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| Year : 2013 | Volume
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| Issue : 4 | Page : 263-269 |
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| Role of fine needle aspiration, imprint and scrape cytology in the evaluation of intraoral lesions |
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Nazoora Khan1, Nishat Afroz1, Aiman Haider1, Mohd Jaseem Hassan1, Sarwat Hussain Hashmi2, Syed Abrar Hasan3
1 Department of Pathology, J.N. Medical College, Aligarh, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Dr. Z.A. Dental College, A.M.U., Aligarh, Uttar Pradesh, India
3 Department of Otorhinolaryngology, J.N. Medical College, Aligarh, Uttar Pradesh, India
Click here for correspondence address and email
| Date of Web Publication | 6-Feb-2014 |
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 Abstract | | |
Aim: The primary goal of our study was to evaluate the value and accuracy of fine needle aspiration cytology (FNAC) in the diagnosis of various intraoral lesions and to correlate the cytological diagnosis with final histopathological findings.
Materials and Methods: Fine needle aspiration was performed in 229 patients presented with different lesions of the oral cavity at our institution. Cytological findings were then compared with final histopathological diagnosis.
Results: With a male to female ratio of 1.79:1, 229 patients presented with different lesions of the oral cavity were aspirated. Histopathological correlation was available in 86.9% of cases while inadequate material was obtained in 13.1% cases. The diagnostic accuracy of fine needle aspiration in diagnosing benign, pre-malignant and malignant lesions were 95.8%, 84.6% and 97% respectively. Overall the diagnostic accuracy of FNAC in diagnosing intraoral lesions was 94.9% with sensitivity and specificity of 93.2% and 96.8% respectively.
Conclusion: FNAC of intraoral lesion is recommended as a valuable procedure for the initial evaluation of all intraoral lesions as it is simple, inexpensive, convenient and comfortable to the patient. Moreover, it can offer a rapid and accurate diagnosis for further management of the patient. Keywords: Benign oral lesions; fine needle aspiration cytology; histopathological correlation; malignant oral lesions; oral lesions
How to cite this article:
Khan N, Afroz N, Haider A, Hassan MJ, Hashmi SH, Hasan SA. Role of fine needle aspiration, imprint and scrape cytology in the evaluation of intraoral lesions. J Cytol 2013;30:263-9 |
How to cite this URL:
Khan N, Afroz N, Haider A, Hassan MJ, Hashmi SH, Hasan SA. Role of fine needle aspiration, imprint and scrape cytology in the evaluation of intraoral lesions. J Cytol [serial online] 2013 [cited 2023 Mar 25];30:263-9. Available from: https://www.jcytol.org/text.asp?2013/30/4/263/126661 |
| Introduction | |  |
Fine needle aspiration cytology (FNAC) is routinely being used for the diagnosis of various neoplastic and non-neoplastic lesions and for both superficial and deep seated lesions. Although FNAC has been used extensively in the diagnosis of head and neck masses, [1] its use is underutilized as far as intraoral lesions are concerned. As FNAC is a minimally invasive procedure, it does offer an advantage over incisional biopsy in sensitive areas and it has a high diagnostic value when done in conjunction with a good clinical and morphological correlation.
Though many lesions in the oral cavity, floor of mouth, tongue, palate, tonsils and posterior pharyngeal wall can be needled under visual control, surprisingly little data had been published to evaluate the use of FNAC in the diagnosis of intraoral lesions. [2],[3],[4] Günhan et al.[3] pointed out that diversity of oral maxillofacial lesions, heterogeneity of cell population and the rarity of the types makes the cytological diagnosis of some of these lesions difficult.
FNAC is a valuable procedure for the initial evaluation of intraoral lesions as it can easily differentiate inflammatory from neoplastic lesion and benign from malignant neoplasm. FNAC is simple, safe, rapid, reliable, painless, cost-effective, relatively non-invasive and easy procedure, which can be done as an out-patient department procedure without any special equipment or preparation and thus can eliminate the need for open biopsy procedure with their potential untoward effects. [3],[5],[6] Practically, there is no contraindication to FNAC as it can be done in pregnant women, children and high risk patients without any major complication. [3],[5],[6]
Imprint and scrape cytology are commonly used as an adjunct to frozen section. The frozen section biopsy requires specialized equipments, which may not be available all the time especially in underdeveloped countries. The imprint and scrape cytology can reliably and independently be used as a method for intraoperative evaluation to confirm or make a diagnosis for timely and appropriate surgical intervention. To differentiate benign from malignant lesions both frozen section and cytological evaluation alone has an acceptance rate of 93-97% for correct diagnosis. [7],[8],[9],[10] When compared to frozen section, cytological evaluations in the form of imprint and scrape cytology is simple, inexpensive and rapid with the same accuracy rate. With this method there is excellent preservation of cellular details without any freezing artifact, no loss of tissue and there is a possibility of identifying focal, macroscopically undetectable neoplastic lesion in large tissue fragments. [10],[11],[12],[13] Disadvantages of this method are few and include the inability to differentiate between in-situ from infiltrating carcinoma and to evaluate the depth of invasion. [10] In recent years, many authors in their study also revealed the importance of cytology in analysis of various intraoral lesions and their relation with other diseases. [14],[15],[16] Prasad et al.[14] in their study revealed that diabetes produces definite morphological and morphometric changes in exfoliated buccal mucosal cells, which can be used as a diagnostic tool for diabetes while Patel et al.[15] in their study of normal gingival cells obtained by scrape cytology revealed age and sex related variation of nuclear area, cytoplasmic area and nuclear cytoplasmic ratio in normal exfoliated gingival cells and establish a baseline for these variables with which pathological lesions of the oral cavity can be compared. Jadhav et al.[16] in their study correlate the frequency of micronuclei in oral exfoliated cells from patients of oral squamous cell carcinoma and revealed three to four fold increase in number of micronuclei in patients with oral squamous cell carcinoma as compared with the normal groups.
The goal of this study was to evaluate the diagnostic accuracy of cytological diagnosis in various intraoral lesions and its correlation with final histopathological findings.
| Materials and Methods | | |
The present study was conducted in the department of pathology, otorhinolaryngology and oro-maxillo-facial surgery. A total of 229 patients presenting with complains related to the oral cavity were included in this study. All the FNACs were performed by cytopathologist in the presence of an ear, nose and throat/dental surgeon. The procedure was well-explained to the patient and consent was taken from them. The samples were taken in supine/sitting position with a head support. A light source and tongue depressor were utilized to visualize the lesions whenever necessary. Local anesthesia was not used during the aspiration. For fine needle aspiration, after localizing the lesion, a 23-24 gauge needle attached to 10 ml disposable plastic syringe was inserted into the lesion and a negative suction was created after withdrawing the piston. Repeated passes in different directions were made while maintaining the vacuum, following which the piston was released and needle withdrawn. The aspirated material was then spread on to clean numbered slides. Following aspiration there was minimal bleeding in some cases, which was controlled by pressing gauze in the involved area of the oral cavity. Scrape smears were prepared by using wooden Ayer's spatula from the pathological sites, mostly from mucosal and ulcerative lesions and also from other sites wherever possible. Wet Smears were fixed in 95% ethyl alcohol for hematoxylin and eosin (H and E) and Papanicolaou stains while air dried smears were stained with May-Grünwald Giemsa stain. [17] Material for histopathological study was subsequently obtained either by open surgical biopsy or excision of the lesion. Imprint smears were also prepared from fresh unfixed specimens by gently pressing the cut surface of the suspicious areas against clean albuminized glass slides. Smears thus prepared were fixed in 95% alcohol and stained with rapid H and E method with some modification of the technique originally used by Shidham et al. [11] The slides were dipped immediately in hematoxylin for 1 min, rinsed rapidly with distilled water, differentiated with ammonium hydroxide, counter stained with eosin by three slow dips, washed in tap water, dried, mounted in DPX and cover slip affixed. The results were excellent and a good cytoplasmic as well as nuclear detail was obtained. Specimen was then fixed and submitted for routine processing and staining. [18] Cytological findings were then correlated with final histopathological diagnosis.
| Results | | |
In this study, 229 patients presented with different lesions of the oral cavity were subjected to fine needle aspiration, imprint and scrape cytology. There were 147 males and 82 females. Male to female ratio in benign, premalignant and malignant lesions was 1.1:1, 1.8:1 and 3:1 respectively. The maximum number of cases were seen in the fifth decade of life (53 cases), followed by 40 cases in the third decade, 39 cases in the sixth decade, 31 cases in the fourth decade, 25 cases in the second decade, 16 cases in the first decade and 25 cases in patients above the age of 60 years. All 229 cases were broadly classified into three main categories, benign lesions (97 cases), premalignant lesions (28 cases) and malignant lesions (104 cases) depending upon final histopathological diagnosis. The 30 cases were inadequate for cytological diagnosis because of insufficient material leaving 199 cases for histological correlation. A total of six sites were aspirated from oral regions. Maximum number of cases (75) aspirated from cheek followed by 73 cases from tongue, 27 cases from the floor of mouth, 19 cases from lips, 18 cases from gingival and 17 cases from palate. Cheek was the most common site for benign lesions while tongue was the most common site for both pre-malignant and malignant lesions.
Benign lesions
[Table 1] shows the distribution and cyto-histo correlation of various lesions of the oral cavity. The total 97 cases of benign lesions were further subdivided into inflammatory lesions (78 cases), cystic lesions (two cases) and tumor and tumor like conditions (17 cases). Inflammatory lesions included acute inflammatory lesions (30 cases), chronic inflammatory lesions (46 cases) and fungal infection (two cases) while cystic lesion included two cases of retention cysts, 17 cases of tumor and tumor like conditions comprised of pleomorphic adenoma (four cases), basal cell adenoma (one case), hemangioma (eight cases), lipoma and fibrolipoma (two cases each). The maximum number of benign lesions were seen in 2 nd decade of life (25 cases), followed by 22 cases in 3 rd decade and these lesions showed slight predilection for males with male to female ratio of 1.1:1.
Fifteen of 30 cases of acute inflammatory lesions yielded insufficient material for diagnosis, whereas rest 15 cases showed concordance with histological findings. Two cases of chronic inflammatory lesions were inadequate for cytological diagnosis leaving 44 cases for histological correlation. Out of 44 cases, 3 cases turned out to be squamous cell carcinoma on histology (false negative) while rest 41 cases showed concordant results. One of two cases of fungal infection showed inadequate cellularity for evaluation while other case showed concordant diagnosis of oral histoplasmosis. Both cases of retention cyst were correctly diagnosed by FNAC.
Among 17 cases of tumor and tumor like lesions, aspirates from five cases of hemangioma and one case of fibrolipoma were inadequate for diagnosis. Excluding these six cases, rest 11 cases showed concordant results with final histopathological diagnosis. The FNAC diagnosis was correct in all four cases of pleomorphic adenoma. FNAC of a single case of basal cell adenoma in the palate of a 50-year-old female showed the presence of cohesive clusters of small uniform epithelial cells having scanty cytoplasm and showing rimming of hyalinized membrane and peripheral palisading at places. The FNAC diagnosis was confirmed by histopathology.
Cytological smears from lipoma showed fragments of monomorphic and univacuolated mature fat cells having abundant vacuolated cytoplasm and small eccentric dark nucleus. A few strands of branching capillaries were seen in the tissue fragments while smears from fibrolipoma showed fibrous strand of spindle shaped cells with tapering cytoplasm in addition to fragments of monomorphic and univacuolated fat cells.
FNAC and imprint cytology was done in eight cases of hemangioma. Five cases yielded blood only and were unsatisfactory for diagnosis while rest three cases showed hemorrhagic background with few strands of endothelial cells with pale spindle shaped nuclei. Final diagnosis was made by histopathology. The same problem was also encountered by other authors. [3],[19] Günhan et al.[3] in their study reported hemorrhagic aspirate in both the cases of hemangioma.
Pre-malignant lesions
A total of 28 cases of pre-malignant lesions included in our study comprised of 26 cases of leukoplakia and two cases of carcinoma in-situ. Majority of premalignant lesions were seen in 5 th decade of life (eight cases), followed by seven cases in 3 rd decade. Male to female ratio was 1.8:1. Scrape smears was carried out in all 26 cases of leukoplakia by means of wooden Ayre's spatula. Out of 26 cases of leukoplakia, smears from two cases were inadequate for evaluation leaving 24 cases for cytological and histological correlation. 21 cases were correctly diagnosed by FNAC. Two cases turned out to be keratinizing squamous cell carcinoma (false negative) and one case was diagnosed as carcinoma in-situ (false negative) on histology. One of two cases of carcinoma in-situ turned out to be infiltrating squamous cell carcinoma on histology (false negative).
The cytological diagnosis was correct in 21 of 24 adequate aspirate of leukoplakia. Smears showed many squamous cells and anucleated squames in a background of inflammatory infiltrate. Few smears showed mild to moderate dysplasia [Figure 1]a. | Figure 1: (a) Leukoplakia. Cytosmear showing benign squamous cells along with inflammatory infiltrate. Few cells are showing moderate dysplasia (H and E, ×400). (b) Adenoid cystic carcinoma. Cytosmear showing prominent hyaline globules (arrow) surrounded by malignant cells (H and E, ×400)
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Malignant lesions
Among 104 cases of malignant lesions, squamous cell carcinoma was the most common malignancy (91 cases), followed by mucoepidermoid carcinoma (four cases), verrucous carcinoma (three cases), basal cell carcinoma, adenosquamous carcinoma and adenoid cystic carcinoma (two cases each). Maximum number of cases seen in 5 th decade (37 cases), followed by 23 cases in 6 th decade of life and males were affected more than females with a ratio of 3:1. Inadequate material for diagnosis was obtained in two cases of squamous cell carcinoma and one case each of adenosquamous carcinoma and mucoepidermoid carcinoma. Excluding these four cases histological correlation was available in rest 100 cases. The 97 cases showed concordant result with final histological findings while three cases of squamous cell carcinoma turned out to be a case of severe dysplasia on histopathology (false positive).
FNAC material was adequate in three of four cases of mucoepidermoid carcinoma. Smears were of variable cellularity with a background of mucus and debris showing clusters and sheets of non-keratinizing squamous epithelial cells with enlarged nuclei. Large clear to foamy cells were also seen.
Both cases of adenoid cystic carcinoma were correctly diagnosed by FNAC alone based on the presence of cells lying singly and in clusters with hyaline spherical globules of varying sizes. Cells had scant cytoplasm and high nucleo-cytoplasmic ratio with round hyperchromatic nuclei and coarse chromatin [Figure 1]b. | Figure 2: (a) Keratinizing squamous cell carcinoma. Cytosmear shows isolated and groups of pleomorphic cells having enlarged and hyperchromatic nuclei with evidence of keratinization (H and E, ×100). (b) Non-keratinizing squamous cell carcinoma. Cytosmear shows sheets of pleomorphic cells with high N/C ratio and hyperchromatic nuclei without any evidence of keratinization (H and E, ×100)
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Among 89 cases of squamous cell carcinoma, FNAC was performed in 80 patients, scrape smears in 85 cases and imprint smears in 50 cases. The cytodiagnosis of squamous cell carcinoma was correct in 86 of 89 evaluable cases. The most common type of squamous cell carcinoma was well-differentiated (44 cases), followed by moderately differentiated (28 cases), poorly differentiated (14 cases) and basaloid variant (one case). Cytosmears were divided into keratinizing and non-keratinizing squamous cell carcinoma. Keratinizing smears showed isolated and groups of keratinizing squamous cells with anisonucleosis, hyperchromatic nuclei and opened up chromatin [Figure 2]a. Non-keratinizing smears showed cohesive clusters of pleomorphic non-keratinizing cells with spindle shaped nuclei and minimal keratin debris in a necrotic background [Figure 2]b.
Of the total 97 cases of benign lesions comparison between cytological and histological diagnosis was possible in 73 cases and was concordant in 70 cases, thus giving diagnostic accuracy of 95.8%. In 24 cases, the material was inadequate for diagnosis. False negative result was seen in three cases.
Cytological and histological correlation was available in 26 of 28 cases of premalignant lesions. Concordant result was seen in 22 cases giving diagnostic accuracy of 84.6%. Material was inadequate in two cases and there were four false negative cases.
Among 104 cases of malignant lesions, histological correlation was possible in 100 cases. Cytological diagnosis was correct in 97 cases giving diagnostic accuracy of 97%. Four smears were inadequate for evaluation and there were three false positive cases.
Thus among 229 cases of oral lesions cytological and histological correlation was available in 199 cases (86.9%). Concordant result was seen in 189 cases giving diagnostic accuracy of 94.9% while discordant result was seen in 10 cases (5.1%). Inadequate material was obtained in 30 of 229 cases (13.1%) while adequate material for cytological diagnosis was obtained in 199 cases giving diagnostic yield of 89.1%. There were seven false negative cases and three false positive cases, thus giving sensitivity and specificity of cytology in the diagnosis of various intraoral lesions as 93.2% and 96.8% respectively.
| Discussion | | |
Although surgical biopsy is the traditional method for evaluating various intraoral lesions, but this method may be inconvenient, painful and costly due to hospitalisation and may breach the overlying epithelium and damage the underlying tissue. Over the years, FNAC has been found to be very useful, simple, cost-effective and accurate in assessing and diagnosing various neoplastic and non-neoplastic lesions of many body sites including especially the head and neck region. [20]
FNAC plays an important role in the diagnosis of intraoral lesions presenting mainly as a mass or growth. Except for minimal bleeding at aspiration site in few cases, FNAC was uneventful otherwise. Inadequate sampling by needle aspiration was mainly due smaller size and superficial location of the lesion, the limited space for manoeuvring the needle and difficulty in immobilizing the lesion to obtain sufficient material. [5],[21]
Dejmek and Lindholm [22] reported 85% diagnostic accuracy of FNAC for cystic and solid lesions of the oral cavity while Günhan et al.[3] reported diagnostic accuracy of 92% for malignant lesions and 97% for benign lesions of the oral cavity and jaw. Cramer et al.[4] found FNAC to be especially useful for parapharyngeal, palatal masses and submucosal lesions of the oral cavity while Domanski and Akerman [23] recommended this method as the first diagnostic step in the evaluation of tongue swellings.
In this study, a total of 229 cases were subjected to cytological study from a variety of oral lesions. Insufficient material was obtained in 13.1% of cases, which was lower than that found by Scher et al.[8] and Günhan et al.[3] of 16% and 17.6% respectively. Insufficient aspirates were mainly due to peculiar anatomic site of the lesion, non-homogeneity of the lesion, poor placement of the needle and due to the little amount of the aspirated material. All 229 cases were broadly classified into three main categories, benign lesions (42.4%), pre-malignant lesions (12.2%) and malignant lesions (45.4%) depending upon final histopathological diagnosis. Inflammatory lesions were the most common benign lesion (78/97 cases), followed by tumour and tumour like lesions (17/97 cases). Leukoplakia was the most common premalignant lesion (26/28 cases). Squamous cell carcinoma was the most common tumor in malignant category (91/104 cases) followed by mucoepidermoid carcinoma (4/104 cases).
Among the benign lesions diagnosed by cytological smears, diagnosis showed concordance with histopathological findings in 70 cases, thus giving diagnostic accuracy of 95.8%, which was almost similar to that obtained by Günhan et al.[3] and Fulciniti et al. [6] of 97% and 96.2% respectively. Cyto-histo correlation was available in 26 of 28 cases of pre-malignant lesions. Concordant result was seen in 22 cases giving diagnostic accuracy of 84.6%, which was much higher than 33.3% as reported by Seetharam and Ramachandran [24] Among malignant lesions cyto-histo correlation was possible in 100 out of 104 cases and was concordant in 97 cases giving diagnostic accuracy of 97%, which was much higher than the values of 92%, 86.4% and 76.49% as reported by Günhan et al.,[3] Fulciniti et al.[6] and Domanski et al.[23] respectively.
In this study, there were seven false negative cases (3.5%) and three false positive cases (1.5%). False negative cases includes three cases of chronic inflammatory lesions and two cases of leukoplakia, which turned out to be squamous cell carcinoma while one case of leukoplakia proved to be carcinoma in-situ and one case of carcinoma in-situ was finally diagnosed as squamous cell carcinoma on histopathology. On the other hand, three cases of squamous cell carcinoma diagnosed on cytology turned out to be a case of severe dysplasia on histopathology (false positive). Scher et al.[25] in their study of 93 FNA cases of oral and oropharyngeal lesions had seven false negative cases (7.5%), but no false positive cases, while Devesh et al.[26] in their study of 52 FNA cases of oral and oropharyngeal tumors had one false negative (1.9%) and two false positive cases (3.8%). Lee et al.[27] in their study of 44 cases of intraoral lesions found three false negative cases (6.8%), but no false positive cases, while Saleh et al.[5] in their small series of 16 cases of intraoral and oropharyngeal mass lesions found two false negative cases (12.5%). Castelli et al.[21] in their series of 44 intraoral fine needle aspiration biopsies found 19.4% of false negative cases and 3.1% of false positive cases while Baykul et al.[28] in their study reported four false negative cases (5.79%), but no false positive cases. Thus in our study, rate of false negative cases were lower than that obtained by other authors. [5],[21],[25],[26],[27] False positive cases in our study was lower than that reported by some authors, [21],[26] while it is more than that obtained by other authors. [25],[26],[27],[28] This may be due to relatively small sample size in their study.
Thus in this study, overall 94.9% diagnostic accuracy of FNAC for various intraoral lesions was obtained, which was much higher than the values of 86.8% and 77.8% obtained by other authors. [5],[29] In our study, cytological diagnosis of intraoral lesions showed sensitivity of 93.2% and specificity of 96.8%. Fine needle aspiration biopsy of oral and pharyngeal lesions showed sensitivity of 80.6% and specificity of 96.9% by Castelli et al., [21] while sensitivity of 93% and specificity of 86% was obtained by Shah et al. [30] Inadequate material was obtained in only 13.1% cases.
To conclude, we highly recommend FNAC as a valuable procedure for the initial evaluation of all intraoral lesions as it is fairly sensitive and specific procedure in addition to being simple, inexpensive and comfortable to the patient and above all it can offer a rapid and accurate diagnosis without affecting the underlying tissue significantly. Therefore, FNAC when used in conjunction with scrape and imprint smears in the light of clinical findings enhances the diagnostic accuracy of intraoral lesions.
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Correspondence Address:
Mohd Jaseem Hassan
Assistant professor, Department of Pathology, Hamdard Institute of Medical Sciences and Research (HIMSR), Jamia Hamdard, New Delhi - 110 062
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9371.126661
[Figure 1], [Figure 2]
[Table 1] |
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