Fine-needle aspiration cytology: its origin, development, and present status with special reference to a developing country, India

Fine needle aspiration biopsy in low- and middle-income countries

Fine needle aspiration biopsy (FNAB) in low- and middle-income countries (LMIC), can provide minimally invasive, cost-effective tissue diagnosis with rapid assessment and specimen triage, which is advantageous in these resource-limited settings. Nevertheless, challenges such as equipment shortages, reagents, and lack of trained personnel exist. This article discusses the effectiveness of FNAB for diagnosis of malignant and inflammatory conditions across various organs, such as lymph nodes, breast, soft tissue, and thyroid and advocates for increased training opportunities and collaboration with academic centers to enhance diagnostic accuracy and access to pathology services.

Geographic Distribution, Number, and Types of Papers Published in International Cytopathology Journals in the Last 5.5 Years: A Preliminary Study

OBJECTIVE

The aim of this study was to explore the geographic distribution and number of papers published in international and Science Citation Index (SCI)-indexed cytology journals based on their country of origin.

MATERIALS AND METHODS

A country-based geographic analysis of studies published over a 5.5-year period from January 2016 to June 2021 in 5 cytopathology journals indexed as SCI and SCI-E with an impact factor higher than 1 (Cancer Cytopathology, Cytopathology, Diagnostic Cytopathology, Acta Cytologica, and CytoJournal) and papers categorized as "original" and "other" was performed.

RESULTS

A total of 3,063 papers were found, with 1,466 (47.8%) categorized as "original" papers and 1,597 (52.1%) designated as "other" papers. These papers were submitted from 62 different countries. The five countries with the greatest number of papers were the USA (38.4%), India (16.8%), Japan (7.4%), Italy (5.5%), and Brazil (3.1%). A general subgroup analysis was also performed on the original studies without a country breakdown. Cytomorphological, cytomorphological-immunohistochemical, and molecular assessments compose 38.5%, 45.7%, and 15% of the subgroups, respectively.

CONCLUSION

The number of academic papers originating from developing countries in the field of cytopathology has increased in recent years. Although most scientific papers are produced in developed countries, the rate in these countries is much lower than that in some developing countries as the rate of academic growth in developed countries has stabilized. Despite the widespread and sophisticated implementation of cytology in daily practice in Western European countries outside the UK, such as Germany and the Netherlands, and in Scandinavian countries and other developed countries, such as Australia and Canada, these countries rank in the middle to lower end of countries producing cytology papers. Meanwhile, there has been an increase in the number of cytology papers published by authors from Southern European countries, such as Italy (ranked 4th) and Spain (ranked 6th), and Turkey (ranked 8th). There is a remarkable increase in cytology papers originating from Asia, particularly India, Japan, and China.

SUMMARY

We aimed to present a basic survey of the geographic distribution of manuscript submissions to high-impact cytopathology journals and to point out emerging trends in cytology utilization and basic research. However, our results show that the landscape of cytology is changing and suggest geographic regions that are ripe for the production of novel "points of view" and new research findings.

Importance of Cytopathologic Diagnosis in Early Cancer Diagnosis in Resource-Constrained Countries

PURPOSE

The rising cancer burden in low- and middle-income countries (LMICs) stresses already weak health care systems and poses unique challenges. In resource-constrained LMICs and in circumstances where most patients must pay out of pocket for diagnostic tests, these may not be available or affordable for many. Cytopathology provides a simple, inexpensive, standardized, and low-technology diagnostic procedure that is increasingly used as an effective tool to address the hurdles faced in cancer control programs in LMICs. This review explores the potential role of cytopathology in LMICs in reducing the cancer burden.

METHODS

This review studied the existing literature across the globe regarding the utilization of cytopathology as a diagnostic or screening tool for various types of malignancies as well as its advantages and disadvantages, depending on the local situation.

RESULTS

Apart from the usefulness of cytopathology, this review also sheds light on the barriers to using cytopathology in LMICs. Most recently, SARS-CoV-2 has produced several unique challenges for cytopathology. These are being met with innovative measures to combat the effects of the pandemic and ensure the safe delivery of essential cytopathology services.

CONCLUSION

The usefulness of cytopathologic techniques has been demonstrated via various studies, even during the recent pandemic. If cytology is to be used appropriately, the focus needs to be on integrating it into the national cancer screening and diagnostic programs as well as providing well-trained human resources.

The significance of mucinous metaplasia in Warthin tumor: a frequent occurrence and potential pitfall

Mucinous metaplasia in Warthin tumor (WT) is a recognized phenomenon. Nevertheless, its presence can create a diagnostic challenge in the distinction from the newly proposed variant of mucoepidermoid carcinoma (MEC), Warthin-like MEC. In this study, we evaluated the significance and diagnostic relevance of mucinous metaplasia in WTs. A total of 30 WTs diagnosed based on resection specimens formed the basis of this retrospective study. Mucicarmine staining was performed to identify mucinous metaplasia, and fluorescence in situ hybridization (FISH) analysis was used to detect MAML2 gene rearrangement. After review, one MAML2 rearranged case was reclassified as Warthin-like MEC as the classic bilayered epithelium in WT was not identified. The diagnosis of WT was confirmed in the remaining 29 cases. Mucinous metaplasia was encountered in 24 WTs (83%), with 14% (4/29) having an abundant amount. We found that mucinous metaplasia correlated with tumor size (p < 0.05). Age and sex distribution were similar in WT cases with or without mucinous metaplasia. In addition, neither the presence of squamous metaplasia nor the time interval between fine-needle aspiration and surgery was related to mucinous metaplasia (p > 0.05). The MAML2 FISH analyses performed in 18 WTs with variable amounts of mucinous metaplasia were negative for rearrangement. In conclusion, mucinous metaplasia is fairly common in WTs and shows a significant correlation with tumor size. Therefore, caution should be taken to avoid overinterpretation of WT with mucinous metaplasia as MEC in cases showing the classic bilayered oncocytic lining epithelium.

Fusion Image-Guided and Ultrasound-Guided Fine Needle Aspiration in Patients With Suspected Hepatic Metastases

AIM

The aim of this study was to compare the diagnostic adequacy of computed tomography (CT)-ultrasound (US) fusion image-guided fine needle aspiration (FNA) and US-guided FNA in patients with suspected hepatic metastases.

METHODS

Thirty consecutive patients of either sex with known or unknown primary malignancy suspected of having liver metastases on both US and CT, whose multiphasic contrast-enhanced computed tomography was performed using a 64-slice or a higher slice CT scanner, and who were referred for percutaneous FNA were included in this prospective study approved by the institutional review board of the study institute. CT-ultrasound fusion image-guided FNA of the largest lesion using electromagnetic tracking and with freehand ultrasound-guided FNA were performed in the same sitting. Value of fitness, which is a rough estimate of how well the fusion has been achieved, was recorded. Diagnostic adequacy of smears was assessed by a scoring system based on cellular material, background blood/clot, degree of cellular degeneration or trauma, and retention of architecture.

RESULTS

The size of the lesions ranged from 1 to 10 cm, and the depth of location of the lesions ranged from 1.4 to 9.3 cm. The fusion fitness values ranged from 1.2 to 10 mm. The scores of the smears did not correlate with lesion size, depth of location, and fusion fitness value. Diagnostic adequacy was seen in 90% and 93.3% of lesions sampled by fusion image guidance and ultrasound guidance, respectively (p = 0.655). All the lesions that yielded inadequate smears by fusion guidance were deep-seated lesions (>5 cm). All the lesions that yielded inadequate smears by ultrasound guidance were small lesions (<3 cm). No complications were encountered in any of the patients.

CONCLUSION

Fusion image-guided FNA is a safe procedure with a high diagnostic adequacy rate. Fusion image-guided FNA is not better than US-guided FNA for conspicuous hepatic lesions; however, it may be useful in inconspicuous lesions.

Utilisation of fine needle aspiration cytology and biopsy in Sokoto, Nigeria: A five-year review

The histopathology department of Usmanu Danfodiyo University Teaching Hospital in Sokoto, Nigeria, conducted a total of 1435 fine needle aspiration biopsies from 1 January 2011 to 31 December 2015, constituting 30% of cytology specimens received. The most common site for the procedure was the breast (655 cases, 45.6%), and 893 cases (63.3%) were neoplastic lesions. Even in resource-poor settings, this underutilised procedure is useful for patient management.

Needle Biopsy Adequacy in the Era of Precision Medicine and Value-Based Health Care

CONTEXT.—

Needle biopsy of diseased tissue is an essential diagnostic tool that is becoming even more important as precision medicine develops. However, the capability of this modality to efficiently provide samples adequate for diagnostic and prognostic analysis remains quite limited relative to current diagnostic needs. For physicians and patients, inadequate biopsy frequently leads to diagnostic delay, procedure duplication, or insufficient information about tumor biology leading to delay in treatment; for health systems, this results in substantial incremental costs and inefficient use of scarce specialized diagnostic resources.

OBJECTIVE.—

To review current needle biopsy technology, devices, and practice with a perspective to identify current limitations and opportunities for improvement in the context of advancing precision medicine.

DATA SOURCES.—

PubMed searches of fine-needle aspiration and core needle biopsy devices and similar technologies were made generally, by tissue site, and by adequacy as well as by health economics of these technologies.

CONCLUSIONS.—

Needle biopsy adequacy can be improved by recognizing the importance of this diagnostic tool by promoting common criteria for needle biopsy adequacy; by optimizing needle biopsy procedural technique, technologies, clinical practice, professional education, and quality assurance; and by bundling biopsy procedure costs with downstream diagnostic modalities to provide better accountability and incentives to improve the diagnostic process.

Utilization of fine needle aspiration cytology at Kamuzu central hospital

Background

Fine needle aspiration cytology (FNAC) has been widely accepted to be a safe, accurate, prompt and inexpensive procedure for diagnosis of both neoplastic and infectious diseases in adult and pediatric populations. Despite its value for diagnosis, FNAC is underutilized in resource limited countries. We reviewed the utilization of FNAC after it was introduced at Kamuzu Central Hospital (KCH).

Methods

A retrospective review of all FNAC performed at KCH laboratory during the period of January 2012 to July 2014 was conducted using an electronic database from KCH laboratory. We evaluated factors associated with a diagnostic sample using multivariate logistic regression model.

Results

750 FNAC were reviewed from 722 patients: 56.9% were adults >15 years and 54% were female. The number of FNAC increased annually from 56 (2012) to 379 (2013) to 315 (up to July 2014). Of 750 FNAC, 56.4% were performed by non-pathologists. The most common sites were lymph nodes (38.1%), abdomen (25.8%), breast (16.3%), and head & neck (15.7%). Most of the samples (77.6%) were diagnostic. FNAC was more likely to be diagnostic if performed by pathologists versus non-pathologists (OR 1.78, 95% CI 1.20–2.64), in 2013 compared to 2012 (OR 1.95, 95% CI 1.05–3.56), or performed on a deep lesion versus a subcutaneous lesion (OR 1.71, 95% CI 1.15–2.5), or if samples were taken from the head and neck (OR 2.4, 95% CI: 1.39–4.39), and abdomen (OR 2.66, 95%CI1.59–4.42) compared to those from the lymph nodes. The odds of a diagnostic test did not differ significantly according to gender, HIV status, or age groups.

Conclusion

Most FNACs successfully diagnosed the presence or absence of disease, with substantial improvements over time. However, training for non-pathologists may facilitate more diagnostic results.

Diagnostic validity of fine-needle capillary cytology in palpable tumours at the Oncology Institute of Peru

Objective

To evaluate the diagnostic validity of fine-needle capillary cytology (FNCC) in palpable tumours.

Material and methods

A retrospective, single-tray, cross-sectional diagnostic test study was carried out. We reviewed the cytological reports of the case files of the Cytology Unit of the Northern Regional Institute of Neoplastic Diseases (IREN) from January 2012 to December 2016.

Results

A total of 332 patients were selected, with an average age of 54.77 years (range 13-90 years); 61.4% of patients were female. The most frequent anatomical sites were lymph nodes (49.7%), thyroid (13.3%), breast (12.3%) and soft tissues (11.4%). Twenty-five cytologies did not have a histological correlation and six showed an atypical result. In the lymph node study, the most frequent pathology was metastatic carcinoma (49.7%), followed by lymphoma (13.3%). The FNCC had a sensitivity of 99.55%, a specificity of 98.77%, a positive predictive value of 99.55% and a negative predictive value of 98.77%. The positive likelihood ratio was 80.63%.

Conclusions

FNCC is a useful, safe, reliable and economical ambulatory technique with minimal complications and high diagnostic accuracy.

Thyroid Cytology in India: Contemporary Review and Meta-analysis

Fine-needle aspiration cytology (FNAC) is a screening test for triaging thyroid nodules, aiding in subsequent clinical management. However, the advantages have been overshadowed by the multiplicity of reporting systems and a wide range of nomenclature used. The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) was formulated in 2007, to give the world a uniform thyroid cytology reporting system, facilitating easy interpretation by the clinicians. Here, we review the status of thyroid FNAC in India in terms of various reporting systems used including a meta-analysis of the previously published data. An extensive literature search was performed using internet search engines. The reports with detailed classification system used in thyroid cytology were included. The meta-analysis of published data was compared with the implied risk of malignancy by TBSRTC. More than 50 studies were retrieved and evaluated. TBSRTC is currently the most widely used reporting system with different studies showing good efficacy and interobserver concordance. Ancillary techniques have, as of now, limited applicability and acceptability in thyroid cytology in India. Twenty-eight published articles met the criteria for inclusion in the meta-analysis. When compared with TBSRTC recommendations, the meta-analysis showed a higher risk of malignancy for categories I and III. Thyroid FNAC is practiced all over India. TBSRTC has found widespread acceptance, with most institutions using this system for routine thyroid cytology reporting. However, reasons for a high malignancy risk for categories I and III need to be looked into. Various possible contributing factors are discussed in the review.

Should we apply suction during fine needle cytology of thyroid lesions? A prospective study of 200 cases

INTRODUCTION

Fine needle aspiration cytology (FNAC) is a well-established first line diagnostic tool in evaluating palpable thyroid lesions. However, the technique depends on suction and thus is at times painful, sometimes traumatic and yield haemorrhagic material for cytological study. In more recent times, a modified technique called fine needle sampling without aspiration (FNS) has come into vogue which obviates the use of suction and therefore is more patient friendly.

AIMS/OBJECTIVES

To investigate whether fine needle sampling without aspiration (FNS) gives quantitatively and qualitatively superior cytologic material as compared to the conventional technique of fine needle aspiration (FNAC) in thyroid lesions.

MATERIALS AND METHODS

It is a prospective study of 200 cases carried out in the Department of Pathology during two years period. Both techniques were executed on the same thyroid swelling / nodule in the same clinical session beginning with FNS followed by FNAC. The observation recorded by two pathologists were based on the scoring system proposed by Mair et al., Statistical analysis was done by Student's paired t-test using SPSS 13 software. Observation/Results: A total of 200 cases were studied. The non-aspiration technique yielded less diagnostically adequate but more diagnostically superior smears when compared with aspiration technique. The average score per case was 5.31 by aspiration technique and 6.35 by non-aspiration technique.

CONCLUSION

Both the techniques have their own merits and demerits and neither is absolutely superior to the other. A combination of both the technique gives better result.

Making mock-FNA smears from fresh surgical pathology specimens to improve smear preparation technique and to create cytohistological correlation series

BACKGROUND

Fine needle aspiration (FNA) cytology is a well-established diagnostic method based on the microscopic interpretation of often scant cytological material; therefore, experience, good technique and smear quality are equally important in obtaining satisfactory results.

AIMS OF STUDY

We studied the use of fresh surgical pathology specimens for making so-called mock-FNA smears with the potential of cytohistological correlation. Additionally, we studied how this process aids the improvement of preparation technique and smear quality.

METHODS

Cytological aspirates from 32 fresh biopsy specimens from various sites: lung (20), lymph nodes (6), and breast (6) were obtained, all with a clinical diagnosis of tumor. Aspiration was performed from grossly palpable tumors. 25 G needle and Cameco-type syringe holder was used with minimal or no suction.

RESULTS

Unfixed surgical specimens provided sufficient cytological material that resulted in good quality smears. After standard processing of specimens into microscopic sections from paraffin embedded tissues, cytohistological case-series were created. No significant alteration was reported in tissue architecture on hematoxylin-eosin stained sections after the aspiration procedure. A gradual, but steady improvement was observed in smear quality just after a few preparations.

DISCUSSIONS AND CONCLUSIONS

Our study proved that surgical specimens may be used as a source of cytological material to create cytohistological correlation studies and also to improve FNA cytology skills. The use of very fine gauge needle (25 G, 0,6 mm diameter) during the sampling process does not alter tissue architecture therefore the final histopathological diagnosis is not compromised. We conclude that by using fresh surgical specimens useful cytohistological collections can be created both as a teaching resource and as improving experience.

Role of cytopathology in cancer control in low-resource settings: sub-Saharan Africa's perspective

Cancer is an emerging public health problem in Africa especially with increasing exposure to risky life styles, environmental carcinogens and emergence of AIDS-associated cancers. Of the WHO estimated 7.9 million cancer-related deaths in 2007 more than 72% occurred in the low- and middle-income countries and 80% presented in the late stages. To implement the WHO resolution on cancer control programs in these settings, feasible evidence-based interventions for prevention, early diagnosis and detection need to be widely introduced. Fundamental to appropriate cancer treatment and statistics is accurate diagnosis. In low-resource settings, the diagnostic techniques and procedures should be reliable, cost-effective, simple and acceptable to patients. In addition, the required equipment should be affordable, requiring minimal maintenance and with readily available consumables. Cytology, as a simple standardized low-technology procedure, fulfills these criteria and is most effective in addressing the major components of cancer control programs in these areas. The major obstacles to its widespread establishment are lack of awareness and inadequate numbers of trained personnel compounded by sociopolitical factors, poor national planning and implementation. Rather than investing in new technology or alternative screening methods, efforts should focus on the education and training of local personnel, as feasible options, to improve the chances of implementing meaningful cancer control programs.

Fine-needle aspiration cytology in Ethiopia

CONTEXT

Most of the population in Ethiopia lives below the poverty line with severely limited access to health care. The burden of infectious diseases is high, but benign and malignant neoplasms are also encountered frequently. For diagnosis of palpable lesions in this setting, fine-needle aspiration biopsy is the method of choice.

OBJECTIVE

To present findings from several patients from 3 major hospitals in Ethiopia who underwent fine-needle aspiration biopsy.

DATA SOURCES

Representative cytopathology cases of routinely encountered problems are shown. Often patients present with clinically advanced lesions. Staffing, technique, and equipment used for fine-needle aspiration biopsy are described at Black Lion Hospital (Addis Ababa), the University of Gonder Hospital (Gonder), and Ayder Referral Hospital of Mekelle University in the Tigray region of northern Ethiopia.

CONCLUSIONS

Fine-needle aspiration biopsy is a highly effective method for diagnosis of mass lesions, especially in an environment with sparse health care resources, such as Ethiopia. This article illustrates the work of Ethiopian cytopathologists and emphasizes the constraints under which they perform their work.

Modified technique for obtaining mediastinal samples with endobronchial ultrasound-guided transbronchial needle aspiration: results from a prospective observational study

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a widely-accepted method for obtaining both benign and malignant mediastinal lymph node samples. We present the results obtained with a modification that simplifies sampling, known as fine-needle capillary sampling or EBUS-FNC.

METHODS

A prospective observational study with 44 consecutive patients who underwent EBUS at the University of Navarra Clinic in Pamplona (Spain). All samples were obtained by EBUS-FNC instead of by conventional EBUS-TBNA. No suction was used, and the internal stylus was not completely withdrawn at any time.

RESULTS

The examination of the mediastinum by means of EBUS identified the presence of lymphadenopathies or mediastinal masses in 38 patients (86.4%). Samples were taken from more than one lymph node in 23 patients (52.3%). EBUS-FNC provided adequate and representative material for interpretation in all patients, and diagnostic performance was 87%. Sensitivity for the detection of lung cancer with EBUS-FNC was 84%. Mild complications were only recorded in two patients (4.5%).

CONCLUSIONS

Our study suggests that EBUS-FNC is a safe technique, comparable to EBUS-TBNA in efficacy, and is able to obtain adequate samples.

A comparison of specimen adequacy in fine needle aspiration biopsies performed by pathologists, trained nursing staff and clinicians

Fine needle aspiration biopsies (FNAB) performed by trained professional nurses and pathology registrars in an FNAB clinic were compared with aspirates by clinicians from regional clinics and hospitals. Of the 7709 reports retrieved from the archives, the highest number of unsatisfactory aspirates came from clinicians (42%), followed by registrars (20.09%) while the nurses had the lowest overall unsatisfactory rate (14.32%). We conclude that, in countries experiencing a shortage of adequately qualified and experienced medical personnel, it is essential to train nurses to perform and manage FNAB clinics.

Needle stick injuries during fine needle aspiration procedure: Frequency, causes and knowledge, attitude and practices of cytopathologists

Background:

There is no study available on the frequency, predisposing factors and outcome of needle stick injury (NSI) in cytopathologists who perform fine needle aspiration (FNA).

Aim:

To know the frequency, circumstances and sequlae of NSI sustained by cytopathologists, assess their knowledge about risks of NSI and attitudes and practices towards use of standard precautions and post-injury wound care.

Materials and Methods:

Study design: cross sectional. Setting: Tertiary care teaching and non-teaching hospitals and private laboratories. Data collection method: Knowledge, attitude and practices survey using a questionnaire.

Results:

Majority (90.5%) of the respondents have had NSI in their total career. In the previous year, more than half (71.4%) had at least one NSI (mean 3.2). NSI was the most common in index finger of non-dominant hand (59.6%) and occurred during step two of FNA procedure when the needle was being manipulated within the lump. The major predisposing factors were uncooperative patients (88.9%), small children (54%), deep masses (36.5%), hot humid climate (88.9%), heavy workload (76.2%) and poor administrative arrangement (54%). The adherence to standard precautions was not optimal (74.6%). None of them reported NSI to the authorities, nor investigated source patient or themselves. 82.5% of the respondents were not aware of any formal exposure reporting system in their hospital.

Conclusion:

Cytopathologists frequently experience NSI while performing FNA. Frequency of injury is also related to patient characteristics and work site factors. Education and motivation for adhering to standard precautions and post-exposure prophylaxis are often lacking.

A review of the utilization of fine needle aspiration in clinical practice and research in Nigeria

Background:

Research and publications are critical to advancements in the quality of healthcare delivery. This article attempts to highlight the prospects and challenges of fine needle aspiration (FNA) cytology as a tool for research in Nigeria.

Materials and Methods:

Data available in local and international bibliographic databases for the period 1986–2005 (20 years) were collated and analyzed.

Results:

The theme of Nigerian FNA-focused studies correlated with the recognized disease patterns in the country which are tuberculous lymphadenitis, breast tumors and Burkitt's lymphoma. The accuracy of FNA in these situations was high and comparable to the experience in developed countries. It was found that the total number of articles published during two contiguous periods (1986–1995 and 1996–2005) had increased from 5 to 18. Also, in majority of cases, the articles were not published in specialized pathology journals.

Conclusions:

The utilization of FNA is apparently lagging in Nigeria. Given its potential in resource-constrained settings, we are of the opinion that it should be used more often in clinical and translational research.

Assisting cytopathology training in medically under-resourced countries: defining the problems and establishing solutions

Cytology is able to deliver rapid accurate diagnoses with minimal equipment and laboratory infrastructure at minimal cost, and this is especially so for fine needle biopsy (FNB), which is a powerful diagnostic tool in medically resource-poor environments, where histopathology laboratories are small in number and poorly supported financially. The crucial element in the development of cytology services is to train a sufficient number of well trained cytopathologists and cytotechnologists to create a 'critical mass' of personnel who not only provide routine diagnostic services, but also can train an ever expanding number of pathologists, cytotechnologists, and health workers. A review of practical programs to train cytopathologists and cytotechnologists in their own countries will be presented, including a recent series of FNB and cytology tutorials run in sub Saharan Africa. The need for local cytopathology programs and the potential for both local and visiting cytopathologists to provide a faculty will be discussed, as well as a range of possible programs which can bring African pathologists and trainee pathologists to Western institutions for periods of their training. Ideally, the regional Societies of Cytology, including the recently formed West African Society of Cytology, will establish their own diagnostic protocols, training programs, syllabuses, examinations and accreditation and career pathways for both cytopathologists and cytotechnologists, and organize tutorials where they will invite overseas faculty to contribute. Crucially, these new societies will empower cytopathologists and cytotechnologists to approach health services and governments to state the need for cytology services as a cost-effective accurate diagnostic service that enhances patient care.