Does a joint ultrasound guided cytology clinic optimize the cytological evaluation of head and neck masses?

Comparison of thyroid fine needle aspiration cytology results before and during the COVID-19 pandemic: the impact of the pandemic

Purpose: The aim of this study was to compare the Bethesda classification to report the distribution of thyroid cytology diagnostic categories and total thyroid fine needle aspiration cytology numbers before and during the pandemic. Materials and Methods: This study was planned in two phases: (1) before the pandemic, from March 15, 2018, and 29 February 2020, and during the pandemic period, from 1 March 2020 to 12 March 2022. Each period consisted of 24 months. The total number of thyroid fine needle aspiration cytology performed before the pandemic and during the pandemic dates and histopathological data were obtained from the hospital database. Results: 432 thyroid fine needle aspiration biopsies were performed in the pre-pandemic period and 351 during the pandemic. There was no significant difference considering age and gender in patients who underwent thyroid fine needle aspiration cytology before and during the pandemic. According to the Bethesda classification, those who were benign were 70.8% (n:306) and 59.0% (n:207) respectively before pandemia and during the pandemia. According to the Bethesda classification, malignant lesions were 4.4%(n:19), and 9.1%(n:32) before and during the pandemia, respectively. During the pandemic, malignant lesions were detected significantly more than before the pandemic. Conclusion: Malignant lesions were detected significantly more in the thyroid fine needle aspiration cytology results according to the Bethesda classification during the pandemic period compared to before the pandemic period.

Comparison of preoperative diagnostic accuracy of fine needle aspiration and core needle biopsy in parotid gland neoplasms

BACKGROUND

Fine needle aspiration (FNA) and core needle biopsy (CNB) are two commonly used approaches for the diagnosis of suspected neoplastic parotid gland lesions. We aimed to compare the diagnostic efficiency of FNA and CNB performed with ultrasound guidance preoperatively for the diagnosis of parotid neoplasms.

METHODS

We retrospectively analysed the preoperative specimens of 113 patients (66 FNA, 47 CNB) who underwent surgical excision at our institute between 2014 and 2017. Patient selection was based on lesion type and dimension, preliminary and final pathology, imaging characteristics, clinical course, and treatment data for accurate statistical analysis. The final diagnosis was based on surgery in all of the patients. We compared the diagnostic accuracy of FNA and CNB regarding the correct tissue-specific diagnosis of benign and malignant tumours. The recurrence and complication rates were analysed to determine the safety of each technique.

RESULTS

Among the 113 patients, the average follow-up period was 65.4 (50-88) months. Seventy-one patients (62.8%) were males, and the median age was 50 years. The most common type of surgery was superficial parotidectomy (83.2%), and the median tumour size was 30.0 mm. Pleomorphic adenoma was the most frequent neoplasm. The diagnostic rates of preoperative pathological evaluation of FNA and CNB samples were 68.2% and 91.5%, respectively. The sensitivity, specificity, and positive predictive value of FNA for detecting malignant lesions were 40, 100, and 100%, respectively, and those of CNB were 100, 100, and 100%, respectively. Only one complication occurred (haematoma) in the biopsy area after CNB. No recurrences were seen after CNB and FNA during the follow-up period.

CONCLUSION

Our findings suggest that the diagnostic ability, sensitivity, and specificity of CNB are excellent compared with those of FNA. The only disadvantage of CNB is the need for experienced staff and good-quality equipment. The complication rates of each technique are very low, and the risk of tumour tract seeding is controversial. CNB should be considered the technique of choice when a nodule is detected in the parotid glands.

Ultrasound core biopsies of neck lumps: an experience from a tertiary head and neck cancer unit

BACKGROUND

Traditionally, fine needle aspiration cytology was the primary diagnostic investigation for head and neck lumps; however, ultrasound-guided core biopsy offers the advantage of preserving tissue architecture with increased tissue yield. This study reviews the diagnostic utility of ultrasound-guided core biopsy for investigating head and neck lumps.

METHODS

Overall, 287 ultrasound-guided core biopsies were reviewed between May 2017 and April 2019 at a single tertiary site for head and neck cancer.

RESULTS

On initial ultrasound-guided core biopsy, a diagnostic sample was obtained in 94.4 per cent of patients and in 83.7 per cent of patients with lymphoma. Where the initial ultrasound-guided core biopsy was non-diagnostic, 50 per cent of samples were diagnostic on repeat ultrasound-guided core biopsy. Overall, five complications were seen related to ultrasound-guided core biopsy, and all were managed conservatively. No cases of disease recurrence were identified at the biopsy site.

CONCLUSION

Ultrasound-guided core biopsy is a safe procedure with a high diagnostic yield when investigating head and neck lumps. Patients whose ultrasound-guided core biopsies were non-diagnostic should be considered for excisional biopsy over repeat ultrasound-guided core biopsy.

A radiologist's perspective of the value of ultrasound-guided fine needle aspiration cytology in the assessment of head and neck lesions

This viewpoint presents a radiologist's perspective of the value that can be added by close collaboration and teamwork with cytopathologist colleagues to maximise specimen quality, adequacy, and patient outcomes. Various models are discussed and service evolution through teamwork emphasised. The importance of utilising ultrasound guidance for fine needle aspiration in head and neck lesions and critical appraisal of the literature are reviewed.

Utility of ultrasound-guided fine needle aspiration cytology in assessing malignancy in head and neck pathology

OBJECTIVE

Fine needle aspiration cytology (FNAC) is a well-established diagnostic procedure for head and neck masses not clearly originating from mucosal or cutaneous surfaces. We analysed head and neck masses evaluated over a 2-year period, to assess the reliability of FNAC for the evaluation of malignancy.

METHODS

We enrolled all patients undergoing FNAC, from April 2013 to July 2015, in a single service of a large Italian university hospital. Relevant clinical data and ultrasonographic parameters of the lesions were recorded. We performed both conventional and thin-prep smears. Clinical presentation, ultrasonographic features and final cytology diagnoses were analysed and correlated with histology.

RESULTS

The series included 301 lesions in 285 patients, with a single (94.4%) or two (5.6%) lesions. Only eight samples were considered non-diagnostic/inadequate (2.6%). Among the cases, 139 FNAC (46.1%) underwent surgery. Cytological-histological correspondence was found in 89% of the cases. Concerning malignancy, we documented less than 4% false positives and less than 2.5% false negatives, with 92.7% sensitivity and 94.6% specificity.

CONCLUSION

FNAC diagnosis can be highly specific. Most importantly, it is highly reliable in assessing malignancy, thus defining the priority and guiding the management procedures.

Clinical Practice Guideline: Evaluation of the Neck Mass in Adults

Objective Neck masses are common in adults, but often the underlying etiology is not easily identifiable. While infections cause most of the neck masses in children, most persistent neck masses in adults are neoplasms. Malignant neoplasms far exceed any other etiology of adult neck mass. Importantly, an asymptomatic neck mass may be the initial or only clinically apparent manifestation of head and neck cancer, such as squamous cell carcinoma (HNSCC), lymphoma, thyroid, or salivary gland cancer. Evidence suggests that a neck mass in the adult patient should be considered malignant until proven otherwise. Timely diagnosis of a neck mass due to metastatic HNSCC is paramount because delayed diagnosis directly affects tumor stage and worsens prognosis. Unfortunately, despite substantial advances in testing modalities over the last few decades, diagnostic delays are common. Currently, there is only 1 evidence-based clinical practice guideline to assist clinicians in evaluating an adult with a neck mass. Additionally, much of the available information is fragmented, disorganized, or focused on specific etiologies. In addition, although there is literature related to the diagnostic accuracy of individual tests, there is little guidance about rational sequencing of tests in the course of clinical care. This guideline strives to bring a coherent, evidence-based, multidisciplinary perspective to the evaluation of the neck mass with the intention to facilitate prompt diagnosis and enhance patient outcomes. Purpose The primary purpose of this guideline is to promote the efficient, effective, and accurate diagnostic workup of neck masses to ensure that adults with potentially malignant disease receive prompt diagnosis and intervention to optimize outcomes. Specific goals include reducing delays in diagnosis of HNSCC; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected. The target patient for this guideline is anyone ≥18 years old with a neck mass. The target clinician for this guideline is anyone who may be the first clinician whom a patient with a neck mass encounters. This includes clinicians in primary care, dentistry, and emergency medicine, as well as pathologists and radiologists who have a role in diagnosing neck masses. This guideline does not apply to children. This guideline addresses the initial broad differential diagnosis of a neck mass in an adult. However, the intention is only to assist the clinician with a basic understanding of the broad array of possible entities. The intention is not to direct management of a neck mass known to originate from thyroid, salivary gland, mandibular, or dental pathology as management recommendations for these etiologies already exist. This guideline also does not address the subsequent management of specific pathologic entities, as treatment recommendations for benign and malignant neck masses can be found elsewhere. Instead, this guideline is restricted to addressing the appropriate work-up of an adult patient with a neck mass that may be malignant in order to expedite diagnosis and referral to a head and neck cancer specialist. The Guideline Development Group sought to craft a set of actionable statements relevant to diagnostic decisions made by a clinician in the workup of an adult patient with a neck mass. Furthermore, where possible, the Guideline Development Group incorporated evidence to promote high-quality and cost-effective care. Action Statements The development group made a strong recommendation that clinicians should order a neck computed tomography (or magnetic resonance imaging) with contrast for patients with a neck mass deemed at increased risk for malignancy. The development group made the following recommendations: (1) Clinicians should identify patients with a neck mass who are at increased risk for malignancy because the patient lacks a history of infectious etiology and the mass has been present for ≥2 weeks without significant fluctuation or the mass is of uncertain duration. (2) Clinicians should identify patients with a neck mass who are at increased risk for malignancy based on ≥1 of these physical examination characteristics: fixation to adjacent tissues, firm consistency, size >1.5 cm, or ulceration of overlying skin. (3) Clinicians should conduct an initial history and physical examination for patients with a neck mass to identify those with other suspicious findings that represent an increased risk for malignancy. (4) For patients with a neck mass who are not at increased risk for malignancy, clinicians or their designees should advise patients of criteria that would trigger the need for additional evaluation. Clinicians or their designees should also document a plan for follow-up to assess resolution or final diagnosis. (5) For patients with a neck mass who are deemed at increased risk for malignancy, clinicians or their designees should explain to the patient the significance of being at increased risk and explain any recommended diagnostic tests. (6) Clinicians should perform, or refer the patient to a clinician who can perform, a targeted physical examination (including visualizing the mucosa of the larynx, base of tongue, and pharynx) for patients with a neck mass deemed at increased risk for malignancy. (7) Clinicians should perform fine-needle aspiration (FNA) instead of open biopsy, or refer the patient to someone who can perform FNA, for patients with a neck mass deemed at increased risk for malignancy when the diagnosis of the neck mass remains uncertain. (8) For patients with a neck mass deemed at increased risk for malignancy, clinicians should continue evaluation of patients with a cystic neck mass, as determined by FNA or imaging studies, until a diagnosis is obtained and should not assume that the mass is benign. (9) Clinicians should obtain additional ancillary tests based on the patient's history and physical examination when a patient with a neck mass is deemed at increased risk for malignancy who does not have a diagnosis after FNA and imaging. (10) Clinicians should recommend evaluation of the upper aerodigestive tract under anesthesia, before open biopsy, for patients with a neck mass deemed at increased risk for malignancy and without a diagnosis or primary site identified with FNA, imaging, and/or ancillary tests. The development group recommended against clinicians routinely prescribing antibiotic therapy for patients with a neck mass unless there are signs and symptoms of bacterial infection.

The Role of In-Office Ultrasound in the Diagnosis of Neck Masses

To evaluate the efficacy of otolaryngologist-performed in-office ultrasound (US) in the clinical assessment of lateral neck masses, we performed a retrospective review of patients with lateral neck masses who had both a surgeon-performed US and US-guided fine-needle aspiration (USGFNA) at our tertiary academic center from 2012 to 2015. Fifty-nine patients were included. USGFNA results included 32 (54%) malignant lesions, 23 (39%) benign lesions, and 4 (6%) nondiagnostic lesions. USGFNA demonstrated 85% accuracy. In 22 (37%) patients, in-office US revealed additional findings that were not identified on physical examination (eg, nonpalpable lymph nodes or elucidated anatomical structures), which either assisted in surgical planning or altered treatment. In-office US and USGFNA on initial evaluation by the otolaryngologist augment physical examination and have potential value as the primary imaging and diagnostic modality in the workup of lateral neck masses.

Role of Fine-Needle Aspiration Biopsy in the Management of Salivary Gland Masses

Objective

Fine-needle aspiration biopsy (FNAB) is widely used in the management of salivary gland masses. Its main advantage is its ability to differentiate benign from malignant disease. In this study, we aimed to evaluate the diagnostic ability of FNAB in salivary gland masses.

Methods

The records of patients who had undergone FNAB before parotidectomy or submandibular gland excision between 2005 and 2013 were retrospectively analyzed. FNAB results were classified as negative, positive, suspicious for malignancy, and non-diagnostic. Preoperative FNAB results were compared with definitive histopathological results. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of FNAB results were calculated.

Results

A total of 285 patients were enrolled. Among them, 230 (80.7%) had parotid gland and 55 (19.3%) had submandibular gland masses. Following a definitive histopathological examination, the most common benign tumor was pleomorphic adenoma (52.6%), whereas malignant tumors were mucoepidermoid carcinoma (2%) and squamous cell carcinoma (2%). The sensitivity, specificity, PPV, NPV and accuracy of FNAB results were 76.9%, 95.4%, 75%, 95.9%, and 92.6%, respectively. The rate of a suspicious cytology was 5.2% (15 patients) and that of a non-diagnostic cytology was 8.8% (25 patients).

Conclusion

FNAB is a safe and simple diagnostic tool for the diagnosis of salivary gland masses and has a relatively high sensitivity and specificity. It may provide valuable information for patient counselling and surgical planning. The major drawbacks include a lower sensitivity than specificity and a relatively high rate of non-diagnostic results.

Skeletal Muscle Involvement in Six Cases of Non-Hodgkin's Lymphoma of the Head and Neck Region

Extra-nodal involvement of non-Hodgkin's lymphoma (NHL) is well described. Skeletal muscle involvement is rare with the muscles of the extremities being most commonly affected. We present a series of six patients that have attended our Joint Head and Neck Ultrasound and Cytopathology clinic. In these cases, skeletal muscle involvement by NHL was demonstrated in the head and neck region. The ultrasound findings in these cases are presented and discussed.

A diagnostic head and neck fine needle aspiration service can be provided using liquid-based cytology only

OBJECTIVE

Liquid-based cytology (LBC) has been used for non-gynaecological specimens since its introduction into routine use in cervical cytology in the mid-1990s. There are still relatively few large studies comparing performance in reporting the head and neck fine-needle aspirations (H&N FNA) processed by LBC only to conventional direct smears (CDS).

METHODS

This study compared 686 H&N FNAs processed by LBC only with 3719 CDS. All were taken under ultrasound (US) guidance by a small cohort of three consultant radiologists and reported by the author.

RESULTS

The (smaller) LBC sample was statistically representative of the larger CDS population at an alpha level of 0.05. There was no difference between CDS and LBC at a 95% confidence interval (CI) when comparing specificity and sensitivity (specificity: 94.8-96.5% versus 90.2-95.4%; sensitivity: 91.4-94.1% versus 86.8-93.4%). The inadequate rate between the two techniques was similar, 0.5-1.0% for CDS versus 0.7-2.5% for LBC. The significance difference was in the suspicious rate which was greater at 2.8-5.8% for LBC versus 1.7-2.6% for CDS. Consequently, there was a slight but non-significant difference between the two populations with respect to the overall accuracy: 93.5-95.1% for CDS versus 89.4-93.7% for LBC.

CONCLUSIONS

While there are morphological differences between LBC and CDS in H&N FNAs, once a degree of familiarity is achieved, the two techniques have equivalent sensitivity, specificity and inadequate rates.

Biopsy of parotid masses: Review of current techniques

Definitive diagnosis of parotid gland masses is required optimal management planning and for prognosis. There is controversy over whether fine needle aspiration cytology (FNAC) or ultrasound guided core biopsy (USCB) should be the standard for obtaining a biopsy. The aim of this review is to assess the current evidence available to assess the benefits of each technique and also to assess the use of intra-operative frozen section (IOFS). Literature searches were performed using pubmed and google scholar. The literature has been reviewed and the evidence is presented. FNAC is an accepted and widely used technique. It has been shown to have variable diagnostic capabilities depending on centres and experience of staff. USCB has a highly consistent diagnostic accuracy and can help with tumour grading and staging. However, the technique is more invasive and there is a question regarding potential for seeding. Furthermore, USCB is less likely to be offered as part of a one-stop clinic. IOFS has no role as a first line diagnostic technique but may be reserved as an adjunct or for lesions not amenable to percutaneous biopsy. On balance, USCB seems to be the method of choice. The current evidence suggests it has superior diagnostic potential and is safe. With time, USCB is likely to supplant FNAC as the biopsy technique of choice, replicating that which has occurred already in other areas of medicine such a breast practice.

Cytologic separation of branchial cleft cyst from metastatic cystic squamous cell carcinoma: A multivariate analysis of nineteen cytomorphologic features

BACKGROUND

The separation of branchial cleft cysts from metastatic cystic squamous cell carcinomas in adults can be clinically and cytologically challenging. Diagnostic accuracy for separation is reported to be as low as 75% prompting some authors to recommend frozen section evaluation of suspected branchial cleft cysts before resection. We evaluated 19 cytologic features to determine which were useful in this distinction.

METHODS

Thirty-three cases (21 squamous carcinoma and 12 branchial cysts) of histologically confirmed cystic lesions of the lateral neck were graded for the presence or absence of 19 cytologic features by two cytopathologists. The cytologic features were analyzed for agreement between observers and underwent multivariate analysis for correlation with the diagnosis of carcinoma.

RESULTS

Interobserver agreement was greatest for increased nuclear/cytoplasmic (N/C) ratio, pyknotic nuclei, and irregular nuclear membranes. Recursive partitioning analysis showed increased N/C ratio, small clusters of cells, and irregular nuclear membranes were the best discriminators.

CONCLUSION

The distinction of branchial cleft cysts from cystic squamous cell carcinoma is cytologically difficult. Both digital image analysis and p16 testing have been suggested as aids in this separation, but analysis of cytologic features remains the main method for diagnosis. In an analysis of 19 cytologic features, we found that high nuclear cytoplasmic ratio, irregular nuclear membranes, and small cell clusters were most helpful in their distinction. Diagn. Cytopathol. 2016;44:561-567. © 2016 Wiley Periodicals, Inc.

Establishing an accurate diagnosis of a parotid lump: evaluation of the current biopsy methods - fine needle aspiration cytology, ultrasound-guided core biopsy, and intraoperative frozen section

The optimum technique for histological confirmation of the nature of a parotid mass remains controversial. Fine needle aspiration cytology (FNAC), which has traditionally been used, is associated with high non-diagnostic and false negative rates, and ultrasound (US)-guided core biopsy and frozen section have been explored as alternatives. US-guided core biopsy is more invasive than FNAC, but is safe, well-tolerated, and associated with improved diagnostic performance. Although frozen section offers better specificity than FNAC, it has a number of important drawbacks and cannot be considered as a primary diagnostic tool. US-guided core biopsy should be considered as the initial diagnostic technique of choice, and in units where the accuracy of FNAC is good it can be used when FNAC is equivocal or non-diagnostic.

A systematic review of ultrasound-guided FNA of lesions in the head and neck--focusing on operator, sample inadequacy and presence of on-spot cytology service

The objective of this review is to perform a systematic review of ultrasound-guided fine-needle aspiration (FNA) services for head and neck lesions with assessment of inadequacy rates and related variables such as the presence of immediate cytological assessment. A computer-based systematic search of articles in English language was performed using MEDLINE (1950 to date) from National Health Service evidence healthcare database and PubMed. Full texts of all relevant articles were obtained and scrutinized independently by two authors according to the stated inclusion and exclusion criteria. The primary search identified 932 articles, but only 78 met all the study criteria. The overall inadequacy rate was 9.3%, 16 studies had on-site evaluation by a cytopathologist/specialist clinician with a rate of 6.0%. In seven studies, a cytotechnician was available to either assess the sample or prepare the slides with an average inadequacy rate of 11.4%. In 1 study, the assessment was unclear, but the inadequacy rate for the remaining 54 studies, without immediate assessment, was 10.3%. The rate for the cytopathologist/specialist clinicians was significantly different to no on-site assessment but this was not found for assessment by cytotechnicians. The review suggests that the best results are obtained with a cytopathologist-led FNA service, where the pathologist reviews the specimen immediately, in relation to the clinical context, thereby deciding on adequacy and need for further biopsies. A systematic review looking at ultrasound-guided FNA of head and neck lesions has not been published previously.

Diagnostic investigation of parotid neoplasms: a 16-year experience of freehand fine needle aspiration cytology and ultrasound-guided core needle biopsy

This study aimed to examine the diagnostic yield of fine needle aspiration cytology (FNAC) and ultrasound-guided core needle biopsy (USCB) in the diagnosis of parotid neoplasia. A 16-year retrospective analysis was performed of patients entered into our pathology database with a final diagnosis of parotid neoplasia. FNAC and USCB data were compared to surgical excision where available. One hundred and twenty FNAC, 313 USCB, and 259 surgical specimens were analyzed from 397 patients. Fifty-six percent of FNAC and 4% of USCB were non-diagnostic. One hundred and thirty-two (33%) patients had a final diagnosis made by USCB and did not undergo surgery. Surgery was performed in 257 (65%) patients, 226 (88%) of whom had a preoperative biopsy. Most lesions were benign, but there were 62 parotid and 13 haematological malignancies diagnosed; false-negative results were obtained in three FNAC and two USCB samples. The sensitivity and specificity of FNAC were 70% and 89%, respectively, and for USCB were 93% and 100%, respectively. This study represents the largest series of patients with a parotid neoplasm undergoing USCB for diagnosis. USCB is highly accurate with a low non-diagnostic rate and should be considered an integral part of parotid assessment.

Lean Six Sigma Applied to Ultrasound Guided Needle Biopsy in the Head and Neck

Objectives

(1) Confirm the positive value stream of office-based ultrasound using Lean Six Sigma; (2) demonstrate how ultrasound reduces time to diagnosis, costs, patient inconvenience and travel, exposure to ionizing radiation, intravenous contrast, and laboratory tests.

Study Design

Case series with historical controls using chart review.

Setting

Tertiary Veterans Administration Hospital (university-affiliated).

Subjects and Methods

Patients with a consult request or decision for ultrasound guided fine needle aspiration (USFNA) from 2006 to 2012. Process evaluation using Lean Six Sigma methodologies; years study conducted: 2006-2012; outcome measurements: type of diagnostic tests and imaging studies including CT scans with associated radiation exposure, time to preliminary and final cytopathologic diagnosis, episodes of patient travel.

Results

Value stream mapping prior to and after implementing office-based ultrasound confirmed the time from consult request or decision for USFNA to completion of the USFNA was reduced from a range of 0 to 286 days requiring a maximum 17 steps to a range of 0 to 48 days, necessitating only a maximum of 9 steps. Office-based USFNA for evaluation of head and neck lesions reduced costs, time to diagnosis, risks and inconvenience to patients, radiation exposure, unnecessary laboratory, and patient complaints while increasing staff satisfaction. In addition, office-based ultrasound also changed the clinical management of specific patients.

Conclusion

Lean Six Sigma reduces waste and optimizes quality and accuracy in manufacturing. This is the first known application of Lean Six Sigma to office-based USFNA in the evaluation of head and neck lesions. The literature supports the value of office-based ultrasound to patients and health care systems.

Review of ultrasonography of malignant neck nodes: greyscale, Doppler, contrast enhancement and elastography

Assessment of neck lymph nodes is essential in patients with head and neck cancers for predicting the patient’s prognosis and selecting the appropriate treatment. Ultrasonography is a useful imaging tool in the assessment of neck lymph nodes. Greyscale ultrasonography assesses the size, distribution, and internal architecture of lymph nodes. Doppler ultrasonography evaluates the intranodal vascular pattern and resistance of lymph nodes. Contrast-enhanced ultrasonography provides information on lymph node parenchymal perfusion. Elastography allows qualitative and quantitative assessment of lymph node stiffness. This article reviews the value of greyscale, Doppler and contrast-enhanced ultrasonography as well as elastography in the assessment of malignant nodes in the neck.

On-site cytotechnician evaluation of the adequacy of fine needle aspiration in a neck lump clinic

INTRODUCTION

The gold standard for assessing neck lumps is a one-stop clinic with an on-site cytopathologist who can provide an immediate fine needle aspiration (FNA) report. However, this has considerable resource implications and is not available in all units. In our department, surgeons perform FNAs guided by palpation. The FNA is evaluated for specimen adequacy by an on-site cytotechnician. This study evaluated the impact of the cytotechnician on the adequacy of neck lump FNA.

METHODS

FNA performed between June 2010 and February 2012 was examined. The FNA performed at a neck lump clinic with an assessment of adequacy by an on-site cytotechnician were considered the test group. All other neck lump FNAs from other sources without an assessment of adequacy by an on-site cytotechnician were considered the control group.

RESULTS

Of the FNAs, 134 met the inclusion criteria for this study. Of these, 87 FNAs (65%) were analysed for adequacy by the on-site cytotechnician and the remaining 47 (35%) were not. The results demonstrated an FNA inadequacy with and without on-site cytotechnician assessment of 29.9% and 40.4% respectively. This is equivalent to an absolute risk reduction of an inadequate FNA of 10.5%, which equates to a number needed to treat of 9.5, ie the cytotechnician needs to assess 9.5 (ie the cytotechnician [...] specimen).

CONCLUSIONS

In neck lump clinics where on-site cytopathology is not available, an on-site cytotechnician is a compromise measure that does reduce the number of inadequate FNAs.

On-site cytotechnician evaluation of the adequacy of fine needle aspiration in a neck lump clinic

Introduction

The gold standard for assessing neck lumps is a one-stop clinic with an on-site cytopathologist who can provide an immediate fine needle aspiration (FNA) report. However, this has considerable resource implications and is not available in all units. In our department, surgeons perform FNAs guided by palpation. The FNA is evaluated for specimen adequacy by an on-site cytotechnician. This study evaluated the impact of the cytotechnician on the adequacy of neck lump FNA.

Methods

FNA performed between June 2010 and February 2012 was examined. The FNA performed at a neck lump clinic with an assessment of adequacy by an on-site cytotechnician were considered the test group. All other neck lump FNAs from other sources without an assessment of adequacy by an on-site cytotechnician were considered the control group.

Results

Of the FNAs, 134 met the inclusion criteria for this study. Of these, 87 FNAs (65%) were analysed for adequacy by the on-site cytotechnician and the remaining 47 (35%) were not. The results demonstrated an FNA inadequacy with and without on-site cytotechnician assessment of 29.9% and 40.4% respectively. This is equivalent to an absolute risk reduction of an inadequate FNA of 10.5%, which equates to a number needed to treat of 9.5, ie the cytotechnician needs to assess 9.5 (ie the cytotechnician […] specimen).

Conclusions

In neck lump clinics where on-site cytopathology is not available, an on-site cytotechnician is a compromise measure that does reduce the number of inadequate FNAs.

Sonographically guided fine-needle aspiration biopsy of major salivary gland masses: a review of 245 cases

OBJECTIVE

The purpose of this study was to determine the diagnostic accuracy of sonographically guided fine-needle aspiration biopsy (FNAB) for major salivary gland tumors by comparing the biopsy results for 245 salivary gland masses with the final pathologic diagnosis after surgical excision.

MATERIALS AND METHODS

This retrospective study included a total of 245 major salivary gland tumors from 244 patients who had undergone sonographically guided FNAB followed by surgical excision. To evaluate the diagnostic accuracy of FNAB, we compared the histopathologic diagnoses with the preoperative cytology results obtained from FNAB. False-negative diagnoses based on the FNAB results were reviewed.

RESULTS

Two hundred fifteen aspirates (87.8%) yielded adequate cytology results. In the 215 masses from which adequate material was obtained and an unequivocal cytology result was obtained, the overall sensitivity, specificity, and accuracy of sonographically guided FNAB in differentiating malignant from benign tumors was 75.7%, 100%, and 95.8%, respectively. The false-negative diagnostic rate was 4.2% (9/215), but there were no false-positive diagnoses of malignancy. Among the 47 malignancies, only 28 cases (59.6%) were detected preoperatively by FNAB.

CONCLUSION

For the preoperative evaluation of major salivary gland tumors, sonographically guided FNAB is feasible for distinguishing between benign and malignant salivary gland tumors in the subset of patients with satisfactory cytologic diagnoses. However, negative or nondiagnostic cytologic results cannot always guarantee benignity of the final diagnosis, and therefore careful consideration of the sonographic features and cytologic results is necessary to avoid false reassurance.

The benefits of on-site cytology with ultrasound-guided fine needle aspiration in a one-stop neck lump clinic

INTRODUCTION

In the National Institute for Health and Clinical Excellence (NICE) guidance on cancer services published in 2004, it was recommended that specialist clinics should be set up for the assessment of patients with neck lumps, structured in a similar way to one-stop breast lump clinics with a cytopathologist present and preferably ultrasound guidance. The aim of this study was to audit the performance of ultrasound-guided fine needle aspiration (FNA) with on-site cytology in a one-stop neck lump clinic at The Royal Liverpool University Hospital.

PATIENTS AND METHODS

Data were collected between November 2008 and May 2009 (7 months). Details of the adequacy rate for the FNA were recorded and whether multiple passes were required. The likely adequacy rate if ultrasound guidance was not available was also calculated.

RESULTS

A total of 274 patients were included in the audit. Of these, 227 (83%) patients required a single pass for adequate diagnostic material. Of the remaining, 45 (16%) required two passes and 2 (1%) required three passes. The overall sample inadequacy rate was 11 of 274 (4%). From these results, it could be predicted that, if immediate cytological evaluation was unavailable, the inadequacy rate would have been 41 of 274 (15%).

CONCLUSIONS

This audit has illustrated the benefits of a one-stop clinic with on-site cytology in providing a rapid diagnostic head and neck cancer service.

The benefits of on-site cytology with ultrasound-guided fine needle aspiration in a one-stop neck lump clinic

INTRODUCTION

In the National Institute for Health and Clinical Excellence (NICE) guidance on cancer services published in 2004, it was recommended that specialist clinics should be set up for the assessment of patients with neck lumps, structured in a similar way to one-stop breast lump clinics with a cytopathologist present and preferably ultrasound guidance. The aim of this study was to audit the performance of ultrasound-guided fine needle aspiration (FNA) with on-site cytology in a one-stop neck lump clinic at The Royal Liverpool University Hospital.

PATIENTS AND METHODS

Data were collected between November 2008 and May 2009 (7 months). Details of the adequacy rate for the FNA were recorded and whether multiple passes were required. The likely adequacy rate if ultrasound guidance was not available was also calculated.

RESULTS

A total of 274 patients were included in the audit. Of these, 227 (83%) patients required a single pass for adequate diagnostic material. Of the remaining, 45 (16%) required two passes and 2 (1%) required three passes. The overall sample inadequacy rate was 11 of 274 (4%). From these results, it could be predicted that, if immediate cytological evaluation was unavailable, the inadequacy rate would have been 41 of 274 (15%).

CONCLUSIONS

This audit has illustrated the benefits of a one-stop clinic with on-site cytology in providing a rapid diagnostic head and neck cancer service.

How good are we at fine needle aspiration cytology?

Objectives:

To determine the accuracy of fine needle aspiration cytology conducted within a standard ENT out-patients service (rather than a one-stop neck lump clinic), and also to assess the value of ultrasound guidance during fine needle aspiration cytology.

Design:

Retrospective study of all patients undergoing fine needle aspiration cytology of a neck lump, from 2005 to 2008 in Leeds teaching hospitals.

Main outcome measures:

Accuracy of fine needle aspiration cytology, compared with the corresponding histology report of the original surgical specimen, and non-diagnostic fine needle aspiration cytology rates with and without ultrasound.

Results:

Fine needle aspiration cytology yielded the following respective sensitivity, specificity and accuracy rates: 85, 91 and 87 per cent for lymph nodes; 80, 93 and 89 for salivary glands; and 52, 80 and 69 for thyroid. The proportion of non-diagnostic procedures was 28 per cent, both with and without ultrasound guidance.

Conclusion:

Cytologist-led fine needle aspiration cytology would have reduced the time to diagnosis and the number of clinic visits per patient. Fine needle aspiration cytology was accurate for predicting malignancy in salivary gland and lymph node lesions, and for diagnosing lymph node pathology. Study results did not support the use of ultrasound guidance during fine needle aspiration cytology.

Diagnostic efficacy of surgeon-performed ultrasound-guided fine needle aspiration: A randomized controlled trial

Objective: To evaluate the clinical efficacy of surgeon-performed, office-based head and neck ultrasound in facilitating diagnostic fine needle aspiration (FNA) of lesions in the head and neck.

Study Design: A randomized controlled trial of ultrasound-guided FNA versus traditional palpation-guided technique for palpable masses in the head and neck.

Setting: An office-based study performed in a military academic medical center.

Subjects and Methods: Eighty-one adults older than 18 years of age with a palpable head and neck mass (less than 3 cm in largest diameter) were randomized to ultrasound-guided or traditional palpation-guided FNA of a head and neck mass. Measured variables and outcomes for the study included tissue adequacy rates, tissue type, and operator variability.

Results: Following three passes using either palpation or ultrasound guidance, a comparative tissue adequacy rate of 84 percent for ultrasound guidance versus 58 percent for standard palpation was established ( P < 0.014). With regard to tissue type, a statistically significant comparative diagnostic advantage for ultrasound guidance was observed in thyroid tissue while remaining statistically insignificant for lymphatic and salivary tissues. No statistical significance was found when comparing the ability of otolaryngology residents versus attending otolaryngologists to obtain ultrasound-guided diagnostic samples.

Conclusion: Office-based surgeon-performed ultrasound-guided FNA of palpable lesions in the head and neck yields a statistically significant higher diagnostic rate compared to standard palpation technique. Our institutional experience supports the utility of surgeon-performed ultrasound as a core competency in clinical practice.

BSCC Code of Practice--fine needle aspiration cytology

The British Society for Clinical Cytology Code of Practice on fine needle aspiration cytology complements that on exfoliative cytopathology, which was published in the last issue (Cytopathology 2009;20:211-23). Both have been prepared with wide consultation within and outside the BSCC and have been endorsed by the Royal College of Pathologists. A separate code of practice for gynaecological cytopathology is in preparation. Fine needle aspiration (FNA) cytology is an accepted first line investigation for mass lesions, which may be targeted by palpation or a variety of imaging methods. Although FNA cytology has been shown to be a cost-effective, reliable technique its accurate interpretation depends on obtaining adequately cellular samples prepared to a high standard. Its accuracy and cost-effectiveness can be seriously compromised by inadequate samples. Although cytopathologists, radiologists, nurses or clinicians may take FNAs, they must be adequately trained, experienced and subject to regular audit. The best results are obtained when a pathologist or an experienced and trained biomedical scientist (cytotechnologist) provides immediate on-site assessment of sample adequacy whether or not the FNA requires image-guidance. This COP provides evidence-based recommendations for setting up FNA services, managing the patients, taking the samples, preparing the slides, collecting material for ancillary tests, providing rapid on-site assessment, classifying the diagnosis and providing a final report. Costs, cost-effectiveness and rare complications are taken into account as well as the time and resources required for quality control, audit and correlation of cytology with histology and outcome. Laboratories are expected to have an effective quality management system conforming to the requirements of a recognised accreditation scheme such as Clinical Pathology Accreditation (UK) Ltd.

Thyroid FNAC cytology: can we do it better?

This article reviews recent developments in thyroid fine needle aspiration cytology (FNAC). While thyroid nodules are common, carcinoma is comparatively rare. Although histological assessment is used in most studies as the benchmark, the differential diagnosis on cytology or histology is not always reproducible. The literature shows wide variations in criteria for inadequate thyroid FNAC and study inclusion or exclusion criteria. In-clinic assessment of specimen adequacy and in-clinic reporting of thyroid FNAC has become popular although the costs and resource implications of in-clinic thyroid FNAC assessment and reporting are substantial. Many centres continue to use conventional techniques although liquid-based cytology and ultrasound-guided FNAC are gaining in popularity. Standardized categorical systems for FNAC reporting can make results easier to understand for clinicians and give clear indications for therapeutic action. Multidisciplinary case review is also essential, especially when there is diagnostic uncertainty. While currently of limited use, molecular pathology testing holds out some promise for the future.

Sonographically Guided Core Biopsy of A Parotid Mass

OBJECTIVE

The purpose of this study was to evaluate the accuracy of sonographically guided core biopsy in the evaluation of parotid masses.

SUBJECTS AND METHODS

Between 1998 and 2004, 135 patients consecutively presenting with a parotid mass were prospectively enrolled into this study. A single operator performed initial diagnostic sonography and then sonographically guided core biopsy using local anesthesia. Biopsy was performed with an 18- or 20-gauge needle and a spring-loaded biopsy gun with a mean of two passes per patient. Outcome measures were accuracy, sensitivity, specificity, and predictive values of sonographically guided core biopsy compared with the final pathologic diagnosis in the surgical group. In the nonsurgical group, final diagnosis was established on the basis of histologic findings after adequate core biopsy and clinical follow-up.

RESULTS

All sonographically guided core biopsy specimens were considered satisfactory for histologic evaluation. Overall there were 71 benign tumors, 35 malignant tumors, and 29 miscellaneous, nonneoplastic lesions. In 76 (56%) of the 135 patients who underwent surgery, sonographically guided core biopsy and surgical histologic findings were correlated for 74 patients. In two cases sonographically guided core biopsy and surgical histologic findings did not correlate. In one case, the sonographically guided core biopsy finding was mucoepidermoid carcinoma, but the final diagnosis was squamous cell carcinoma. In the other case, the finding at sonographically guided core biopsy was squamous cell carcinoma, but the final diagnosis was mucoepidermoid carcinoma. The treatment of these patients was not affected. Fifty-nine (44%) of the 135 patients avoided surgery. In differentiation of benign from malignant disease, sonographically guided core biopsy had a sensitivity, specificity, and diagnostic accuracy of 100%. Sonographically guided core biopsy also had positive and negative predictive values of 100% in the diagnosis of malignancy. There were no significant complications of sonographically guided core biopsy.

CONCLUSION

Sonographically guided core biopsy is a highly accurate technique for evaluation of parotid lesions and can be safely performed as an outpatient procedure. Sonographically guided core biopsy has potential advantages over fine-needle aspiration cytologic examination, particularly in the typing and grading of lymphoma and carcinoma and in improved differentiation of reactive nodal hyperplasia from lymphoma. The use of sonographically guided core biopsy may help reduce the need for surgical biopsy and facilitates prompt referral to the appropriate clinical team.

The value of fine-needle aspiration cytology in salivary gland lesions, 1994-2004

OBJECTIVE

Fine-needle aspiration cytology (FNAC) of the salivary gland is a commonly accepted, sensitive and specific technique in the diagnosis of both neoplastic and nonneoplastic lesions of the salivary gland. The aim of this study was to investigate the efficacy of FNAC of salivary gland lesions and to decide whether the radiologist could perform it or not.

METHODS

We aspirated 162 salivary gland lesions of 56 patients undergoing biopsy and excision. A cytopathologist and a surgical pathologist made histopathological and cytological examinations in a blinded fashion.

RESULTS

In the present study, among the FNAC performed in 162 patients with salivary gland masses, 15 (9%) were inadequate, and the remaining 147 were diagnostic. Of the 162 cases, 56 (35%) were also checked histologically. With FNAC there were 89 (55%) nonneoplastic and 58 (36%) neoplastic lesions. With FNAC 45 of the neoplastic lesions were benign and 13 malignant tumors. When cytohistopathological correlation was performed, the overall accuracy in diagnosing benign and malignant lesions was 91 and 78%, respectively, except for 2 malignant lymphoma cases. The sensitivity and specificity for benign and malignant lesions were 72 and 100%, respectively. The diagnostic sensitivity for all neoplastic and nonneoplastic lesions was 84% and the specificity 92%. There was 1 false-positive result, in which a nonneoplastic lesion was misdiagnosed as a Warthin's tumor. Fifteen (26%) cases were false-negative, 12 of which were undefined.

CONCLUSION

FNAC is a useful and reliable tool in the diagnosis of salivary gland masses when performed by a radiologist or a clinician. There are no contraindications, and complications are minimal.

Fine needle aspiration cytology: a survey of current European practice

Fine needle aspiration cytology (FNAC) is practised widely throughout Europe. The majority of countries have dedicated cytopathologists as well as histopathologists practicing cytology. Despite this, FNAC is performed mostly by clinicians and radiologists except in the larger centres with dedicated staff with a special interest in cytopathology. The advent of One-Stop diagnostic services and image-guided procedures are prompting further development of FNAC clinics where cytopathologists take their own samples, issue reports in the same clinical session and take extra material for ancillary tests to complete the diagnosis. The volume of FNAC work varies accordingly; in dedicated centres FNAC represents up to 80% of the workload whilst, in the majority of countries, it represents one quarter or less. Hence, the rate of inadequate FNAC varies widely, depending on the local sampling policies and the organ, but does not exceed 25% in any of the countries. The most sampled organs are breast and thyroid, followed by lymph nodes. Most countries have dedicated training in cytopathology for pathology trainees, the duration varying between 6 months and 2 years of the total training time. This discussion, focusing on European practices, highlights the heterogeneity of FNAC activity but also its success in many centres where it is practiced to a high standard, particularly in breast, thyroid and lymph node pathology. The relatively high rate of inadequate material in some centres reflects local policies and calls for greater uniformity of FNAC practice, particularly specimen sampling. To achieve this, the future direction should concentrate on specialist training, to include performing as well as interpreting FNAC, as part of the curriculum. Current emphasis on web-based training may not provide first hand experience of the FNAC procedure and should be supplemented by attending FNAC clinics and developing the technique to its full potential.

Ultrasound-guided fine needle aspiration cytology in the diagnosis and management of thyroid nodules

OBJECTIVE

To examine the accuracy of fine needle aspiration cytology (FNAC) in the diagnosis of thyroid nodules and compare the inadequacy rates for ultrasound-guided and freehand FNAC.

METHODS

A retrospective study of 434 patients with thyroid nodules who underwent diagnostic FNAC over a 2-year period. Cytological diagnoses have been compared with the histological assessment of resection specimens in 69 cases.

RESULTS

The inadequacy rate was significantly lower from ultrasound guided FNAC (24/373 cases, 6.4%) than from freehand FNAC (8/61 cases, 13.1%) (P = 0.043). Seventy-six percentage of patients had a non-neoplastic cytological diagnosis and, after multidisciplinary review, the patients were reassured and assigned to clinical follow-up. Sixty-seven patients had a resection for cytological appearances consistent with non-neoplastic disease (n = 34), suspicious of follicular neoplasia (n = 23), or suspicious of malignancy (n = 10), and two patients had resections following inadequate cytology with ultrasound appearances suspicious of a neoplasm. The overall accuracy of FNAC analysis for malignancy was 97.0%, with sensitivity 83.3%, specificity 98.0%, positive predictive value 71.4% and negative predictive value 98.4%. The overall accuracy of FNAC analysis for the prediction of neoplasia was 97.5%, with sensitivity 80.5%, specificity 97.8%, positive predictive value 89.2% and negative predictive value 95.9%. Difficulties in cytological diagnosis were associated with lymphoid infiltrates and with degenerative changes in follicular adenomas.

CONCLUSION

Ultrasound-guided FNAC has a significantly lower yield of inadequate aspirates than palpable FNAC. The ability of FNAC to predict neoplasia in 89% patients and to exclude neoplasia in 95.9% patients makes an important contribution to the multidisciplinary assessment of patients.

"One-stop" clinics in the investigation and diagnosis of head and neck lumps

This article considers the issues raised by the NICE guidelines "Improving outcomes in head and neck cancers" (2004) with particular emphasis on the guidelines regarding the creation of "one-stop" neck lump assessment clinics. Tissue sampling is an essential function of the clinics and the relative merits of fine needle aspiration cytology (FNAC) and ultrasound-guided core biopsy (US-CB) in the context of a one-stop model are discussed. All cancer service providers in the UK have a duty to implement the NICE guidelines, with the intention of improving cancer services to our patients. The measures against which head and neck cancer teams are to be accredited through the process of peer review will specify such a clinic to be in place. Teams should implement the guidance in such a way that there is a genuine benefit to patients. In many centres this may require clinicians to learn new skills and adopt different ways of working.

Diagnosing a parotid lump: fine needle aspiration cytology or core biopsy?

Fine needle aspiration cytology (FNAC) has been widely adopted for the cytological diagnosis of parotid lumps. FNAC does have drawbacks, even under optimum conditions and may be associated with poor levels of diagnostic accuracy, particularly outside the specialized clinic environment. Ultrasound-guided core biopsy (USCB) is a relatively recently described technique in the parotid gland which has been well tolerated and has demonstrated a high degree of diagnostic accuracy in several studies. This article discusses the merits and pitfalls of FNAC, together with the technique of USCB and also highlights the potential advantages benefit provided by USCB in parotid diagnosis.

Fine-needle aspiration cytology in the diagnosis of superficial lymphadenopathy: a 5-year Brazilian experience

To determine the accuracy of fine-needle aspiration (FNA) in the diagnostic assessment of lymphadenopathies, a retrospective study was conducted on 627 cases of FNA of the lymph nodes performed at Department of Pathology, UNIFESP (Federal University of São Paulo), between 1997 and 2001. Cytology results were compared to the results of biopsies if available. The cytological diagnosis was unsatisfactory in 14.7% of cases, positive in 46%, and negative in 39.3%. Among the positive cases, 79.4% were classified as metastases, 14.2% as lymphoma, and 6.4% as indeterminate. Anatomopathological exams for the determination of cytohistological correlation were available in 218 of the 627 cases. There were three (1.88%) false-negative and two (1.25%) false-positive cases. Accuracy tests revealed 97.41% sensitivity, 95.45% specificity, and 96.88% efficacy, with cytohistological agreement being almost perfect (kappa = 0.92). The high accuracy of this study based only on cytomorphological criteria associated to the variety of malignant neoplasias diagnosed by the procedure demonstrates its relevance on patient care, especially in areas of limited financial resources.

Thyroid cancer review 1: presentation and investigation of thyroid cancer

Thyroid cancer is uncommon with an estimated lifetime risk of 0.8% for women and 0.3% for men. The incidence appears to be increasing by 4% per year and is currently the eighth commonest cancer in women. Managing thyroid cancer is challenging, as no prospective randomised trials exist. Most of the information is derived from large patient cohorts in which therapy has not been randomly assigned. This is the first of the three review papers we have written on the management of thyroid cancer.

Ultrasound-guided core biopsy for the diagnosis of lumps in the neck: results in 82 patients

Ultrasound-guided core biopsy of nodes (n = 78) and other lumps (n = 4) in the neck allowed a firm histological diagnosis in 76 of 82 patients (93%). Of the remaining six patients, histological examination was equivocal in four and valueless in two. Of 18 patients with a diagnosis of lymphoma only 3 required excision of the node to provide additional information for the planning of treatment.

Ultrasound in head and neck surgery: thyroid, parathyroid, and cervical lymph nodes

Ultrasound (US) of the neck is extremely sensitive in detecting thyroid, parathyroid, and cervical lymph node pathology, and is regarded as the most complete and cost-effective imaging method for evaluating the thyroid and parathyroid glands, as well as for the diagnostic evaluation of the cervical lymph node basin. US is widely used in screening high-risk individuals, evaluation of palpable and nonpalpable thyroid nodules, needle guidance for biopsy of nonpalpable and suspicious nodules, and preoperative evaluation of the extent of thyroid neoplasms, as well as in the detection of residual, recurrent, or metastatic thyroid tumors, and in observing nonsurgical cases. It has thus become an important adjunct to the practice of head and neck surgery.

Utility and safety of ultrasound-guided fine-needle aspiration of salivary gland masses including a cytologist's review

OBJECTIVE

To evaluate the utility and safety of ultrasound-guided fine-needle aspiration of the salivary glands for diagnosis of focal masses in the salivary glands, including the prevalence of nondiagnostic sampling, the impact of the presence of a cytologist during the procedure, and the usefulness of flow cytometry.

METHODS

A retrospective analysis of 43 ultrasound-guided fine-needle aspirations of the salivary glands from 36 lesions in 33 patients was performed. Fine-needle aspirations were obtained under sonographic guidance, and 1 to 6 punctures were made with 20- to 25-gauge needles. Ultrasound-guided fine-needle aspirations obtained in the presence of a cytologist were compared with those performed without a cytologist regarding the adequacy of the specimen and the number of punctures performed. Postprocedural complications and the frequency with which flow cytometry was performed were noted. Cytopathologic diagnosis was correlated with clinical follow-up (n = 33) and surgical pathologic findings (n = 10).

RESULTS

Cytologic diagnosis was made in 31 (94%) of 33 patients, confirming a neoplastic process in 18 (50%) of 36 and a non-neoplastic process in 16 (44%) of 36. Although the presence of a cytologist at the bedside resulted in a higher prevalence of diagnostic sampling (P < .05), it did not alter the number of punctures performed (mean, 3 punctures). No complications were encountered except for pain in 2 patients. Flow cytometry was helpful in 8 (22%) of 36 patients.

CONCLUSIONS

Ultrasound-guided fine-needle aspiration of the salivary glands is a safe procedure with a low prevalence of nondiagnostic sampling. Approximately 44% of patients can be spared surgical intervention through diagnosis of a non-neoplastic process. The presence of a cytologist increases the likelihood of obtaining a diagnostic sample. Flow cytometry was helpful in 22% of patients.