Fine-needle aspiration cytology versus open biopsy for the diagnosis of chronic cervical lymphadenopathy

Shafia Arshad; Amina Arif; Maria Shakeel; Memoona Zahra; Romana Mehwish; Amna Riaz; Faheem Hadi

doi:10.4103/bbrj.bbrj_6_23

ORIGINAL ARTICLE

Year : 2023 | Volume : 7 | Issue : 1 | Page : 67-71

Fine-needle aspiration cytology versus open biopsy for the diagnosis of chronic cervical lymphadenopathy

Shafia Arshad¹, Amina Arif², Maria Shakeel³, Memoona Zahra⁴, Romana Mehwish⁵, Amna Riaz⁶, Faheem Hadi¹
¹ University College of Conventional Medicine, Faculty of Medicine and Allied Health Sciences, Islamia University, Bahawalpur, Pakistan
² Department of Basic and Applied Chemistry, Faculty of Science and Technology, University of Central Punjab, Pakistan
³ University College of Medicine and Dentistry, The University of Lahore, Pakistan
⁴ School of Pharmacy and Medical Sciences, Griffith University, Australia
⁵ Bakhtawer Ameen Medical College, Multan, Pakistan
⁶ Centre of Research in Molecular Medicine, Institute of Molecular Biology and Biotechnology, The University of Lahore, Lahore, Pakistan

Date of Submission	10-Nov-2022
Date of Decision	11-Jan-2023
Date of Acceptance	16-Jan-2023
Date of Web Publication	14-Mar-2023

Correspondence Address:

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bbrj.bbrj_6_23

Abstract

Background: For the diagnosis of cervical lymphadenopathy, an open biopsy is recommended. When compared to open biopsy, fine-needle aspiration cytology (FNAC) is considered safe, less invasive, and cost-effective. However, its diagnostic efficacy remains in debates. This study was conducted to know that how accurately FNAC can detect the pathology as compared to an open biopsy. The purpose of this study was to assess the diagnostic efficacy of FNAC versus open biopsy in the diagnosis of cervical lymphadenopathy. Methods: It is a comparative study at Lahore General Hospital, Lahore, for 6 months. The study comprised 100 patients who had been diagnosed with chronic cervical lymphoma. All of the patients underwent FNAC, which was followed by an open biopsy. Calculating the sensitivity, specificity, and diagnostic accuracy of each technique was used to determine the diagnostic efficacy of the both techniques. Results: FNAC had a sensitivity and specificity of 92% overall. Non-Hodgkin's lymphoma, tuberculosis, Hodgkin's lymphoma, metastatic carcinoma, reactive hyperplasia, and chronic nonspecific lymphadenopathy had a diagnostic accuracy of 96.2%, 85.7%, 100%, 87.5%, 100%, and 100%, respectively. Conclusions: In the management of cervical lymphadenopathy, FNAC is a reliable and safe procedure with a high diagnostic efficacy. It should be used as the first line of examination.

Keywords: Cervical lymphadenopathy, fine-needle aspiration cytology, Hodgkin's lymphoma, metastatic carcinoma, open biopsy

How to cite this article:
Arshad S, Arif A, Shakeel M, Zahra M, Mehwish R, Riaz A, Hadi F. Fine-needle aspiration cytology versus open biopsy for the diagnosis of chronic cervical lymphadenopathy. Biomed Biotechnol Res J 2023;7:67-71

How to cite this URL:
Arshad S, Arif A, Shakeel M, Zahra M, Mehwish R, Riaz A, Hadi F. Fine-needle aspiration cytology versus open biopsy for the diagnosis of chronic cervical lymphadenopathy. Biomed Biotechnol Res J [serial online] 2023 [cited 2023 Jun 10];7:67-71. Available from: https://www.bmbtrj.org/text.asp?2023/7/1/67/371701

Introduction

Chronic cervical lymphadenopathy is a reasonably common clinical problem in our community. The cervical lymph nodes, which drain the head, neck, and the portion of the chest, are representative lymph node of the body.^[1] Chronic painless lymphadenopathy may be due to tuberculosis (TB) or secondary to malignant diseases like squamous cell carcinoma.^[2] Other differential diagnoses include chronic nonspecific inflammation and lymphoma. Cervical lymph node metastasis effect one out of every five patients with cancer of larynx, oral cavity, oropharynx, hypopharynx, and nasopharynx.

A high-profile index of speculations is required for the diagnosis of TB cervical lymphadenopathy. A comprehensive history and physical examination, tuberculin test, microbial staining, radiological examination, fine-needle aspiration, and biopsy are required for early diagnosis. It is important to discriminate tuberculous from nontuberculous mycobacterial cervical lymphadenopathy because their treatment procedures are different. Tuberculous adenitis is excellently treated as a systemic disease with antituberculosis medication.^[3],[4],[5] For the evaluation of cervical lymphadenopathy, different techniques are used which include automatic core needle biopsy, fine-needle aspiration cytology (FNAC), flow cytometry, open biopsy, and radiologically guided core needle biopsy.^[6] Conventionally, open cervical lymph node biopsy has played a significant role in the diagnosis of cervical lymphadenopathy, especially the atypical mycobacterium TB. The identification of lymphadenopathy by excision of a gland requires anesthesia and may result in complications. FNAC does not require anesthesia, is easy to perform, and is safe. Its diagnostic efficacy, particularly in tubercular lymphadenitis, has been reported to be as high as histopathology.^[7]

Open biopsy is frequently performed for the diagnostic purpose, when FNAC (for unexplained cervical lymphadenopathy) yields a nondiagnostic or inconclusive result. Tissue sample sufficiency for diagnostic purpose is the advantage of open biopsy. However, there are several disadvantages linked to open biopsy including increased infection risk, very invasive, nerve and vascular injury, and scarring are all disadvantages. Aside from these, an open biopsy is a expensive procedure because it requires the use of an operation theater, including a delay in diagnosis followed by a delay in therapy due to the need to plan the operation theater in advance and sensitivity to general anesthesia. In addition, open biopsy puts up with a threat of tumor seeding and can infringe on a potential surgical field, causing surgical treatment more complex.^[8] Over the past 10 years, FNAC has gained a more important role than open biopsy in the diagnosis of cervical lymphadenopathy with high sensitivity and specificity. The purpose of this study was to compare the diagnostic accuracy of the both two approaches so that a technique could be offered to the patients with cervical lymphadenopathy in future. It was found that, Although FNAC is a quick, safe, reliable, and cost-effective diagnostic techniques for lymphadenopathies, it is important to keep in mind the limitations of the procedure.

Materials

It was a comparative study conducted at the Lahore General Hospitals Department of Surgery, Lahore, this study comprised a total of 100 patients. The duration of the study was 6 months.

Type of sampling

The sampling technique was simple random (random table method). The patients above 12 years presenting with undiagnosed chronic cervical lymphadenopathy were included in the study and the children under 12 years were excluded from the study.

Data collection procedure and ethical issue

All patients were explained about the procedures (FNAC and open biopsy) and their written consent was taken. The patients were asked a lot of questions about their neck inflammation. Detailed clinical examinations were done, noting the site, size, shape, consistency, and matting of the affected cervical lymph nodes. Other systemic and general examinations especially for extra cervical lymph node, hepatomegaly and/or splenomegaly, ascites, jaundice, bleeding tendency, and skin rash were carried out in all patients.

Data analysis procedure

The data were entered and analyzed using SPSS version 16.0 (statistical package for social sciences). Sensitivity and specificity of both open biopsy and FNAC techniques were calculated. The ability of the test to precisely recognize those who had the disease out of the total diseased population was called sensitivity. Specificity refers to a test's capacity to correctly identify people who do not have the disease within the healthy (un-diseased) population.

Results

Hundred patients with a diagnosis of cervical lymphadenitis were included in the study in two groups. Both groups had FNAC followed by an open biopsy of the cervical lymph nodes. The mean age of the patients was 30.52 + 8.69 years [range 12–70]. Out of all 59 (59%) patients were male and 41 (41%) female [Table 1]. The female-to-male ratio was 1:1.4 [Figure 1].

Figure 1: Distribution of patients by sex (n = 100)

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Table 1: Distribution of patients by age (n=100)

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Histopathology (gold standard)-based diagnosis after open biopsy

The histopathology reports resulted in the diagnosis of TB in 54 (54%) patients, non-Hodgkin's lymphoma (NHL) in 14 (14%) patients, Hodgkin's lymphoma in 4 (4%) patients, metastatic carcinoma (MC) in 16 (16%) patients, reactive hyperplasia (RH) in 2 (2%) patients, and chronic nonspecific lymphadenitis (CNL) in 3 (3%) patients [Table 2] and [Table 3].

Table 2: Distribution of patients by diagnosis based on histopathology (Gold standard) after open biopsy (n=100)

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Table 3: Comparison between fine-needle aspiration cytology reports and histopathological diagnosis (Gold standard) after open biopsy (n=100)

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Comparison between fine-needle aspiration cytology reports and histopathological diagnosis (gold standard) after open biopsy

The FNAC reports were also compared with that histopathology reports. It was found that FNAC results were positive in 52 (96.2%) out of 54 patients, NHLs were positive in 12 (85.7%) out of 14 patients. FNAC was also positive in 4 (100%) Hodgkin's patients, MC was positive in 12 (87.5%) patients, RH in 2 (100%), and chronic nonspecific lymphadenopathy (CNL) in 3 (100%) patients [Table 4].

Table 4: Fine-needle aspiration cytology results relative to histopathological diagnosis (Gold standard) after open biopsy

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Discussion

The present study showed that in the majority of cases of cervical lymphadenopathy FNAC can independently be used as a diagnostic technique because of the 85% accuracy, all diagnoses that went up to the cytology were confirmed on histological bases, i.e., the gold standard reported identical observations on FNAC.^[9]

Advani et al. in 2008 in 35 patients, researchers evaluated the accuracy and effectiveness of FNAC in the diagnosis of lymphadenopathy. The study demonstrated that on the whole, the sensitivity was 87.5%, specificity was 90.0%, and accuracy was 91.4%.^[10] All these studies proved our findings that in cervical lymphadenopathy FNAC is reliable, safe, and accurate test, it could be adopted effectively as a first line of evaluation to avoid unnecessary surgeries. According to the research carried out at surgical unit-II Chandka Medical College Hospital Larkana, by Shaikh et al. on 200 patients with cervical lymphadenopathy. Primarily, FNAC was used in all cases, while in the cases, where FNAC was inconclusive, incisional/excisional biopsy was carried out. Interpretations indicated that in 99 (49.5%) patients. The most common cause of cervical lymphadenopathy was TB.

Reactive changes reported in 36 cases (18%) were the second most common source. In 24 cases (12%), chronic nonspecific inflammation was observed and non-Hodgkin's lymphoma in 16 cases (8%), MC was reported in 14 cases (7%), Hodgkin's lymphoma in 10 cases (5%) and as expected least accrued disease was Kikuchi lymphadenopathy appeared in 1 case (0.5%).

A case study was done by Shaikh et al. FNAC cytology of cervical lymphadenopathy TB was performed in this study. In this study, 188 cases of cervical lymph adenopathy were examined, and it was discovered that diagnostic accuracy for TB was 84.4%, and the diagnostic accuracy for metastatic cancer was equally high at 98%, demonstrating the importance of FNAC cytology. In our study, the TB was 96.2% that also confirms the observations of our study.^[11]

A similar study by Bhargava and Jain has reported 98.50% accuracy for tuberculous lymphadenopathy.^[12] The accuracy of 96.00% for tuberculous lymphadenopathy. In the present study, the accuracy for tuberculous lymphadenopathy is 96.2% which is comparable with most of the studies.

Bhargava et al. supplied data showing that TB being the most common disease of cervical lymphadenopathy prevailed in 54% population. With such prevalent conditions about TB in our region, there is hardly any choice than relying completely upon FNAC for screening of TB. This is economic and time-saving procedure with results up to satisfaction.

There is another grieved and alarming situation disclosed through research, that TB which is becoming uncommon in the developing countries but unfortunately it is still the most widespread disease in our country.^[13] He included all age groups of patients in his research (ranging from 2.5 years to 65 years) in the diagnosis of cervical lymphadenopathy, FNAC had 89.5% sensitivity, 100% specificity, 100% positive predictive value, 90.5% negative predictive value, and 91% diagnostic efficacy, according to his findings. Ashfaq et al described that there is solid research to support the idea that TB can be adequately diagnosed with FNAC, and that if FNAC results are negative, excision biopsy should not be performed because of the possibility of sinus formation when a patient's clinical history suggests the existence of tuberculosis. Excision biopsy might be utilised as an additional investigation.^[14]

According to the recent study from India, FNAC is a simple and cost-effective diagnostic for diagnosing tuberculous cervical lymphadenitis.^[15] The accuracy of FNAC in our study was 85.7% the diagnostic accuracy of up to 80%–90% has been reported by other researchers. The reported accuracy of 82.2%, but this study had 157 cases of NHL while our study had only 14 cases.^[16]

FNAC is a very useful diagnostic tool for patients having significant lymphadenopathy. By the application of FNAC, the MC, and tuberculous lymphadenopathy can be diagnosed accurately. However, the distinguishing features of RH and nonlymphoma Hodgkin's are not adequately separated.^[17] In this study, the accuracy for tuberculous lymphadenitis was 96.2%. When the fine-needle aspirate appears purulent but the TB is clinically assumed, to solve the problem the sample should be put forward for staining of acid-fast bacilli that improves the diagnostic capability of FNAC.

In the current study, overall diagnostic accuracy was 87.5% for MC. Although open biopsy for histological confirmation is gold standard, it has its limitations because it alters surgical planes and may increase the probability of tumor dissemination, particularly in metastatic upper and middle cervical lymph nodes that can be treated with radiotherapy or node dissection. FNAC is preferred, and if it is a positive, therapy of the neck can be advanced without an excisional biopsy of inflamed lymph nodes.

Despite the fact that FNAC is effective in therapeutics settings, it is not without problems; it has a number of drawbacks connected with its use, for example, there is a significant limitation in the assessment of NHL. The sensitivity of FNAC samples can be improved by subjecting them to dual parameter flow cytometry, T-cell, B-cell tumor markers, and immunocytochemistry analysis.

Conclusion

FNAC is a straightforward, safe, reliable, and cost-effective, diagnostic techniques for lymphadenopathies, but the procedure's restriction should be borne in mind.

If FNAC is negative, it does not rule out the disease and should be followed by open biopsy for histopathological confirmation.

Limitations of the study

The “suspect” category, for which a positive diagnosis is based solely on histological grounds, is the fundamental weakness of FNAC in thyroid pathology. The abundance of “unrepresentative” aspirates was the second drawback found in this investigation. However, the method is still helpful.

Ethical Statement

In this study, the participants' rights to informed consent and confidentiality was protected, and the procedure was performed with the highest regard for their safety and well-being. The potential benefits and risks were fully disclosed and any pain or discomfort was minimized. The data collected was used solely for the purpose of advancing medical knowledge and will not be disclosed or used for any other purposes without the participants' explicit permission.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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