Year : 2007 | Volume
: 24 | Issue : 4 | Page : 173--177
Ultrasound guided fine needle aspiration biopsy of gastrointestinal masses
SS Ahmad1, K Akhtar1, SS Akhtar1, SH Arif1, A Nasir1, M Khalid2, T Mansoor3,
1 Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
2 Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
3 Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
S S Ahmad
Department of Pathology, JNMC, AMU, Aligarh-202002, Uttar Pradesh
The study was undertaken to evaluate the role of ultrasound guided fine needle aspiration cytology (FNAC) of gastrointestinal masses in providing higher diagnostic yield and assess its reliability in distinguishing between benign and malignant gastrointestinal lesions. 86 patients with gastrointestinal masses after thorough clinical examination underwent ultrasonographic examination. Those found to have a mass were subjected to FNAC. Smears prepared were fixed in 95% ethyl alcohol and stained with Haematoxylin and Eosin and Papanicolaou stains. Forty (46.5%) were males and 46 (53.5%) females with majority of patients in the third decade in both sexes. Malignant lesions constituted the maximum number of 42 (48.8%) cases, followed by 36 (41.8%) cases of benign and inflammatory lesions. Adenocarcinoma was the most common malignancy accounting for 36 (85.7%) cases; out of which 16 (44.4%) cases were adenocarcinoma stomach and 20 (55.6%) cases were adenocarcinoma intestine. Among the inflammatory and benign lesions, 30 (83.3%) cases were tuberculous followed by 4 (11.1%) cases appendicitis, The mean age of malignancy was 39.2 years and the average age of tuberculous patients in our study was 25.5 years. On cytohistological correlation, 30 were found to be true positive for malignancy, 5 true negative and 1 false negative. There were no false positive cases. We obtained a sensitivity of 93.8%, specificity of 100% and diagnostic accuracy of 94.4% in our study. Ultrasound guided FNAC is an effective and useful method which eliminates the need for surgical biopsy and provides sufficient information for the initiation of therapy.
|How to cite this article:|
Ahmad S S, Akhtar K, Akhtar S S, Arif S H, Nasir A, Khalid M, Mansoor T. Ultrasound guided fine needle aspiration biopsy of gastrointestinal masses.J Cytol 2007;24:173-177
|How to cite this URL:|
Ahmad S S, Akhtar K, Akhtar S S, Arif S H, Nasir A, Khalid M, Mansoor T. Ultrasound guided fine needle aspiration biopsy of gastrointestinal masses. J Cytol [serial online] 2007 [cited 2021 Jun 24 ];24:173-177
Available from: https://www.jcytol.org/text.asp?2007/24/4/173/41889
Ultrasound guided fine needle aspiration biopsy is a rapid, accurate, economical and safe diagnostic procedure in which any structure visualized, can be reached quickly and precisely by a fine needle in any desired plane with constant visualization of the needle tip during insertion. 
Mass lesions of gastrointestinal tract (GIT) are usually diagnosed by conventional barium meal examination or by endoscopy. But barium meal examinations are occasionally limited in their demonstration of exophytic or infiltrating mass lesions which do not significantly encroach on bowel lumen.Ultrasound can frequently demonstrate a mass in these patients providing a strong evidence of extraluminal extension or infiltrative process, when it is not demonstrable by other radiographic techniques or endoscopy. ,
Though endoscopic ultrasound guided FNAC (EUSFNA) is a recent innovation in the evaluation of lesions adjacent to the wall of the upper gastrointestinal tract, there is a greater complication rate for this new technique in the form of infections, perforation and haemorrhagic events after puncturing cystic lesions. , Also, the poor condition of the patients precluding the use of barium studies and/or endoscopy, non specific radiographic images and inability to obtain an adequate biopsy sample during endoscopy  led us to evaluate the role of ultrasound guided FNAC of gastrointestinal masses as its application is relevant in developing countries, where non-invasive investigations are a luxury for the poor in providing higher diagnostic yield.
Materials and Methods
The present study was conducted in the departments of Pathology and Radiodiagnosis of Jawaharlal Nehru Medical College, AMU, Aligarh in 86 patients with gastrointestinal masses. After thorough clinical examination, ultrasonographic examination was performed with Sonoline 500 (Siemen's) ultrasound machine having 35 MHz sector probe; and those found to have a mass were subjected to fine needle aspiration cytology by a 2022G needle attached to a 10 ml syringe for superficial masses and a 9 cm, 20-22G spinal needle for deep seated masses. Smears prepared were fixed in 95% ethyl alcohol and stained with Haematoxylin and Eosin (H&E) and Papanicolaou stains. In all cases where the cytological diagnosis was of a granulomatous disease, Ziehl Neelsen staining was performed to demonstrate acid-fast/ tuberculous bacilli. Subsequent to cytologic diagnosis, tissue obtained from operated patients was processed and stained with H&E stain.
Most of the patients included in the study presented with an abdominal mass or with pain in the abdomen and ultrasonographic examination revealed gastrointestinal masses. Forty (46.5%) were males and 46 (53.5%) females with majority of patients found in the third decade in both sexes [Table 1]. All the patients were subjected to fine needle aspiration of their masses under ultrasound guidance. Malignant lesions constituted the maximum number of cases accounting for 42 (48.8%), followed by 36 cases (41.8%) of benign and inflammatory lesions [Table 2].
Adenocarcinoma was the most common malignancy in 36 cases (85.7%), out of which 16 cases (44.4%) were adenocarcinoma stomach with thickened gastric wall on ultrasonography [Figure 1]. The smears showed sheets of cells with mild nuclear atypia, nuclear crowding with moderate amount of eosinophilic cytoplasm or mucin vacuoles [Figure 2]. The remaining 20 cases (55.6%) were adenocarcinoma intestine, with bowel mass on ultrasonography [Figure 3] and smears revealed cells in small clusters with acinar formation and having intracytoplasmic mucin [Figure 4]. There were 3(3.5%) cases of intestinal carcinoid; the cytomorphologic features depicted a profusely cellular smear with groups of small cells in sheets and rosettes. There was a striking degree of cellular and nuclear monomorphism with small round to oval nuclei exhibiting a characteristic fine granular, evenly distributed chromatin pattern and minimal to moderate, finely granular, fragile cytoplasm [Figure 5].
Among the inflammatory and benign lesions, 30 (83.3%) cases were tuberculous, which on cytology demonstrated epithelioid cell granulomas with or without caseous necrosis. Ziehl Neelsen stain demonstrated acid fast bacilli mainly in cases with extensive necrosis. There were 4 (11.1%) cases of appendicitis, with very atypical clinical findings in the form of mild fever and slight pain in right lower abdominal quadrant, with only leucocytosis on blood examination and ultrasonography revealing a mass effect in 3 cases and non-specific changes in a single case. The mean age of malignancy cases was 39.2% years and the average age of tuberculous patients in our study was 25.5 years.
Histological examination was performed in 36 cases. On cytohistological correlation, 30 were found to be true positive for malignancy, 5 true negative and 1 false negative. The false negative case was that of a leiomyosarcoma of the intestine which was diagnosed as leiomyoma on cytology. There were no false positive cases. We obtained a sensitivity of 93.8%, specificity of 100% and diagnostic accuracy of 94.4% in our study.
The present study was conducted on 86 cases with gastrointestinal mass discovered either on clinical or ultrasonographic examination.
Out of the 86 cases, 40 (46.5%) were males and 46 (53.5%) were females. The male patients ranged from 14 to 65 years and females from 17 to 62 years. Das and Pant  reported 78 patients between 1 - 85 years with gastrointestinal masses. The majority of patients were found in the third decade in both sexes with no case in the first decade of life.
On cytologic evaluation, 42 cases (48.8%) were found to have malignancy, 36 cases (41.8%) had inflammatory or benign smears, and 6 cases (6.9%) were suspicious for malignancy. Ballo and Guy  in their study on 20 cases of gastrointestinal wall masses reported neoplastic process in 15 cases (75.0%) whereas Pedersen et al  noted 61 cases (78.2%) of malignant lesions and 17 cases (21.8%) of benign lesions in their study on 78 patients with ultrasonographically demonstrable gastrointestinal masses.
Adenocarcinoma was the most common malignancy in 36 cases (85.7%), similar to the results of 78.2% by Pederson et al  in their study on 61 malignant patients. Most common site was intestine, 20 cases (55.6%) followed by 16 (44.4%) cases in stomach, a finding similar to Carson et al  who obtained 34.1% and 65.9% cases of adenocarcinoma stomach and intestine respectively. A slightly higher percentage of cases of adenocarcinoma intestine, 40 cases (80%) were reported by Javid et al  in their study.
Among the inflammatory and benign cases, the maximum (83.3%) were tuberculous followed by appendicitis (11.1%), with perforation leading to the formation of a periappendiceal mass in 3 cases and fibrous induration in a single case; very similar to the findings of Rex et al  . Das and Pant  in their study on 25 benign cases reported 72% tuberculous cases. Similarly S Radhika  also reported a high percentage of tuberculous cases among benign lesions on abdominal aspiration biopsy.
The mean age of malignancy in our study was 39.2 years, which was much lower to 71 years as reported as Heriot et al  and Misra et al.  This could be because the youngest patient in our study was a 14 year old male, found to be suffering from papillary adenocarcinoma of the descending colon, whose diagnosis was confirmed on histopathology. The average age for tuberculosis of the intestine was 25.5 years.
Histopathological examination was performed on 36 cases and on correlation, 30 cases were found to be true positive for malignancy, 5 true negative and 1 false negative. The false negative case was that of a leiomyosarcoma of the intestine which was diagnosed as leiomyoma on cytology. According to Liang-Che and Davidson  , the histopathological diagnosis of malignancy in well-differentiated tumours of smooth muscle origin is to a large extent dependent on mitotic count, invasive growth and size, which generally cannot be evaluated on FNAC smear.
In one patient, a mass in the ileocaecal region suspected to be a sarcoma on ultrasonography was found to be a benign cystic teratoma on cytology. But the patient refused surgery and the diagnosis could not be confirmed.
We obtained a sensitivity of 93.8%, specificity of 100% similar to that of Heriot et al,  who obtained a sensitivity of 94% and specificity of 100%. A diagnostic accuracy of 94.4% obtained by us was similar to 94.1% as reported by Kedar et al  and Silverman et al. 
Ultrasound guided FNAC is an effective and useful method which eliminates the need for surgical biopsy and provides sufficient information for the initiation of therapy. Moreover it helps in arriving at a tissue diagnosis of neoplastic and non-neoplastic lesions, especially tuberculosis.
|1||Pederson JF. Percutaneous puncture guided by ultrasonic multitransducer scanning. J Clin Ultrasound 1997; 5: 175-7.|
|2||Winawer SJ, Posner G, Lightdale CJ. Endoscopic diagnosis of advanced gastric cancer. Factors influencing yield. Gastroenterology 1975; 69: 1183-7.|
|3||Walls WJ. The evaluation of malignant gastric neoplasms by ultrasonic B scanning. Radiology 1976; 118: 159-63.|
|4||Maurits JW, Peter V, Marc G, Kenneths JC, Urersima LM. Endosonography-guided FNAC-diagnostic accuracy and complication assessment. Gastroenterology 1997; 112: 108795.|
|5||Fritscher RA, Schirrow L, Petiaschz, Sochendra N. Endosonographically controlled FNAC-indications and results in routine diagnosis. Gastroenterol 1999; 37: 343-51.|
|6||Vander Noot MR, Eloubeidi MA, Chen VK, Jhala D, Jhala N, Syed S. Diagnosis of gastrointestinal tract lesions by endoscopic US guided FNAC. Cancer 2004; 102: 157-63.|
|7||Das DK, Pant CS. Fine needle aspiration cytologic diagnosis of gastrointestinal tract lesions. A study of 78 cases. Acta Cytol 1994; 38: 723-6.|
|8||Ballo MS, Guy CD. Percutaneous fine needle aspiration of gastrointestinal wall lesions with image guidance. Diagn Cytopathol 2001; 24: 16-20.|
|9||Pedersen S, Gronvall S, Holm HH. Ultrasonographically guided FNAC of GI mass lesions. J Ultrasound Med 1984; 3: 65-8.|
|10||Carson BW, Brown JA, Cooperberg PL. Ultrasonographically guided percentaneous biopsy of gastric, small bowel and colonic abnormalities. J Ultrasound Med 1998; 17: 739-42.|
|11||Javid G, Gulzar GM, Khan B, Shah A, Khan MA. Percutaneous sonography-guided FNAC of colonic lesions. Indian J Gastroenterol 1999; 18: 146-8.|
|12||Rex JC, Harrison EG, Priestley JT. Appendicits and ligneous perityphlitis. Arch Surg 1961; 82: 735-45.|
|13||S Radhika. Abdominal tuberculosis diagnosis by fine needle aspiration cytology. Acta Cytol 1993; 37: 673-7.|
|14||Heriot AG, Kumar D, Thomas V, Young M, Joseph A. Ultrasonographically guided fine needle aspiration cytology in the diagnosis of colonic lesions. Br J Surg 1998; 85: 1713-5.|
|15||Misra SP, Misra V, Dwivedi M, Singh M. Diagnostic value of fine needle aspiration biopsy of palpable colonic masses. Acta Cytol 1999; 43: 624-9.|
|16||Liang Che T, Davidson D. Aspiration cytology of smooth muscle tumours. A cytologic approach to the differentiation between leiomyosarcoma and leiomyoma. Acta Cytol 1993; 37: 300-8.|
|17||Kedar RP, Patel VH, Merchant SA, Agarwal V. Ultrasound guided aspiration cytology - a valuable diagnostic aid. J Postgrad Med 1991; 37: 84-7.|
|18||Silverman JF, Finley JL, O'Brien KF. Diagnostic accuracy and role of immediate interpretation of fine needle aspiration biopsy specimens from various sites. Acta Cytol 1989; 33: 791-6.|