other showed hyperechoic areas.

In this study, in one case, which was diagnosed clinically as submandibular lymphadenopathy, but the ultrasound showed hyperechoic foci casting posterior acoustic shadowing and enlargement of the gland, duct dilation proximal to obstruction was seen. It was diagnosed as submandibular sialadenitis with sialolithiasis.

In our study, in the group of inflammatory swellings, sonographic diagnosis had a sensitivity of 75%, specificity of 98.5%, and accuracy of the test 96.1%. Our findings were consistent with findings given by Chandak et al.[1] which had sensitivity of 97.1%, specificity of 100%, and accuracy of the test was 98.5%.

Cysts on the sonogram appear as anechoic with a well-defined boundary and homogeneous echotexture. If the cysts become infected then the content of the lesion can produce some echoes, producing hypoechoic structures. In this study, 20 cases of cystic neck masses were studied. 19 cases showed very clear boundaries, posterior echoes appeared enhanced and homogeneous internal echoes. In our study, in the group of cystic swellings, sonographic diagnosis had a sensitivity of 100%, a specificity 98.28%, and accuracy of the test 98.7%. Our findings were consistent with findings given by Chandak et al.[1] which had sensitivity of 100%, specificity of 98.3%, and accuracy of the test was 98.5%.

In this study, both cases of pleomorphic adenoma had well-defined boundaries, were rounded in shape and had hypoechoic echo intensity associated with heterogeneous internal architecture. Lipoma appeared on ultrasound as a solid homogeneous mass of similar echogenicity to that of subcutaneous fat. In our study, sonographic diagnosis had a sensitivity of 100% and a specificity 98.3%, and the accuracy of the test was 97.4% as shown in [Table 9]. Our findings were consistent with findings given by Chandak et al.[1] which had sensitivity of 97.14%, specificity of 97.62%, and accuracy of the test was 97.4%.
Table 9: Comparison of ultrasonographic diagnosis of different neck masses on the basis of sensitivity, specificity, and accuracy with other studies

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Ultrasound can predict malignancy in 80% of cases, but various forms of malignancy cannot be differentiated. On ultrasounds of lower grade tumors, smaller lesions may appear as well-defined and similar to a benign tumor. Larger lesions developed more overtly with malignant features, including irregular and poorly defined margins with heterogeneous internal architecture. In this study, sonographic diagnosis had a sensitivity of 80% and a specificity 95.16% and the accuracy of the test was 92.2%. Our findings were consistent with findings given by Chandak et al.which had sensitivity of 100%, specificity of 98%, and accuracy of the test was 98.5% [Table 9].

Mohamed et al.,[8] in their study, divided diseases into the above three categories only based on findings of FNAC. Gogoi and Borgohain[9] divided neck masses into four categories based on FNAC findings. Comparing the other studies by authors our study had a similar result to Sardar et al.[5] [Table 10] and [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Table 10: Comparison of disease-wise distribution of masses of our study with other studies with reference to fine-needle aspiration cytology finding

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Figure 4: Tubercular lymphadenitis: (a) Clinical photograph. (b) Ultrasonography. (c) Histopathological examination

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Figure 5: Laryngocoele: (a) Clinical photograph. (b) Ultrasonography. (c) CT scan. (d) Intraoperative photograph. (e) Excised specimen. (f) Histopathological examination

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Figure 6: Vagal schwannoma: (a) Clinical photograph. (b) Intraoperative photograph. (c) Excised specimen. (d and e) Histopathological examination

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Figure 7: Branchial cyst: (a) Clinical photograph. (b) Ultrasonography. (c) Intraoperative photograph. (d) Excised specimen. (e) Histopathological examination

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Figure 8: Thyroglossal cyst: (a) Clinical photograph. (b) Ultrasonography. (c) Histopathological examination

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Of the 19 cases of inflammatory lymphadenitis, reactive hyperplasia constituted the majority of the cases (65%), and granulomatous tubercular lesions (26.3%) and rest showed nonspecific lymphadenitis. Results by Lawrence et al.[10] in 2003, showed 59% of cases with reactive hyperplasia followed by granulomatous lesion (41%). Hag et al.[11] carried out a similar study in Saudi Arabia over a period of 5 years which included 225 patients which showed reactive/nonspecific lymphadenitis to be the commonest cause of neck masses accounting for 33% of cases. In our study, tuberculous lymphadenitis [Figure 4] comprised 10.53% of the cases with male preponderance (75%) and similar to the study by Fatima et al.[12] done in a tertiary hospital at Pakistan. Rest included 3 cases of parotid abscess and 2 cases of submandibular sialadenitis.

Among the cystic lesions (20 cases), thyroglossal duct cyst [Figure 8] is the most commonly seen accounting to 45%. Branchial cyst [Figure 7] (4 cases) and sebaceous cyst (4 cases) were 20% each. Two cases of laryngocoele [Figure 5] (10%) and 1 case of cystic hygroma (5%) were seen. The incidence of different neck lesions was diagnosed through FNAC was compared with the other studies carried out by Al-Khateeb and Al Zoubi.[13] and Hsieh et al.[14] as shown in [Table 11].
Table 11: Incidence of cystic neck lesions diagnosed by fine-needle aspiration cytology in different studies

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Among the salivary gland lesions, the parotid was the most commonly involved gland. Our observation is similar to that of Cristallini et al.[15] and Cajulis et al.[16] Among benign tumors, pleomorphic adenoma was the most common tumor [Figure 9]. Out of 22 benign thyroid lesions, colloid goiter was the most common comprising 71.54% of cases and follicular neoplasm comprising 5.21% of cases. Five cases (5.21%) diagnosed as follicular neoplasm and 1 case (1.1%) as follicular lesion of undetermined significance. The major limitation of FNAC in cases of tumor of the thyroid is in the evaluation of the nature of the neoplasm, which is done by histopathology. The differentiation of follicular adenoma from follicular carcinoma based on cytological criteria is difficult and challenging as cytological appearance of both is very similar. This requires capsular/vascular invasion to be demonstrated, which cannot be seen in the smears. Histopathological examination was done in all 6 cases, which showed 5 follicular adenomas and one case of FLUS turned out to be follicular carcinoma.
Figure 9: Pleomorphic adenoma of PAROTID gland: (a) Clinical photograph. (b) Ultrasonography. (c) Fine-needle aspiration cytology. (d) Histopathological examination

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Löwhagen et al.[17] advocated that a cytological report should only state that a follicular neoplasm is present with no implication of its benign or malignant nature. Friedman et al.[18] as early as in 1979 advised histopathological examination in such cases for final diagnosis based on capsular and vascular invasion. Bethesda system (2007) also mentions about follicular neoplasm (category-IV) with no differentiation between adenoma and carcinoma on cytology.

Antonello et al.,[19] in 2005 and Klemi et al.,[20] in 1991, which showed 57% of multinodular goiter and 29% of follicular neoplasm. A study in Pakistan conducted by Tariq et al.[21] 2007 which showed 56.9% of nodular goiter and 23.08% of follicular neoplasm. In all these studies, the most common thyroid lesion was colloid goiter as in our study, though the percentage in our study is significantly high. This may be due to the increased number of female patients in our study. On the other hand, histopathological findings of all the surgically treated cases of benign thyroid lesions in our study were consistent with FNAC reports.

In our study, metastatic lymph nodes constituted 37.5% of the malignant neck mass cases with male preponderance and majority were diagnosed as squamous cell carcinoma. In the study by Jasani et al.,[4] metastatic lymph node comprised of 11.3% of cases. In our study, one case was malignant submandibular gland lesion (HPE-inflammatory). Rest included malignant thyroid lesions (62.5%) in our study, of which majority were papillary carcinoma (70%) [Figure 10], medullary type (20%), and follicular type (10%).
Figure 10: Papillary carcinoma of the thyroid: (a) Clinical photograph. (b) Fine-needle aspiration cytology. (c) Histopathological examination

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On FNAC, 2 suspicious smears for malignancy were also seen in the study of 100 cases, so constituting 5.71%. In literature, the incidence of suspicious FNAC diagnosis for malignancy is mentioned 2%–20%. (Wondwossen et al.,[11] 2002 = 2%, Kaur et al.,[22] 2002 = 20%). In our study, out of these 2 suspicious (for malignancy) cytological diagnosis, one was suspicious for papillary carcinoma, while in other cases suspicious diagnosis of follicular variant of papillary carcinoma was obtained on FNAC. Both cases were posted for surgery because of high index of suspicion of malignancy and histopathological examination revealed papillary carcinoma in both cases.

In our study, FNAC diagnosis of inflammatory neck masses had a sensitivity of 87.5%, specificity of 100%, and accuracy of the test was 93.5%. FNAC diagnosis of cystic masses had a sensitivity, specificity and accuracy of the test of 100%. FNAC diagnosis of benign swellings had a sensitivity of 85.71%, specificity of 100% and accuracy of the test was 93.5%. FNAC diagnosis of malignant swellings had a sensitivity of 100%, specificity of 98.9%, and accuracy of the test was 98.7%, as shown in [Table 12].
Table 12: Comparison of fine-needle aspiration cytology diagnosis of different masses on the basis of sensitivity, specificity, and accuracy of the test

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A study on FNAC was done by Chauhan et al.[23] on 641 cases of neck lesions, out of which 71 were further subjected to conventional surgical biopsy and results were correlated histologically. Out of a total of 591 satisfactory smears, there were 140 thyroid lesions, 20 salivary gland lesions, 400 lymph node lesions, 31 cystic lesions of neck. The overall sensitivity, specificity, accuracy, positive predictive value and negative predictive value of FNA for neck lesions in their study were 93.1%, 100%, 98.4%, 90.1%, and 100%, respectively.

FNAC has certain limitations also because of sample inadequacy and suspicious diagnosis. Unsatisfactory aspirates are the result of poor handling of the aspirated material and the lack of trained cytopathologists. Inadequacy is also attributable to the small size of the lesions.

In our study, 3.71% (n = 4) cytology was inadequate, which was still below acceptable range unsatisfactory sample as suggested by guidelines of the Papanicolaou Society of Cytopathology for fine-needle aspiration procedure and reporting, which is below 15%[24] [Table 13]. Hence, inadequate samples seen in the present study were comparable with that of Bajaj et al.[27] and Kaur et al.[22]
Table 13: Incidence of inadequate smears as observed in other studies

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Inadequate aspirates present an important obstacle in proper cytologic evaluation of neck masses. Accurate localization of small neck masses (<2 cm), sampling of at least 2 separate areas, and avoidance of excessive pressure during procedure, will result more often in a satisfactory specimen, on which a diagnosis can be established.[18] There are differences among authors regarding the definition of the adequacy of FNAC specimens.[28],[29]


  Conclusion Top


High-resolution grayscale ultrasound can differentiate inflammatory, cystic, benign and malignant neck masses.

FNAC is useful for final confirmation of the diagnosis in sonographically detected suspicious neck mass as well as highly efficacious in distinguishing benign and malignant neck masses.

FNAC is more sensitive and specific than USG in diagnosing inflammatory neck masses.

FNAC and USG findings have almost equivalent sensitivity, specificity, and accuracy in diagnosing cystic masses.

USG is more sensitive and accurate in diagnosing benign masses, whereas FNAC has a better specificity than USG.

FNAC had a better sensitivity, specificity and accuracy in diagnosing malignant neck masses than USG.

A teamwork between a cytopathologist, radiologist, and clinician maximizes the diagnostic utility of USG and FNAC.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]



 

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