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ORIGINAL ARTICLE
Year : 2023  |  Volume : 21  |  Issue : 1  |  Page : 3-8

Clinical significance of repeat fine-needle aspiration in managing patients with suppurative lesion


1 Department of Pathology, Dhanalakshmi Srinivasan Medical College and Hospital, Perambalur, India
2 Department of Pathology, Aarupadai Veedu Medical College and Hospital, Vinayaka Mission's Research Foundation, Puducherry, India
3 Department of Pathology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Date of Submission27-Sep-2022
Date of Decision14-Oct-2022
Date of Acceptance01-Nov-2022
Date of Web Publication17-Jan-2023

Correspondence Address:
V Archana
Department of Pathology, Dhanalakshmi Srinivasan Medical College and Hospital, Keelakanavai - Road, Perambalur - 621 113, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_107_22

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  Abstract 

Background: Fine-needle aspiration (FNA) has been challenged about its role in the management of patients with clinical suspicion of infective or neoplastic etiology but cytological picture showing features of acute suppuration. This study emphasizes the need to perform repeat FNA cytology (FNAC), especially if the mass lesion is indicating suppuration and has not responded to the initial course of antibiotics. Materials and Methods: All patients with a previously diagnosed suppurative lesion on cytology smears who have undergone repeat FNA were included in the study. Insufficient material on FNA and the nonavailability of slides were excluded from this study. Results: Repeat FNA assisted in the detection of malignant lesions (3), tubercular lesions (20), fungal lesions (9), and benign lesions (9) out of the 123 cases of previously diagnosed acute suppurative lesions. Comparison of FNAC findings with histopathological specimens was available for 52 cases, following which repeat FNA had a sensitivity of 66.67% (95% confidence interval 34.89%-90.08%) in detecting neoplastic, specificity was 100%, positive predictive value was 100%, negative predictive value was 90.91%, and the total diagnostic accuracy was 92.31%. Conclusion: Patients with acute suppurative lesions should be followed by repeat FNA, especially if the lesion is not responded to initial antibiotic therapy. Repeat FNA will enhance the diagnostic accuracy of malignant lesions and many other lesions, such as fungal or tubercular infections. It will reduce the need for surgical interventions and molecular detection of infectious diseases.

Keywords: Cytology, infection, suppuration


How to cite this article:
Elancheran M, Siva K, Sriram V, Archana V, Ragavendran S. Clinical significance of repeat fine-needle aspiration in managing patients with suppurative lesion. Curr Med Issues 2023;21:3-8

How to cite this URL:
Elancheran M, Siva K, Sriram V, Archana V, Ragavendran S. Clinical significance of repeat fine-needle aspiration in managing patients with suppurative lesion. Curr Med Issues [serial online] 2023 [cited 2023 Feb 4];21:3-8. Available from: https://www.cmijournal.org/text.asp?2023/21/1/3/367856


  Introduction Top


Fine-needle aspiration (FNA) cytology is a widely used rapid, inexpensive, accurate, and minimally invasive procedure for diagnosing palpable and impalpable, superficial, and deep-seated lesions. In general, neoplastic and nonneoplastic lesions, such as fungal and tubercular infections, were diagnosed on FNA cytology (FNAC) in the presence of classical cytomorphological features.[1] For diagnosing tuberculosis and fungal organisms, cytological features are the presence of granulomas or caseous necrosis or AFB positivity on special stains and fungal hyphae, respectively.[2] Likewise, for malignant lesions, the cellularity and atypical nuclear features are the salient features for the diagnosis. However, it is not very rare that these neoplastic or infective lesions can undergo suppuration. Patients with lesions categorized as suppurative on FNAC were treated with a course of antibiotics.[3] Cases that were reported as suppurative lesions in cytological smears sometimes remain undiagnosed on FNAC because suppuration often obscures the presence of other classical findings. In most of the centers, these cases not responding to antibiotic therapy after the first FNAC were advised to undergo incision and drainage or molecular testing instead of subjecting to repeat FNAC. In medically under-resourced countries where histopathological and microbiological laboratories are few in number and surgical biopsies, PCR is expensive options; FNAC is the most powerful tool to make a rapid diagnosis.[4] This study aims to analyze the diagnostic accuracy of repeat FNAC in patients with suppurative mass lesions along with histopathological correlation, and this can be a valuable tool for patients in developing countries who do not have assess to higher diagnostic centers. In the literature search, very limited articles are available to emphasize the role of repeat FNAC in patients with suppurative lesions.

Aims and objectives

To study the diagnostic utility of repeat FNAC in managing patients with suppurative lesions and its histopathological correlation.


  Materials and Methods Top


Study location and duration

The current study is a laboratory-based retrospective study that was carried out in the Department of Pathology, Dhanalakshmi Srinivasan medical college and hospital, Perambalur. The duration of this study was 3 years, from January 2018 to 2021.

Study population

One hundred and twenty-three patients with a previously diagnosed suppurative lesion on cytology smears who have undergone repeat FNA were included in the study.

Methodology

Patient's clinical details were collected from the request form and on clinical examination findings during the FNAC procedure. The routine hospital protocol was followed wherein, under aseptic precautions, FNAC was performed by the attending pathologist. Aspiration was conducted by using 10 ml disposable syringes connected with 22-24 bore hypodermic needles.[5] Cytological material was aspirated from the lumps. If there was a cystic lesion, FNAC was also attempted from the cystic as well as solid areas. The cytological smears were prepared from the aspirate were fixed with alcohol and stained with standard hematoxylin and eosin stain. Apart from the wet fixed smears, at least two dry smears were made from the aspirated material and preserved for special stains. When suppuration was present in FNA smears, PAS staining was done on one smear and Ziehl–Neelsen staining on other smears. Whenever epithelioid granuloma with or without necrosis was seen on wet smears, one of the dried smears was stained with PAS and the other with Ziehl–Neelsen stain. When septate or nonseptate hyphae or spores was detected on wet smears, one of the dried smears was stained with the Periodic acid–Schiff.

The corresponding histomorphological correlation was also made wherever possible. Among the 123 FNA patients, we were able to correlate 52 cases based on histomorphological features and diagnosis.

Selection criteria

The records available at the laboratory were retrieved for the study. All patients with suppurative lesion who has undergone repeat FNAC were included in the study. Insufficient material on FNAC and the nonavailability of slides were excluded from the study.

Ethical consideration

IRB of Dhana Lakshmi Srinivasan Medical College and Hospital approved the conduct of this study (Ref: IECHS/IRCHS/DSMCH/Cert/135).

Statistical methods

Descriptive statistics were used to analyze data in accordance with the study's objectives. Data were expressed as the mean, 95% confidence interval (CI; lower and upper bounds), minimum and maximum, and percentage, where appropriate. HPE was considered the gold standard. FNAC was considered screening test. The sensitivity, specificity, predictive values, and diagnostic accuracy of the screening test along with their 95% CI, were presented.

Data were analyzed by using SPSS software, V.22.[6]


  Results Top


A total of 123 cases were included in the final analysis

This study included 123 cases of repeat FNAC from our institute for 3 years. The cases in this study were 40.7% of males and 59.3% of females. The patients included in this study were mostly above 20 years, around 83.1%. The most common sites of the lesion was lymph node, soft tissue, followed by the breast [Table 1].
Table 1: Summary of baseline parameter (n=123)

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Out of the 123 cases of the previously diagnosed acute suppurative lesion, repeat FNAC showed malignant lesion (3), tubercular lesion (20), fungal lesion (9), and benign lesions (9).

Among the 123 cases, the majority of them were from lymph nodes and soft tissue. In Lymph nodes, out of 44 cases, on repeat FNAC majority of them were granulomatous lesions. In skin and soft tissues, the acute suppurative lesion was diagnosed in 75% of cases and fungal abscess with suppuration in 20.4% of the cases (9 out of 44). In breast pathology, the proportion of acute suppurative lesions and granulomatous mastitis with suppuration was 42.86% and 23.81%, respectively [Table 2].
Table 2: Summary of cytological diagnosis (n=123)

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Out of 123 cases of repeat FNAC, only 52 cases were available for histopathological correlation. Among the 52 cases in FNAC, 8 patients were diagnosed with neoplastic lesions and 44 patients were diagnosed as nonneoplastic lesions. When histopathological correlation was done, it showed that 12 patients were diagnosed as neoplastic when compared to FNAC where only eight cases were diagnosed as neoplastic. Four patients who were cytologically diagnosed as acute suppurative lesions were categorized as infected keratinous cyst (n = 2), Ganglion cyst (n = 1), and lymphoma (n = 1) on histopathological examination [Table 3] and [Table 4].
Table 3: Summary of histopathological diagnosis (n=52)

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Table 4: Comparison of histopathological diagnosis with fine-needle aspiration cytology (n=52)

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Photomicrographs of cytomorphological and histopathological findings of epithelioid granulomas are shown in [Figure 1] and [Figure 2], fungal hyphae are shown in [Figure 3] and [Figure 4], malignant squamous cells are shown in [Figure 5] and [Figure 6] and suppuration are shown in [Figure 7] and [Figure 8].
Figure 1: FNA smear shows epithelioid cell clusters forming granulomas (H and E stain ×400). FNA: Fine-needle aspiration

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Figure 2: Histopathological expamination shows multiple granulomas composed of epithelioid cells, lymphocytes and multinucleated giant cells along with suppuration and E stain-×400)

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Figure 3: FNA smear shows thin septate fungal hyphae in a background of dense acute inflammation (H and E stain ×400). FNA: Fine-needle aspiration

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Figure 4: Histopathological examination shows thin septate fungal huphae along with suppuration (H and E stain ×400)

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Figure 5: FNA smear shows atypical squamous cells in a necrotic background(H and E stain ×400). FNA: Fine-needle aspiration

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Figure 6: Histopathological examination shows nests of atypical squamous cells along with mixed inflammatory cell infiltrates (H and E stain ×400)

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Figure 7: FNA smear shows densed inflammatory cell infiltration predominatly neutrophils (H and E stain ×400). FNA: Fine-needle aspiration

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Figure 8: Histopathological examination shows sheets of neutrophils and few lymphocytes (H and E stain ×400)

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When compared to HPE, FNAC had a sensitivity of 66.67% (95% CI 34.89% to 90.08%) in detecting neoplastic, specificity was 100%, false-positive rate was 0%, false-negative rate was 33.33%, positive predictive value was 100%, negative predictive value was 90.91%, and the total diagnostic accuracy was 92.31% [Table 5].
Table 5: Predictive validity of fine-needle aspiration cytology in predicting histopathological diagnosis (n=52)

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  Discussion Top


FNA has established its role in the primary diagnosis of various neoplastic and nonneoplastic lesions. It is not very rare that these lesions may undergo suppuration at any point of time, then, the chances are more that these cases were underdiagnosed as suppurative lesions on FNA.[7] Invariably these cases were advised to take antibiotics or subjected to incision and drainage or otherwise referred to the higher center for molecular testing in case of infective etiology. It is also a very well-known fact that once the neoplastic lesion and infective diseases were underdiagnosed, then the morbidity and mortality of the patients is on the higher side, especially with tuberculosis and malignancy. Hence, early and accurate diagnosis is of immense value.[8] The findings of the current study have showed that repeat FNAC can be used as an early diagnostic modality in suppurative lesions which are not responding to antibiotics therapy. This study also brings out the definitive role of repeat FNAC by providing accurate information of the disease process in comparison with histopathological findings, and this would prevent unnecessary surgical intervention or molecular testing for the patients.

In the present study, 20 aspirates were reported as suggestive of tubercular lymphadenitis [Figure 1] and [Figure 2]. In the twenty aspirates, the most common cytological features are epithelioid cell clusters with necrosis at 22.73% (n = 10), followed by granulomas without necrosis at 18.8% (n = 8) and Ziehl-Neelsen stain positivity in two cases 4.55% (n = 2). Our findings of tuberculous lymphadenitis are similar to Gupta et al., Bhide SP et al., and Bhalla AS et al.[9],[10] In the lymph node FNA, acute suppurative lesions were diagnosed in 21 (47.73%) cases. The proportion of Suppurative bacterial lymphadenitis was more as compared to 27% in Singh Bhagar et al. and 25.45% in Patro et al.[11],[12] In our study, metastatic carcinomatous deposits on lymph node were about 3 (6.82%) cases. All the metastatic carcinomatous deposits are showing squamous differentiation. These findings are very similar to Pierotti et al., where squamous cell carcinoma predominanted over adenocarcinoma.[13] Hence, the total percentage of diagnosis of tuberculous and metastatic carcinoma in repeat FNAC of lymph nodes with the previous diagnosis of the acute suppurative lesion showed 52.27%.

Among the skin and soft-tissue lesions, the most common cytological features are bacterial cause for suppuration comprised 75% (n = 33) and followed by surprisingly 20.45%(n = 9) cases where we detected fungal colonies [Figure 3] and [Figure 4] in repeat aspirate smears, morphologically consistent with phaeohyphomycosis and remaining cases were benign neoplastic lesion with suppuration. These findings were not matching with Sanjay Nath et al., where the bacterial cause of suppuration constitutes only 31.76%, and no fungal organisms have been identified in their study.[14]

In the thyroid lesions, we had encountered only five cases of acute suppuration lesions. No granulomas or neoplastic lesions or fungal organisms were identified on thyroid FNA. Among the breast lesions, we had frequently encountered bacterial suppuration, which comprised 42.86% (n = 9), followed by granulomatous mastitis with suppuration consisting of 23.81% (n = 5), and the remaining cases were categorized under benign neoplastic lesions. We have not encountered any malignant lesions with suppuration [Table 1]. These findings are not compatible with GMK Tse et al., where only six cases of suppuration were detected among the cases of granulomatous mastitis.[15]

Out of 123 patients who came for repeat FNAC, 52 patients had followed up with histopathological examination. Among the people diagnosed with nonneoplastic lesions on histopathological evaluation, 100% of them were identified as nonneoplastic lesions on FNA also [Table 4]. Out of 12 patients with histopathological diagnosis of the neoplastic lesion, four patients were diagnosed with nonneoplastic lesions by FNAC and the remaining (n = 8) patients were diagnosed as neoplastic lesions like the histopathological examination, and the probable reason could be due to extensive suppuration of the native lesion. However, no carcinoma cases were underdiagnosed on repeat FNAC. We could not follow-up on the 71 cases, and the reasons could be either the patient may have been cured or the patient might have been referred to the higher center or lost to follow-up.

Our findings emphasize the need to perform repeat FNAC before assuming a suppurative bacterial etiology, especially if there is a clinical suspicion of neoplastic or nonbacterial etiology.


  Conclusion Top


Patients with acute suppurative lesions should be followed by repeat FNAC, especially if the lesion is not responded to initial antibiotic therapy. Repeat FNAC will enhance the diagnostic accuracy of malignant lesions and many other lesions, such as fungal or tubercular infections. Repeat FNAC has a definite role in the early and accurate diagnosis of suppurative lesions and it will reduce the need for surgical interventions and molecular detection of infectious diseases. This procedure is simple, cost-effective, and less painful as compared to incision and drainage and molecular techniques. Our study concluded that the diagnostic accuracy of repeat FNAC was around 92.31%.

Acknowledgments

We acknowledge the technical support in data entry, analysis, and manuscript editing by “Evidencian Research Associates.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical statement

Institutional ethical clearance was obtained (IECHS/IRCHS/DSMCH/Cert/ 135), and waiver of consent was given as this being a retrospective study. However, consent for performing the procedure was collected during FNAC.



 
  References Top

1.
Ravi S, Stephen N, Sreerekha J, Ramassamy S, Behera B, Gochhait D. Cyto-morphological and clinical approach to infections presenting with discharging sinuses mimicking malignancy. Diagn Cytopathol 2020;48:1265-72.  Back to cited text no. 1
    
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Rammeh S, Romdhane E. Pathology of Tuberculosis. In: Ladeb MF, Peh WCG, editors. Imaging of Tuberculosis. Cham: Springer International Publishing; 2022. p. 29-58 [DOI: 10.1007/978-3-031-07040-2_3].  Back to cited text no. 2
    
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Tatla TS, Navaratnam A, Gibson D, Weller A. Head and Neck Fascial Planes and Deep Neck Space Imaging. In: Tatla TS, Manjaly J, Kumar R, Weller A, editors. Head and Neck Imaging: A Multi-Disciplinary Team Approach. Cham: Springer International Publishing; 2021. p. 37-65.  Back to cited text no. 3
    
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Smitesh G. Prevalence of Cervical Lymphadenopathy in Acute CNS Infections-Testing the Glymphatics in Humans [Dissertation]. Vellore: Christian Medical College; 2020. p. 114.  Back to cited text no. 4
    
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Verma S, Chowdhury M, Ray S, Guha R. Diagnostic accuracy of the Bethesda system of reporting thyroid cytopathology in the evaluation of thyroid nodule in a tertiary care hospital of Kolkata. J Evid Based Med Health 2021;8:241.  Back to cited text no. 5
    
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IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, New York, USA: IBM Corp.  Back to cited text no. 6
    
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Modi P, Oza H, Bhalodia J. FNAC as preoperative diagnostic tool for neoplastic and non-neoplastic breast lesions: A teaching hospital experience. Natl J Med Res 2014;4:274-8.  Back to cited text no. 7
    
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Yuan QQ, Xiao SY, Farouk O, Du YT, Sheybani F, Tan QT, et al. Management of granulomatous lobular mastitis: An international multidisciplinary consensus (2021 edition). Mil Med Res 2022;9:20.  Back to cited text no. 8
    
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Bhide SP, Katre RY, Joshi SR, Katre R, Resident S. Cytological evaluation of fine needle aspiration cytology in lymph node lesions. JMSCR 2017;5:26869-76.  Back to cited text no. 9
    
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Bhalla AS, Goyal A, Guleria R, Gupta AK. Chest tuberculosis: Radiological review and imaging recommendations. Indian J Radiol Imaging 2015;25:213-25.  Back to cited text no. 10
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Patro P, Lad P, Hoogar MB, Dhar R, Sahu S, Mithila KB, et al. Spectrum of lesions in lymph nodes – A cytological study. Int J Health Sci Res 2018;8:75-81.  Back to cited text no. 11
    
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Kataria G, Saxena A, Bhagat S, Singh B, Kaur M, Kaur G. Deep neck space infections: A study of 76 cases. Iran J Otorhinolaryngol 2015;27:293-9.  Back to cited text no. 12
    
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Pierotti MA, Berrino F, Gariboldi M, Melani C, Mogavero A, Negri T, et al. Targeting metabolism for cancer treatment and prevention: Metformin, an old drug with multi-faceted effects. Oncogene 2013;32:1475-87.  Back to cited text no. 13
    
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Tse GM, Poon CS, Law BK, Pang LM, Chu WC, Ma TK. Fine needle aspiration cytology of granulomatous mastitis. J Clin Pathol 2003;56:519-21.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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