Original article / research
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Clinicopathological Correlation of Abdominal Lesions for Assessment of Diagnostic Efficacy of Minimally Invasive Techniques |
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Shiwangi Garg, Rani Bansal, Shweta Grover, Sameer Verma, Mamta Gupta, Shefali Verma 1. Post Graduate, Department of Pathology, Subharti Medical College, Meerut, UP, India. 2. Professor and Head, Department of Pathology, Subharti Medical College, Meerut, UP, India. 3. Associate Professor, Department of Pathology, Subharti Medical College, Meerut, UP, India. 4. Professor, Department of Radiology, Subharti Medical College, Meerut, UP, India. 5. Associate Professor, Department of Pathology, Subharti Medical College, Meerut, UP, India. 6. Post Graduate, Department of Pathology, Subharti Medical College, Meerut, UP, India. |
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Correspondence
Address : Dr. Shiwangi Garg, Post Graduate, Department of Pathology, Subharti Medical College, Meerut-250005, UP, India. E-mail: Shiwangi2911@gmail.com |
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ABSTRACT | |||||||||||||||||||||||||||||||||||||||||||||||||||||
: Evaluation of abdominal masses may pose difficulty in surgical practice. Distinction between malignant, benign and inflammatory lesions is vital for patient’s management. Hence, use of minimally invasive techniques under radiological guidance with pathological correlation is gaining popularity as a means of diagnosing abdominal lesions. Aim: To assess the pathological spectrum of abdominal lesions and to determine the diagnostic efficacy of minimally invasive techniques. Materials and Methods: Total 102 consecutive patients with clinically or radiologically diagnosed abdominal lesions excluding pelvic masses were evaluated by minimal invasive techniques like direct or guided Fine Needle Aspiration Cytology (FNAC) by 22-24 gauge needle and Tru-cut biopsy (TCB) by Geotex automated gun with 18 gauge needle. Statistical analysis was done by 2x2 contingency table by comparing the test diagnosis with the gold standard diagnosis. Results: Majority (n=32) of lesions were from liver (31.3%) among which metastatic carcinomas were most common followed by primary, next in frequency belonged to gall bladder 17 (16.6%). Among all abdominal lesions, maximum cases were malignant followed by benign and inflammatory. sensitivity, specificity, positive predictive value, negative predictive value and overall diagnostic accuracy of FNAC and TCB were 100% each and 90%, 100%, 100%, 83.3%, 93.3% respectively. No serious complications were observed after these procedures. Conclusion: Minimally invasive techniques are simple, safe and efficient procedures for making an accurate diagnosis in abdominal lesions and helps in choosing the appropriate management. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Keywords : Fine Needle Aspiration Cytology (FNAC), Radiologically guided, Space occupying lesions (SOL) ,Tru-cut biopsy (TCB) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
INTRODUCTION | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Intra-abdominal lesions are a challenge in surgical practice. Diagnosis is dependent upon the use of ancillary tools like percutaneous sampling and advanced radiological imaging that have enabled the detection and localisation of lesions in sites not easily accessible to surgical biopsies (1). Currently, Fine Needle Aspiration Cytology (FNAC) using 20-25 gauge needles and Fine Needle Core Biopsy (FNCB) using wide bore 18 gauge needle or Tru-cut biopsy needle are commonly accepted methods for obtaining diagnostic material under radiological guidance. Both techniques are safe, simple, rapid and efficacious diagnostic modalities in providing cytological and histological diagnosis in various space occupying lesions of abdomen (2). Fine needle Tru-cut biopsies (TCB) provide better sample quality and lower insufficient sampling rate without an increase in the complication rate. Biopsies in addition have an advantage of preservation of tissue architecture necessary for diagnosing and sub typing of tumours. Further histochemical and immunohistochemical techniques can be applied wherever required (2),(3). Complications like haemorrhage, septicaemia, peritonitis, pneumothorax and tumour seedlings after FNAC though rare are reported in literature (4). Cytological and histological examinations are complementary in assessment of abdominal lesions. However, there are conflicting data in literature regarding the accuracy and usefulness of these techniques. Few clinicians prefer FNAC and recommend biopsy in diagnostically challenging cases, while others recommend core biopsy alone. These discrepancies may be due to variations in the type and location of lesion being aspirated or biopsied (2). A multi-modal approach with good clinical, radiological and cyto-histological approach is recommended to improve diagnostic accuracy. Thus, the present study was undertaken to assess the pathological spectrum of abdominal lesions with clinico-pathological correlation and to determine the diagnostic efficacy of minimally invasive techniques in abdominal lesions. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
MATERIAL AND METHODS | |||||||||||||||||||||||||||||||||||||||||||||||||||||
A retrospective and prospective study was conducted in Department of Pathology, Subharti Medical College and the associated CSS Hospital over a period of 3 years (September 2012 to August 2013). Patients with normal coagulation profiles were included. Lesions having high vascularity or close proximity to major vessels, inadequate material for diagnosis or FNAC/TCB of pelvic organs were excluded. For retrospective study, cases in which minimally invasive techniques like FNA cytology and / or Tru-cut biopsy (TCB) had been done were retrieved from the archives of Department of Pathology. Relevant history and radiological findings were obtained from the Medical Record Department (MRD). For prospective study, consent was taken before FNAC/ TCB procedure. Relevant clinical history and physical examination findings were recorded. Radiological examinations-Ultrasonography (USG) or Computerized Tomography (CT-scan) was performed to assess the origin of abdominal mass and its relationship to adjacent organs. Taking aseptic precautions percutaneous FNAC was done with 22-24 gauge needle while for deep seated lesions 22 gauge lumbar puncture needle was used. On an average depending on size and consistency of lesion 2-3 needle passes were made in each case to obtain adequate material. Air dried smears and wet fixed smears in 95% alcohol were prepared. Air dried smears were stained with LeishmanGeimsa (L-G) stain and wet fixed smears were stained by Hematoxylin-Eosin (H&E) and Papanicolaou (Pap) stain. Tru-cut biopsy was done by Geotex Tru-cut automated gun with an 18 gauge needle under radiological guidance. The biopsies were fixed in 10% formalin, Grossing was done and tissue processed by conventional histo processing in automated tissue processor Shandon Citadel 2000. The paraffin embedded blocks were cut at 4µ, serial sections taken and stained by routine H&E staining technique in automatic Thermo Scientific Varistain Gemini ES. The cases were analysed based on cytological and histological features. The final diagnosis was provided with clinico-radiological correlation. Statistical analysis for sensitivity, specificity, positive predictive value, negative predictive value and overall diagnostic accuracy was done by 2x2 contingency table by comparing the test diagnosis with the gold standard histopathological diagnosis. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
RESULTS | |||||||||||||||||||||||||||||||||||||||||||||||||||||
The present study included material obtained from minimally invasive techniques in 102 cases during the study period, which included FNAC from 95 patients and Tru-cut biopsies from 20 patients. Among these, in 10 cases both FNAC and TCB were done. Excised specimen was available in 24/102 cases, including 19/95 FNAC and 15/20 TCB cases. Patient age ranged between 2 - 82 years, with a mean age of 45. Of these 57 (55.88%) were males and 45 (44.11%) were females with a sex ratio of 1.2:1. These patients presented with various clinical symptoms, most common was abdominal pain followed by lump, fever, vomiting, icterus, haematuria, oliguria and constipation. Analysis of organ/site wise distribution of abdominal lesions were done and majority of cases were from liver 32(31.3%) followed by gall bladder 17(16.6%) (Table/Fig 1). Clinicoradiological discordance was seen in 13/95(13.68%) cases of FNAC of which excised specimen were available in 4 cases (Table/Fig 2) and 7/20(35%) of TCB of which excised tissue was there in 5 cases (Table/Fig 3). IHC was recommended in metastatic and unclassifiable tumours. Of total 102 cases, FNAC was done in 95 cases of which excised tissue was available in 19 cases. Sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of FNAC were 100 % each. TCB was done in 20 cases of which excised tissue was available in 15 cases. Sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of TCB were 90 %, 100%, 100 %, 83.3% and 93.3% respectively. Except mild pain and discomfort in few cases no serious complications were observed after both the procedures in our study. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
DISCUSSION | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Evaluation of abdominal masses may pose difficulty in surgical practice. Distinction between malignant and nonmalignant lesions and particularly inflammatory is vital for patient’s management (5). Clinical presentation associated with malignancy can be misleading at times. Use of imaging techniques alone may fail to allow distinction between benign and malignant lesions on the basis of morphological features. Hence, radiologically guided minimally invasive techniques are gaining popularity as a means of diagnosing abdominal lesions with high sensitivity and low complication rates. A clinicopathological correlation of abdominal lesions was done in 102 patients to assess the diagnostic efficacy of minimally invasive techniques.In our study, M:F ratio of 1.2:1 was observed which was consistent with studies done by Tuladhar AS et al., (6). Sensitivity, specificity, diagnostic accuracy, positive predictive value and negative predictive value of FNACand TCB correlated with other studies [3,7,8]. Also it is noted that sample size can affect the statistical values. Liver (31.3%) was the most common organ followed by gall bladder (16.6%), kidney (8.82%) and least were stomach and jejunum (0.92%) each, from which FNAC/TCB were done. In liver, metastatic carcinoma (20.58%) was most common in our series followed by primary tumours. These correlated with Shobha R et al., (3) and Adhikari RC et al., (9). In contrast, Sidhalingreddy et al., (7) found hepatocellular carcinoma (HCC) to be more common. This could be due to high prevalence of Hepatitis B infection and consumption of ground nuts chutney frequently contaminated with afla toxins in that geographical region. Among metastatic carcinomas to liver, adenocarcinoma from gall bladder was the most common, in the present study. In contrast, Soyuer I et al., (10) observed that lung, GIT and breast were common sites. Among five unclassified cases of metastatic carcinoma one was poorly differentiated large cell type carcinoma (Table/Fig 4) (a-b), four unclassifiable malignant tumours on FNAC. IHC was recommended to differentiate between primary and metastatic carcinomas. Cytological examination alone may not differentiate between primary and secondary hepatic malignancies. Therefore, histopathological examination, cell blocks and correlation with serum afetoprotein (AFP) levels are helpful (11),(12). Two cases clinico-radiologically suspicious of malignancy revealed cirrhotic changes on TCB (Table/Fig 4) (c-d). Hepatitis, focal nodular hyperplasia (FNH) and active cirrhosis may mimic HCC2 cases were reported as abscess and correlated clinicoradiologically. Some authors also suggested there is some overlap between the USG and CT features of liver abscess with HCC and metastatic carcinoma. So, a thorough clinical, radiological and pathological examination is recommended to make a diagnosis of liver abscess. Seventeen cases of gall bladder were reported on FNAC in our series among which 13 were adenocarcinoma and four unclassifiable malignant tumours. All the cases correlated clinico-radiologically. Our study showed concurrence with the studies done by Tuladhar AS et al., (6) and Ahmad S et al., (13). However, a negative result should be interpreted with caution when clinical suspicion is high and a repeat FNAC should be carried out to make a diagnosis. Among seven cases of GIT reported in our study, 3 were from colon, 2 from rectosigmoid junction, 1 each from serosal aspect of stomach and jejunum. All cases were clinico-radiologically diagnosed as malignancy. Of these seven cases excised specimens were available in 5 cases. Diagnostic accuracy was 100% on FNAC. Similar findings were observed in study done by Shobha R et al., (3) two cases showed clinic-radiological discordance. Both were suspicious of malignancy, However, one was reported nonneoplastic chronic entero-colitis on FNAC and Tubercular enterocolitis on histopathology specimen. Another case was chronic abscess with extensive fibrosis on both FNAC/TCB and histopathology specimen. Mohammad A et al., (14) reported that aberrant remodeling lead to marked mural thickening owing to proliferation process of smooth muscle cells in muscularIs propria and post inflammatory fibrosis which may produce an indurated mass mimicking tumour. Advances like Endoscopic ultrasound (EUS) guided FNA in evaluating lesions adjacent to GIT wall are there but due to high complication rates USG guided FNA is still preferred (15). Nine cases were from kidney of which excised specimen were available in 7 and FNAC/TCB diagnosis was confirmed in 6 cases. One case clinicoradiologically suggestive of malignancy was false negative on TCB and histotopathological examination of nephrectomy specimen confirmed the diagnosis of RCCclear cell type (Table/Fig 5) (a-c).Two were renal cell carcinoma (RCC), 2 Transitional cell carcinoma (TCC) (Table/Fig 5) (d-f) and one each of nephroblastoma, chronic pyelonephritis and abscess. Rest all cases correlated clinico-radiologically. Shobha R et al., (3) emphasized that cytology and radiology complement each other in diagnosing renal lesions. Four retroperitoneal masses were reported in our study. TCB and excised histopathological specimen were available in 2 cases. All four were reported neoplastic. In contrast, study conducted by various authors concluded that metastatic carcinomas are more common in retropritoneum than primary. One case was diagnosed on both FNAC and TCB as benign mesenchymal tumour and neurofibroma respectively turned out to be MPNST on excised histopathological specimen (Table/Fig 6) (a) (Table/Fig 6) (d). The presence of essentially any mitotic activity in neurofibroma (especially in deep seated tumours with areas of increased cellularity and nuclear atypia) warrants the diagnosis of MPNST (16). Among four cases of abdominal scar and subcutaneous nodules, two had history of laproscopic cholecystectomy for gall bladder adenocarcinoma following which these lesions appeared. Therefore, scar related abdominal nodules should be biopsied/aspirated carefully to rule out tumour deposits. This observation correlated with the study done by Marwah N et al., (17). Other two nodules were reported as necrotizing tubercular inflammation and benign skin adnexal tumour. Two cases from mesentery mass were reported as chronic inflammation and paraganglioma respectively. Many authors have suggested that paraganglioma arising from mesentery is extremely rare and occasional reports have been published and explain that they occur due to abnormal ventral migration of paraganglionic cells from the root of superior and inferior mesenteric arteries and form collections of paraganglionic tissue (18),(19). Among nine cases of iliac region presented as mass in iliac fossa, neoplastic lesions were observed in six cases and non neoplastic in three cases (20). Three cases of omental mass diagnosed as sarcoma/ metastatic anaplastic tumour, Necrotizing tubercular inflammation and chronic granulomatous inflammation. Dhiman DS et al., (21) stated that primary tumours of omentum are rare, also omental TB is rare and occurs as a part of tubercular peritonitis termed as “fibrotic fixed” type. One case of peritoneal deposit was reported as chronic granulomatous inflammation which was clinically suspected as ovarian carcinoma. In young females there are conditions which can mimic advanced ovarian malignancies of which extra pulmonary pelvic peritoneal tuberculosis is the most common (22),(23). Thirteen cases presented with abdominal lumps without any clue of their origin. Nine cases correlated clinicoradiologically. One case was diagnosed as Gastrointestinal stromal tumour on radiological examination. On FNAC, TCB and excised tissue it was diagnosed as malignant giant cell tumour probably arising from stomach. IHC analysis was done and found to be immune negative for CK20/CEA,DOG1/CD117/ CD34 and immune positive for CK 7 (Table/Fig 7) (a) (Table/Fig 7) (d). Final diagnosis was poorly differentiated carcinoma consistent with primary gastric carcinoma. Similar findings were observed by Albores SJ et al., (24) who described anaplastic spindle and giant cell carcinoma usually contain a fewer number of osteoclastic giant cells and their mononuclear cells show variation in shape and size with marked atypia and numerous mitotic activity. Also, adequacy depends upon size, location, consistency of lesion, histologic type, number of blood vessels and amount of necrosis present within the lesion. Hence, a thorough clinical, radiological correlation is recommended with cytohistological correlation to make a definitive diagnosis in such cases (25). As, the excised histopathological tissue was available in some cases only, statistical analysis may not be actual reflection of exact scenario. Also loss of patients for followup was a limitation faced in our study. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
CONCLUSION | |||||||||||||||||||||||||||||||||||||||||||||||||||||
FNAC and TCB are safe, quick, reliable and easily available OPD based procedures which can be performed in patients of almost any extreme age group and can also be done in patients with deteoriated general conditions with less number of complications for diagnosis of abdominal lesions. In our study, FNAC was preferred over TCB in terms of cost as patient’s affordability was poor for TCB. They can be considered as standard technique of pre-operative evaluation and guides clinicians to plan an appropriate management. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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