Fine-needle aspiration of parotid tumors

Sensitivity, Specificity, and Posttest Probability of Parotid Fine-Needle Aspiration: A Systematic Review and Meta-analysis

OBJECTIVES

(1) To analyze the sensitivity and specificity of fine-needle aspiration (FNA) in distinguishing benign from malignant parotid disease. (2) To determine the anticipated posttest probability of malignancy and probability of nondiagnostic and indeterminate cytology with parotid FNA.

DATA SOURCES

Independently corroborated computerized searches of PubMed, Embase, and Cochrane Central Register were performed. These were supplemented with manual searches and input from content experts.

REVIEW METHODS

Inclusion/exclusion criteria specified diagnosis of parotid mass, intervention with both FNA and surgical excision, and enumeration of both cytologic and surgical histopathologic results. The primary outcomes were sensitivity, specificity, and posttest probability of malignancy. Heterogeneity was evaluated with the I(2) statistic. Meta-analysis was performed via a 2-level mixed logistic regression model. Bayesian nomograms were plotted via pooled likelihood ratios.

RESULTS

The systematic review yielded 70 criterion-meeting studies, 63 of which contained data that allowed for computation of numerical outcomes (n = 5647 patients; level 2a) and consideration of meta-analysis. Subgroup analyses were performed in studies that were prospective, involved consecutive patients, described the FNA technique utilized, and used ultrasound guidance. The I(2) point estimate was >70% for all analyses, except within prospectively obtained and ultrasound-guided results. Among the prospective subgroup, the pooled analysis demonstrated a sensitivity of 0.882 (95% confidence interval [95% CI], 0.509-0.982) and a specificity of 0.995 (95% CI, 0.960-0.999). The probabilities of nondiagnostic and indeterminate cytology were 0.053 (95% CI, 0.030-0.075) and 0.147 (95% CI, 0.106-0.188), respectively.

CONCLUSION

FNA has moderate sensitivity and high specificity in differentiating malignant from benign parotid lesions. Considerable heterogeneity is present among studies.

Salivary gland tumor fine-needle aspiration cytology: a proposal for a risk stratification classification

OBJECTIVES

Fine-needle aspiration (FNA) is useful in the evaluation of salivary gland tumors, but currently no standard terminology or risk stratification model exists.

METHODS

FNA smears were reviewed and categorized based on cytonuclear features, stromal characteristics, and background characteristics. Risk of malignancy was calculated for each category. Classifications as benign, neoplasm of uncertain malignant potential (NUMP), suspicious for malignancy, and positive for malignancy were used to aggregate categories into similar risk groups.

RESULTS

Categorization of salivary gland aspirates into morphologic categories resulted in the expected risk stratification. Grouping of categories maintained risk stratification, providing classes with malignancy risk as follows: benign, 2%; NUMP, 18%; suspicious for malignancy, 76%; and positive for malignancy, 100%.

CONCLUSIONS

Salivary gland FNA categorization into commonly encountered morphologic categories provides risk stratification, which translates to a simplified classification scheme of benign, NUMP, suspicious, and positive for malignancy similar to the paradigm in other organ systems.

Value of fine-needle aspiration cytology in the evaluation of parotid tumors

Fine needle aspiration cytology (FNAC) is commonly used in the study of parotid masses; however controversy exists regarding its diagnostic accuracy. The objective of this study was to evaluate the effectiveness of FNAC as a preoperative diagnostic tool of parotid tumors. Sixty-five patients had satisfactory preoperative FNAC and underwent subsequent surgery to the parotid between March 2002 and July 2009 at our institution. The results of the FNAC were compared to the permanent histopathological diagnosis. The sensitivity, specificity, positive predictive value, negative predictive value, and the overall accuracy of FNAC for parotid masses were 57.9, 97.8, 91.7, 84.9, and 86%, respectively. FNAC is useful in the preoperative assessment of parotid tumors and surgical planning. The non-diagnostic and false-negative results are the limitations of FNAC that should be reduced to improve its usefulness in the evaluation of parotid tumors.

A systematic review and meta-analysis of the diagnostic accuracy of fine-needle aspiration cytology for parotid gland lesions

The clinical usefulness of fine-needle aspiration cytology (FNAC) for the diagnosis of parotid gland lesions is controversial. Many accuracy studies have been published, but the literature has not been adequately summarized. We identified 64 studies on the diagnosis of malignancy (6,169 cases) and 7 studies on the diagnosis of neoplasia (795 cases). The diagnosis of neoplasia (area under the summary receiver operating characteristic [AUSROC] curve, 0.99; 95% confidence interval [CI], 0.97-1.00) had higher accuracy than the diagnosis of malignancy (AUSROC, 0.96; 95% CI, 0.94-0.97). Several sources of bias were identified that could affect study estimates. Studies on the diagnosis of malignancy showed significant heterogeneity (P < .001). The subgroups of American, French, and Turkish studies showed greater homogeneity, but the accuracy of these subgroups was not significantly different from that of the remaining subgroup. It is not possible to provide a general guideline on the clinical usefulness of FNAC for parotid gland lesions owing to the variability in study results. There is a need to improve the quality of reporting and to improve study designs to remove or assess the impact of bias.

Primary Carcinoid Tumor of the Parotid Gland: A Case Report and Review of the Literature

Salivary gland tumors account for 3 to 6% of all head and neck neoplasms in adults. Some 70 to 85% of these lesions are found in the parotid. Carcinoid tumors, which represent a distinct and relatively uncommon subset of neuroendocrine tumors, are most commonly found in the gastrointestinal tract, although in rare cases they are known to occur in extragastrointestinal locations, including the larynx, middle ear, and pancreas. Malignancies of the parotid gland are uncommon (approximately 25% of parotid neoplasms), and to the best of our knowledge, a primary carcinoid tumor of the parotid has not been previously described in the literature. Reports of parotid carcinoid tumors during the past 30 years have described the presence of nonparotid primary carcinoid tumors (usually gastrointestinal) that had been diagnosed and treated several years prior to the presentation of the parotid lesion. Under such circumstances, the parotid lesion may be assumed to have been a metastatic rather than a primary carcinoid. This report documents what we believe is the first case of a primary carcinoid tumor of the parotid gland. We detail the clinical, surgical, radiologic, immunologic, and histochemical findings associated with its diagnosis, and we describe our management of this case. Although a primary carcinoid in this location is exquisitely rare, knowledge of such lesions is important because their management is substantially different from that of other parotid tumors. In particular, it is important to differentiate them from metastatic tumors from other sites.

Preoperative computed tomography scans for parotid tumor evaluation

OBJECTIVE

We sought to determine whether an advantage is obtained in the routine use of computed tomography (CT) scans in preoperative assessments of parotid tumors.

METHODS

A prospective study of 32 consecutive cases of patients who underwent evaluation for parotidectomies was performed. Twenty-nine received preoperative CT scans. The scans were systematically reviewed to see if they correlated with the clinical findings. Specifically, we compared clinical and CT assessments of tumor size, location, density, and malignancy. Further comparisons were performed based on postoperative tissue pathology.

RESULTS

In our series of patients, routine preoperative CT scans resulted in the discovery of details not revealed on clinical examination: some masses were found to be extra-parotid rather than primary parotid tumors, some tumors deemed to be deep were superficial, tumor density was more clearly identified, and certain pathology correlates were clarified. Most importantly, there were instances of detection of additional tumors in the same lobe, and in one instance in the opposite lobe, that were not otherwise noticed.

CONCLUSIONS

To reduce errors of omission in the treatment of suspected parotid tumors, it would seem appropriate to consider the inclusion of CT scans for the routine preoperative evaluation of all parotid masses.

Acute facial-nerve paralysis with parotid adenolymphoma

An 82-year-old woman presented with acute facial paralysis in association with parotid swelling following fine-needle aspiration cytology of a parotid adenolymphoma. Evacuation of a tense haematoma decompressed the nerve and led to complete recovery within 6 months. Additionally, the tumour is no longer evident, either clinically or radiologically, and fine-needle aspiration cytology appears to have been both diagnostic and, inadvertently, therapeutic in this case.

Validade da punção biópsia por agulha fina nas doenças da glândula parótida

OBJETIVO: Avaliar o método de punção biópsia aspirativa por agulha fina (PBAAF), técnica relativamente simples, de conhecida importância em cirurgia de cabeça e pescoço. Sua indicação em doenças das glândulas salivares, no entanto, especialmente na parótida, ainda é muito controversa na literatura. O diagnóstico pela PBAAF permite o adequado planejamento terapêutico e preparo do paciente. Muitos, porém, alegam que seu emprego acrescenta muito pouco à conduta terapêutica, além de ser procedimento doloroso e elevar o custo do tratamento. MÉTODO: Os autores analisaram os prontuários de 247 pacientes submetidos a parotidectomias, realizadas entre 1986 e 1998, comparando a punção aspirativa por agulha fina com o anatomopatológico definitivo. Isso foi possível em 211 casos. Houve predomínio do sexo feminino, com idade variando de dez a 84 anos. RESULTADOS: Os tumores benignos foram os mais prevalentes, correspondendo a 85,3% dos casos, com predomínio do adenoma pleomórfico. A punção por agulha fina permitiu diferenciar tumores benignos de malignos em 165 casos (78,1%) e acertou o diagnóstico histológico em 77,6 %. CONCLUSÕES: Concluímos que a PBAAF é um método eficiente e simples que fornece ao cirurgião diagnóstico das neoplasias na grande maioria das vezes e deve fazer parte, sempre que possível, da documentação pré-operatória.

Fine needle aspiration biopsy (FNAB) for lesions of the salivary glands

We examined 112 fine needle aspiration biopsy (FNAB) specimens of salivary glands (80 parotid and 32 submaxillary) taken between January 1989 and December 1995. Cytologic diagnoses were compared with the final histological diagnoses of the surgical specimens. The sensitivity and specificity were 84.8% and 93.7% respectively, and the accuracy was 91.1%. We conclude that FNAB by itself does not provide total security because of the high percentage of false-negatives. It is nevertheless useful when combined with an adequate clinical history, examination and radiological tests.

Sudden parotid swelling due to spontaneous haemorrhage

This paper presents an interesting case of a severe spontaneous haemorrhage within the parotid gland in an adult. A rapidly enlarging parotid mass with absence of causative trauma, inflammation or vascular abnormality, raised the suspicion of a neoplasm. Ultrasound, computed tomography (CT) and tissue biopsy, however, have shown only changes suggestive of previous haemorrhage and no evidence of malignancy. A 30-year review of the literature revealed no similar case reported previously.

Interactive magnetic resonance imaging-guided biopsy in the head and neck: initial patient experience

Because of its excellent soft tissue resolution, magnetic resonance imaging (MRI) can optimize image guidance for interventional and surgical procedures. Notably, needle biopsy of head and neck lesions has been used for years, deeper lesions often requiring some form of image guidance. The closed space of diagnostic MRI scanners proves cumbersome for intervention. The authors report on the first head and neck image-guided biopsies performed in a new, investigational "open configuration" intraoperative MRI scanner. Vertical space between the scanner's upright coils gives access to the patient while imaging; image acquisition is as fast as 2 sec/image. Biopsies were performed on seven patients (parotid, parapharyngeal space, second cervical vertebra); five specimens were diagnostic. Both general anesthesia and intravenous sedation were used. The procedures were without complications. Imaging provided definition of anatomy to direct needle placement. Access to the patient allowed for both percutaneous and transoral approaches. The environment of the open magnet is well suited for biopsy of the head and neck, and near real-time intraoperative MRI has promise for guiding more complex head and neck procedures. Further study should optimize the quality of the images and the interactibility of localization and targeting and fully utilize MRI's three-dimensional imaging capabilities.

The accuracy of clinical examination versus frozen section in the diagnosis of parotid masses

PURPOSE

This study evaluated the role of clinical examination and frozen sections in the diagnosis and management of parotid masses.

PATIENTS AND METHODS

One hundred seventy patients underwent parotidectomy. Of these, the data on 65 were analyzed, with emphasis on accuracy of the clinical diagnosis and frozen section results compared with the final histologic diagnosis.

RESULTS

The results showed that the sensitivity of frozen sections for malignancy was 93.3%, and the specificity for a benign tumor was 95.74%, with a 4.2% false-negative rate and a 6.7% false-positive rate. Of the 65 patients, 58 patients had an explicit clinical diagnosis; 88.4% were correctly identified as benign tumors, and 78.6% were correctly diagnosed as malignancies. The false-positive and false-negative rates were 21.4% and 7.0%, respectively.

CONCLUSIONS

The results of this study suggest that clinical examination can provide information that is not very reliable, and the surgical plan should be based on intraoperative frozen sections rather than the history and clinical features.

Fine-needle aspiration cytology of submandibular gland lesions

The usefulness of fine-needle aspiration cytology (FNAC) in the diagnosis and treatment of submandibular gland lesions is not well known. The 210 FNACs taken from submandibular gland lesions at Turku University Central Hospital between 1984 and 1991 were reviewed. Of these FNACs, 78 samples from primary lesions were confirmed histologically. Within this subset 10 FNACs were taken from benign neoplasms, all of which were correctly classified (sensitivity 100 per cent; specificity 88 per cent). Only four of the 14 FNACs from malignant lesions were cytologically considered malignant (sensitivity 29 per cent). On the other hand, four FNACs raised a false suspicion of malignancy (specificity 6 per cent). Out of 54 FNACs from non-neoplastic lesions 43 were correct (sensitivity 80 per cent; specificity 63 per cent). There were 104 patients (123 FNACs), who had not been operated on: the follow-up of these patients shows that in this subset of FNACs there were no false malignant but probably one false benign finding (1 per cent). We conclude that FNAC can offer valuable information about the type of the submandibular gland lesion, but the decision of operative and other treatment should not be based solely on the result of FNAC.

Accuracy of frozen section in the evaluation of salivary tumors

The records of 333 patients who underwent surgery were reviewed to document the accuracy of frozen section in the evaluation of salivary gland tumors. Frozen sections were obtained in 310 patients. The final pathologic diagnoses included 210 benign tumors and 45 malignancies. The sensitivity for the detection of malignancy was 69%, and the specificity was 96%. The specific accuracy to correctly identify the type of malignancy present was only 51%. In four patients, a false-positive diagnosis of malignancy was made. Frozen section was much more accurate in the evaluation of benign salivary tumors. Forty-three of 45 Warthin's tumors were correctly identified by frozen section. Two tumors thought to be Warthin's tumors on frozen section proved to be low-grade mucoepidermoid carcinomas. One tumor reported to be a benign mixed tumor was actually a malignant mixed tumor. In this series of patients, frozen section proved to be no more accurate in the evaluation of salivary tumors than what has been reported in the literature for fine-needle aspiration biopsy.

Is Fine Needle Aspiration Biopsy of Salivary Gland Masses Really Necessary?

The use of fine needle aspirate biopsies (FNAB's) in the outpatient setting has progressively escalated, particularly in the area of head and neck pathology. An increasing percentage of these are for salivary gland masses. We present our experience with salivary gland FNAB's at our institution for four years, from 1988–1992. One thousand and twenty-two (1,022) FNAB's of superficial masses were performed by two pathologists. One hundred sixty-three (15.9%) were salivary gland biopsies. Of these 163 cases, 21 (12.9%) were normal tissue, 77 (47.2%) were inflammatory processes, 50 (30.7%) were benign tumors, and 15 (9.2%) were malignant tumors. None of the aspirates were unsatisfactory. Tissue correlation was possible in 47 (28.8%) cases. Two false negative cases (4.3%) were identified; these were a Warthin's tumor diagnosed as chronic sialoadenitis by FNAB; and a poorly differentiated squamous cell carcinoma diagnosed as adenocarcinoma by FNAB. There were no false positive cases. Overall sensitivity was 95.7% and specificity was 100%.

Our experience indicates that FNAB of salivary glands is an effective screening procedure in evaluating salivary gland masses. The cytologic diagnosis may assist the clinician in allaying patients' anxieties, as well as in further collateral workup prior to definitive therapy.

Value of fine needle aspiration biopsy of salivary gland masses in clinical decision-making

The accuracy of fine needle aspiration biopsy (FNAB) in the diagnosis of salivary tumors has been well established. This study was undertaken to determine the impact of FNAB on patient management. One hundred one patients underwent FNAB of major salivary gland masses. The physician's initial clinical impression was compared with the FNAB diagnosis and the final diagnosis in each case. Forty patients had solitary masses thought to be benign tumors other than Warthin's tumors. FNAB in 13 of these patients (33%) yielded a diagnosis permitting modification of the planned procedure. The diagnosis of Warthin's tumor was suspected clinically in 23 patients. In nine of these patients (39%), FNAB resulted in a different diagnosis. Of the 10 patients believed to have malignant tumors, using FNAB, 1 was found to have sialadenitis and 1 a lymphoma. Overall, FNAB resulted in a change in the clinical approach to 35% of the patients. We recommend the performance of FNAB in almost all patients with salivary masses.

Fine-needle aspiration of parotid gland lesions

The results of 49 specimens obtained by fine-needle aspiration biopsy of parotid gland lesions were compared with the pathologic diagnoses of the surgically resected specimens. Cytologically, 33 lesions were diagnosed as benign, with 30 of these confirmed histologically and three false-negative results. Fourteen cytologic specimens were called malignant or suspicious for malignancy, with 11 of these confirmed histologically and three false-positive results. The concurrence rate for distinguishing benign from malignant disease was 87.2%. The sensitivity for malignancy was 78.6% and the specificity 90.9%. The pathology of the misdiagnosed lesions will be reviewed. Based on our data and a review of the literature, we conclude that fine needle aspiration biopsy of parotid gland masses, with the observation of certain caveats, is a helpful adjunctive test for diagnosis and treatment planning.

Fine needle aspiration cytology of a head and neck swelling in a child: a non-invasive approach to diagnosis

A 12-year-old boy presented with a three-month history of a painful parotid swelling. Fine needle aspiration cytology indicated a pleomorphic adenoma--an uncommon lesion in a child. This diagnostic technique plays a useful role in the investigation of head and neck swellings.

Bilateral parotid secondaries from primary bronchial carcinoid tumour

Three years following a right lower lobectomy for primary carcinoid tumour of the bronchus, a patient presented with bilateral parotid masses. On investigation, both these were shown to be carcinoid tumours, consistent with metastatic spread from the primary bronchial tumour. This unique case is presented together with a discussion of the diagnostic methods employed.

Needle aspiration biopsy in salivary gland lesions

The value of needle aspiration biopsy in the evaluation and management of salivary gland pathology is controversial. The major reasons for this controversy are the difficulty in cytologic evaluation and the fact that the extent of surgery can be easily defined based on clinical judgement. However, a preoperative diagnosis is helpful in discussions with patients regarding the extent and type of surgery. Apart from the fact that needle biopsy can distinguish benign from malignant conditions, it is also very useful in distinguishing between salivary and other nonsalivary pathology. Over the past 7 1/2 years, we have performed 160 needle aspirations of parotid, submandibular, and submucosal lesions. Adequate specimens for cytologic evaluation were obtained in 155 patients (97%). A total of 84 parotid lesions, 70 submandibular lumps, and 6 submucosal abnormalities were detected. A cytologic diagnosis of benign pathology was made in 120 patients. Twelve patients had lymphoma and the diagnosis was suspected based on needle aspiration. There were 10 patients with tuberculosis and 30 patients with hyperplastic lymph nodes or benign lymphoepithelial disease of the parotid. There were three false-positive and two false-negative reports. No complications such as hematoma, nerve injury, or infection developed. The major difficulty was in distinguishing between malignancy and obstructive sialadenitis in the submandibular region. Needle aspiration was helpful in evaluating lesions in the tail of the parotid and submandibular area. The cytologic distinction between salivary and nonsalivary pathology was useful in planning the appropriate surgery and the extent of surgical resection. From a clinical standpoint, the distinction between benign and malignant salivary and nonsalivary pathology was very helpful. Preoperative diagnosis of Warthin's tumor, lymphoma, or benign lymphoepithelial disease was essential to the correct management of these patients.