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Macroscopic assessment of pulmonary fine needle aspiration biopsies: correlation with cytological diagnostic yield

¹Department of Radiology, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ and ²Department of Cytopathology, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK

Correspondence: Dr F V Gleeson

	Abstract

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Fine needle aspiration biopsy (FNAB) is widely used in the diagnosis of pulmonary neoplasia. Previous studies have advocated the use of immediate cytological review at the time of biopsy to reduce the number of needle passes performed, whilst stating that in the absence of this, simple macroscopic assessment of sample quality was used. This latter practice is widespread, but there is no data regarding its accuracy or the level of intra-observer consistency. We assessed the degree of correlation between a macroscopic grading of the FNAB sample at the time of lung biopsy by the radiologist performing the procedure and subsequent diagnostic yield. 45 consecutive patients in whom pulmonary neoplastic disease was strongly suspected were included. Macroscopic sample appearances were graded on a five-point scale from 1 (blood with no particulate material) to 5 (solid tissue pieces). The positivity rate increased stepwise along with macroscopic grading from 50% for samples graded 1 to 100% for samples graded 5. Grouping the predominately haemorrhagic samples (graded 1–2) together and comparing them with the particulate samples (graded 3–5) demonstrates a statistically significant difference in diagnostic yield (p<0.001). This small study shows that a simple macroscopic grading of pulmonary FNAB samples can provide a good indication of likely cytological diagnostic yield and that radiologists can develop a degree of consistency in their assessment. In the absence of direct cytological input, this may provide a basis for decisions on the number of passes performed.

	Introduction

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Fine needle aspiration biopsy (FNAB) is a well established means of assessing malignant pulmonary disease [1]. While previous studies have explored the value of immediate cytological reading of FNAB samples [2], we know of no studies which have specifically addressed the accuracy and intra-observer consistency of a macroscopic reading of sample quality by the radiologist performing the biopsy. The aim of this study was to assess the diagnostic accuracy of the radiologist in making a simple macroscopic reading of the biopsy material.

	Materials and methods

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Patient population
Biopsy procedures performed over a six-month period on 45 consecutive patients (27 male, 18 female), in whom non-lymphomatous neoplastic disease was strongly suspected on clinicoradiological grounds, were included in the study. The average patient age was 69 years (range 41–88 years). 22 procedures (48.9%) were performed under CT guidance, 14 procedures (31.1%) under ultrasound control and the remaining 9 procedures (20%) using fluoroscopy.

Technique
A standard syringe suction FNAB technique was performed using 22 G spinal needles. Fixed and unfixed slide preparations and needle washings were obtained. Sample appearances were graded on a five-point scale with 1 indicating apparent haemorrhage with no particulate material, 5 indicating fragments of solid tissue with no haemorrhagic component and 2–4 used to grade intermediate sample qualities. All gradings were performed at the time of procedure by the same radiologist. All samples were then processed and reported by the cytology department in the normal way, blinded to the radiologists macroscopic score.

In cases where the fine needle aspirate was non-diagnostic, reference was made to any histological diagnosis obtained following contemporaneous imaging guided core biopsy or subsequent surgical open biopsy.

	Results

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A total of 83 fine needle aspiration passes were performed in the 45 patients, an average of 1.8 per patient (11 patients underwent a single pass, 30 underwent two passes and in four cases three passes were performed).

FNAB was non-diagnostic in seven patients. Two of these patients have been excluded from analysis; one was found to have tuberculosis at surgical biopsy while further investigation of the aetiology of a small pulmonary mass was prevented in the second patient by significant cardiac comorbidity. This nodule (<2 cm) remains of indeterminate aetiology on radiological criteria at 6 months. Both patients excluded from analysis had macroscopic sample grades of 3.

A positive result by FNAB was obtained in 38 of the 43 patients analyzed (sensitivity 88.4%). The cytological diagnoses are shown in Table 1. A positive result by FNAB pass was obtained in 66 of 79 passes (sensitivity 83.5%).

The final diagnoses in the 5 patients (11.6%) with a non-diagnostic FNAB were bronchioloalveolar carcinomas in two patients, squamous cell carcinoma in one patient, adenocarcinoma in one patient and benign pneumocytoma in one patient.

Analysis of macroscopic grading per biopsy pass is shown in Table 2. The positivity rate increases with macroscopic grade from 50% (samples graded 1) to 100% (samples graded 5). Grouping non-particulate predominately haemorrhagic samples, grades 1 and 2, and non-haemorrhagic particulate samples, grades 3, 4 and 5, demonstrates a statistically significant difference in diagnostic yield (p<0.001).

	Discussion

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Cytologists are not routinely present at the time of biopsy in our institution, and provision of this service has considerable resource implications. Other authors have commented that, in the absence of initial microscopic review, they use their own macroscopic assessment of sample quality to determine the need for a further pass [2]. In practice this is how most radiologists probably operate, but to our knowledge there is no data on the reliability of this technique.

In our small study there was a general trend of increasing diagnostic utility with increasing sample grade. Of interest is the finding that a cytological diagnosis of malignancy was possible in 50% of cases when the sample was thought tobe blood only. The small number of samples graded 1 and 5 prevented direct comparison between individual gradings. However, a statistically significant difference did exist between the two lowest, non-particulate grades and the other three particulate grades. This may provide a basis for the practice of deciding which cases require a further needle pass and which do not, on the basis of the gross appearance of the sample. The non-particulate samples have a 59% chance of providing a diagnosis compared with a 93% chance available with the presence of more tissue fragments. A direct comparison of the added value of a cytopathologist or technician in attendance in comparison with a visual grading of the slide by the radiologist may be warranted.

This small study suggests that the radiologist performing the biopsy may be able to estimate the diagnostic yield of a biopsy specimen. This is of importance when evaluating the need for a second or third pass, with the attendant risks.

Received for publication June 11, 2001. Revision received September 11, 2001. Accepted for publication September 18, 2001.

	References

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