Rapid on-site Evaluation of Ultrasound-Guided Fine Needle Aspiration of Hepatic Masses

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1 Med. J. Cairo Univ., Vol. 78, No. 2, September: , Rapid on-site Evaluation of Ultrasound-Guided Fine Needle Aspiration of Hepatic Masses IMAN I. RAMZY, M.D.*; DALIA A. OMRAN, M.D.*; WALEED FOUAD, M.D.; HANY KHATAB, M.D.** and RASHA EL-ETREBY M.Sc.* The Departments of Tropical Medicine* and Pathology**, Faculty of Medicine, Cairo University. Abstract Background: With the advent of frequent ultrasonographic or cross-sectional imaging of the abdomen for various abdominal symptoms, many liver mass lesions are now discovered incidentally during imaging performed for unrelated symptoms. It is important to evaluate these incidentally discovered lesions because a significant proportion of them represent malignant or pre-malignant diseases that require appropriate management. Objective: The purpose of this study was to evaluate the efficacy of using rapid cytological stains in diagnosis of hepatic masses, so we compared the accuracy of Fine needle aspiration cytology of focal hepatic lesions using rapid and routine cytological stains versus routine histopathology. Patients and Methods: Thirty patients with focal hepatic lesions detected by Ultrasound and/or triphasic CT, in non cirrhotic or cirrhotic livers (child A or B patient) were included in the study. In these cases the diagnosis of focal hepatic lesions was uncertain by imaging studies and serum tumor markers, so biopsy together with FNAC were taken. Results: The specificity, sensitivity, positive and negative predictive value of rapid cytology as compared to histopathological examination were %, 82.1%, %, and 28.6% respectively. The diagnostic accuracy was 83.3% and results were statistically significant (p-value : 0.048). value of rapid cytology as compared to routine cytological examination were %, 95.8%, %, and 85.7% respectively. The diagnostic accuracy was 96.6% and results were statistically significant (p-value : 0.001). value of FNAC using routine stain as compared to histopathological examination were %, 85.7%, %, and 33.3% respectively. The diagnostic accuracy was 86.6% and results were statistically significant (p-value : 0.034). value of combined rapid and routine cytology as compared to histopathological examination were %, 85.7%, %, Correspondence to: Dr. Iman I. Ramzy, The Department of Tropical Medicine, Faculty of Medicine, Cairo University. and 33.3% respectively. The diagnostic accuracy was 86.6% and results were statistically significant ( p-value : 0.048). Accurate subtyping of lesions using rapid cytology was possible in (13/28 cases) (46.4%), in which (12/21 lesions) were successfully diagnosed as HCC, while (1/5 lesions) were diagnosed as adenocarcinoma, and (0/2 lesion) was diagnosed as lymphoma with sensitivity of 57.1%, 20% and 0%, respectively. Conclusion: Diagnosis of malignancy can be achieved with on-site cytologic evaluation of hepatic tumors. Specific diagnoses of hepatocellular carcinoma, and adenocarcinoma, can also be made. Key Words: Liver mass lesions Routine cytology Rapid cytology Histopathology Diagnostic accuracy. Introduction ABDOMINAL ultrasonography (US) now is the first line to find Liver tumor [1]. There are two widely used and accepted methods for obtaining diagnostic material, namely fine-needle aspiration cytology (FNAC) and fine needle trucut biopsy (FNTB). FNAC specimens are usually obtained using finer needles, such as those in the range 20- to 25-G, whereas traditionally, core biopsies have used larger 14- to 18-G needles [2]. FNAC has proven to be a safe, fast, minimally invasive, and relatively inexpensive diagnostic technique in the management of liver masses [3]. A successful FNAC requires an adequate specimen, high quality specimen preparation and experience on the part of both the aspirator and the cytopathologist. Several studies have shown that immediate on-site cytopathological evaluation improve the diagnostic sensitivity and accuracy [4,5]. Although many experts advocate immediate cytopathological evaluation of FNAC specimens to maximize the diagnostic yield and accuracy of the procedure, there is scanty data to support this claim [6]. 133

2 134 Rapid on-site Evaluation of Ultrasound-Guided Fine Needle Aspiration In this study, we aimed to determine effectiveness of Fine needle aspiration cytology of focal hepatic lesions using rapid and routine cytological stains versus routine histopathology. Patients and Methods This study was done in the period between 2007 to It comprises 30 patients (22 men, 8 women; mean age was (range years). The diameter of lesions ranged from cm with a mean of 6.09cm. 23 patients were cirrhotic, 17 patients were of Child A and 6 patients were of Child B, while 7 patients were non cirrhotic. The patients were subjected to US guided FNAC and FNTB from one lesion in each patient who signed the informed consent. The indications for FNAC & FNTB were inconclusive triphasic CT or MRI and inconclusive serum AFP level. According to the algorithm for investigation of a nodule found on ultrasound during screening or surveillance published in AASLD guidelines 2005 for management of HCC, it should be >200ng/ml for focal hepatic lesion >2cm. All US guided FNAC and FNTB were performed using Toshiba SSA-340A machine with a 3.5MHz convex linear transducer. Needle aspiration was done under real-time US guidance with gauge needles (GMS-S.N., GHATWARY MED- ICAL) attached to a 20-mL syringe. The needle was advanced into the liver nodular lesion through the abdominal wall and liver parenchyma under the direct guidance of US (Fig. 1). The piston of the syringe was pulled back and maintained in a maximal aspiration position to obtain the maximal negative pressure. The needle was quickly moved back and forth several times (about 3-5 passes) in the lesion under real time US observation [7]. The aspiration material was ejected and smeared onto 5 clean glass slides. It was taken into consideration that the aspirate should be as thin as possible and fixed with ethyl alcohol 95% and left until becoming dry. Three slides were prepared for bed site cytological examination, being stained with rapid stain equivalent to Rapi-Diff II stain, while others were used for routine cytology with papanicolaou stain. FNTB was done at the same setting, The biopsy needles used were automatic true cut needles 14 or 16 gauge (GMS-S.N., GHATWARY MEDI- CAL), advanced under real time sonographic guidance to the lesion, fired during end inspiration or end expiration, and removed [8]. Samples were obtained, preserved in 10% formaldehyde and sent for histopathological examination. Statistical analysis: Data were coded, and entered using the statistical package SPSS version 15. Data were summarized, using mean and standard deviation for quantitative variables and percentage for qualitative variables. Comparisons between groups were done using Chi square test for qualitative variables, and independent sample t-test for normally distributed quantitative variables, while non parametrical Mann-Whitney test was used for quantitative variables not normally distributed. Correlations were done to test for linear relations between quantitative variables. p-value < or equal to was considered as statistically significant. Kappa agreement measure was used to examine the agreement between diagnostic tests. Validity of FNAC with PAP and rapid cytological stains, and histopathology was examined and specificity, sensitivity, Positive and negative predictive values and diagnostic accuracy were calculated for them. Results The histopathological findings of the studied group were presented in Table (1). Fig. (1): US guided aspiration from a focal hepatic lesion. Most of lesions (93.4%) were malignant; these lesions include HCC, adenocarcinoma, and lymphoma. HCC was the most frequent diagnosis occurring in 21 cases (70% of the total number of cases). Grading of HCC was also done with grade II HCC being the most common one (85.7% of HCC cases). Benign lesions were only two (6.6%).

3 Iman I. Ramzy, et al. 135 Table (1): The histopathological findings of the studied group. Histopathology Frequency (no.=30) Percent HCC: Grade I Grade II Grade III Adenocarcinoma Lymphoma FNH* Haemangioma *FNH: Focal nodular hyperplasia. Findings of routine cytological examination, rapid cytological examination and histopathological examination were summarized in Table (2). Table (2): Comparison between (PAP), rapid cytology, and histopathological examination, considering histopathology the standard examination (no. of cases: 30). PAP Rapid cytology Histopathology Subtyping of malignant tumors could be rendered accurately by histopathology in 28/28 cases (%), while by PAP in 17/28 cases (60.71%), and by rapid cytology in 13/28 (46.4%) (Fig. 3) (Table 3). Table (3): Comparison between histopathology, PAP, and rapid cytology in subtyping of malignant focal hepatic lesions (no. of cases = 28). Histopathology PAP Rapid cytology No. % No. % No. % Hepatocellular carcinoma Adenocarcinoma Lymphoma Total No ve for malignancy 24 (80%) 23 (76.7%) 28 (93.3%) ve for malignancy 6 (20%) 7 (23.3%) 2 (6.6%) Specificity % % % Sensitivity 85.7% 82.1% % PPV* % % % NPV** 33.3% 28.6% % Diagnostic accuracy 86.6% 83.3% p-value *PPV: Positive predictive value. **NPV: Negative predictive value. Findings of rapid cytological examination were compared to those of routine cytological examination, taking routine cytology the standard cytological examination, the specificity, sensitivity, positive and negative predictive value of rapid cytology as compared to routine cytological examination were %, 95.8%, %, and 85.7% respectively, and results were statistically significant (p-value : 0.001) as shown in Fig. (2). % Raid cytology Routine cytology (PAP) Specificity Sensitivity PPV NPV Fig. (2): Specificity, sensitivity, PPV, NPV of rapid cytology as compared to routine cytology. Fig. (3): A case of HCC grade II showing few malignant cells (Quick stain, X 400). Discussion The assessment and management of discrete hepatic masses is a common clinical problem [1]. NCB has been the standard procedure for histopathological diagnosis of hepatic lesions for more than 50 years. In recent years, FNAC has emerged as an increasingly popular technique in the diagnosis of hepatic mass lesions. Experts have indicated that FNAC is superior to NCB, in terms of cost, procedure-and associated morbidity [9]. To our knowledge, few studies have been conducted to evaluate on-site cytologic diagnosis of hepatic lesions. This current study examines 30 FNAC cases using rapid and routine stains to determine the accuracy of rapid cytological stains in diagnosis of malignant hepatic lesions taking histopathology as the standard examination.

4 136 Rapid on-site Evaluation of Ultrasound-Guided Fine Needle Aspiration In this study the specificity, sensitivity, positive and negative predictive value of routine FNAC as compared to histopathological examination were %, 85.7%, %, and 33.3% respectively, and results were statistically significant ( p-value : 0.034). These results were acceptable, compared with the reported specificity and positive predictive value of sensitivity of about % [10]. In this study, the specificity, sensitivity, positive and negative predictive value of rapid cytology as compared to histopathological examination were %, 82.1%, %, and 28.6% respectively, and results were statistically significant ( p-value : 0.048). In a series of evaluations of various sites, Silverman et al. [11] found a sensitivity of 96% and a specificity of % for immediate cytologic FNA diagnosis of malignancy in 31 patients with hepatic lesions. Stewart et al. [9] also emphasized the importance of rapid assessment of cytologic preparations. In that series of 141 patients with abdominal lesions (105 with hepatic lesions), a provisional diagnosis was made during the procedure for 103 (73%) FNA specimens (92 malignant cases, 11 reactive or inflammatory lesions). The sensitivity of immediate cytologic evaluation in the diagnosis of malignancy was 71.3%. In that experience, there was no significant difference between provisional and final cytologic diagnoses. Our results show lower sensitivity and negative predictive value than the study [12] evaluating Liustain quick cytodiagnosis of ultrasound-guided fine needle aspiration in diagnosis of liver tumors, where the accuracy of quick cytodiagnosis was 96.9% (220/227), and its sensitivity, specificity and positive and negative predictive values were 97.9%, 95.1%, 97.3% and 96.3%, respectively. In this study, findings of rapid cytological examination were compared to those of routine cytological examination, taking routine cytology the standard cytological examination, the specificity, sensitivity, positive and negative predictive value of rapid cytology as compared to routine cytological examination were %, 95.8%, %, and 85.7% respectively, where there was one case negative for malignant cells by rapid cytology and revealed malignant (HCC grade II) by both routine cytology and histopathology, in this case the liver was cirrhotic and enlarged by US, the focal lesion was detected in the right lobe, measuring 10cm, with heterogenous echopattern. This matches with Ceyhan et al. [13] in which the specificity of on site cytopathological evaluation as compared to conventional smear in diagnosis of liver masses was %, and sensitivity was 92.8%. The current study showed specificity, sensitivity, positive and negative predictive value of combined routine and rapid cytology as compared to histopathological examination were %, 85.7%, %, and 33.3% respectively. In this study, findings of histopathological examination included 28 cases (93.4%) with malignant focal hepatic lesions including HCC, adenocarcinoma, and lymphoma, and only 2 cases (6.6%) with benign focal lesions. This matches with Schwartz and Kruskal [14], who stated that malignant tumors of the liver are more common than benign lesions. Accurate subtyping of malignant lesions using routine cytology was possible in (17/28 cases) (60.7%), while, it was possible in only 13/21 lesions (46.4%) when using rapid cytology. These results are lower than those detected by another study [13] which used the same stain we used, it found that, a specific subtype diagnosis of malignant tumors could be rendered accurately on the basis of on-site cytopathological evaluation in 98/138 (71%), and conventional smear in 104/138 (75.4%). The accuracy of quick cytodiagnosis using Liustain in 227 cases of liver tumor was 96.9% (220/227), and its sensitivity, specificity, positive and negative predictive values were 97.9%, 95.1%, 97.3% and 96.3%, respectively [12]. In another study [15] using Riu s stain, the results were 93.3% sensitivity and % specificity. In this study, HCC was the most frequent diagnosis occurring in 21 of 30 patients (70% of the total number of cases). This matches with a recent Egyptian study [16], who stated that, incidence of HCC in Egypt is currently increasing, which may be the result of a shift in the relative importance of HBV and HCV as primary risk factors. In conclusion, histopathology remains the gold standard for diagnosis of focal hepatic lesions with an accuracy of %. Fine needle aspiration cytology (FNAC) with routine cytological stains is a reasonable diagnostic tool for focal hepatic lesions, with diagnostic accuracy of (86.6%). Quick cytological examination is also considered a reasonable diagnostic tool for focal hepatic lesions, with

5 Iman I. Ramzy, et al. 137 diagnostic accuracy nearly equal to that of routine cytology (83.3%). In this study; the non conclusive smears can be explained by scanty number of cells in the smear, techniqual defect in staining thick smear and poor air fixation. All these factors may lead to inaccurate diagnosis and subtyping of malignancy. Up to 32% of FNACs in various organs may be non-diagnostic because of scant cellularity or poor preservation [17]. The diagnostic accuracy of FNAC can be significantly enhanced by the active on-site evaluation of the smear [3] because this provides information regarding specimen adequacy, whether additional passes are required. This helps in rendering a preliminary diagnosis and/or offering a differential diagnosis [18]. We recommend further studies, including larger number of patients, use of other types of rapid stains (e.g. Liu stain), to ascertain whether FNAC using rapid stain is a useful diagnostic tool for focal hepatic lesions and to better evaluate its significance in the diagnosis of HCC. Training programs to provide better experience in rapid cytodiagnosis are needed to reach higher diagnostic accuracy as the operation is highly operator dependant. References 1- HERTZ G., REDDY V.B., GREEN L., SPITZ D., MAS- SARANI-WAFAI R., SELVAGGI S.M., KLUSKENS L. and GATTUSO P.: Fine-needle aspiration biopsy of the liver: A multicenter study of 602 radiologically guided FNA. Diagn. Cytopathol., 23: , O CONNELL A.M., KEELING F., GIVEN M., LOGAN M. and LEE M.J.: Fine-needle trucut biopsy versus fineneedle aspiration cytology with ultrasound guidance in the abdomen. Journal of Medical Imaging and Radiation. Oncology, 52: , TSAI Y-Y., LU S-N., CHANGCHIEN C-S., et al.: Combined cytologic and histologic diagnosis of liver tumours via one-shot aspiration. Hepatogastroenterology, 49: 644, BALOCH Z.W., TAM D., LANGER J., MANDEL S., LIVOLSI L.A. and GUPTA P.K.: Ultrasound-guided fineneedle aspiration biopsy of the thyroid: Role of on-site assessment and multiple cytologic preparations. Diagn. Cytopathol., 23: 425-9, NASUTI J.F., GUPTA P.F. and BALOCH Z.W.: Diagnostic value and cost-effectiveness of on-site evaluation of fine- needle aspiration specimens: Review of 5688 cases. Diagn. Cytopathol., 27: 1-4, LAYFIELD L.J., BENTZ J.S. and GOPEZ E.V.: Immediate on-site interpretation of fine needle aspiration smears. A cost and compensation analysis. Cancer, 93: , KEDAR R.P., PATEL V.H., MERCHANT S.A., et al.: Ultrasound guided aspiration cytology-a valuable diagnostic aid. J. Postgrad Med., 37: 84-87, GUILHERME J., SCHWARTZ J., CHAIT P., et al.: Sonographically Guided Percutaneous Liver Biopsy in Infants: A Retrospective Review. Department of Diagnostic Imaging, Image Guided Therapy Centre, The Hospital for Sick Children AJR, 187: W644-W649, STEWART C.J.R., COLDEWEY J. and STEWART I. S.: Comparison of fine needle aspiration cytology and needle core biopsy in the diagnosis of radiologically detected abdominal lesions. J. Clin. Pathol., 55: 93-97, JAIN: Diagnosis of hepatocellular carcinoma. Fine needle aspiration cytology or needle core biopsy. J. Clin. Gastroenterol., 35: , SILVERMAN J.F., FINLEY J.L., O'BRIEN K.F., et al.: Diagnostic accuracy and role of immediate interpretation of fine needle aspiration biopsy specimens from various sites. Acta. Cytol., 33: , CHANGCHIEN C.H., WANG J., SHENG-NAN LU, et al.: Liu-stain quick cytodiagnosis of ultrasound-guided fine needle aspiration in diagnosis of liver tumors. World J. Gastroenterol., 21: 13 (3): , CEYHAN K., KUPANA S., BEKTAS M., et al.: The diagnostic value of on-site cytopathological evaluation and cell block preparation in fine-needle aspiration cytology of liver masses. Cytopathology, 17: , SCHWARTZ J.M. and KRUSKAL J.B.: Approach to the patient with a focal liver lesion. Up to date website, version 16.2, TSOU M.H., LIN Y.M., LIN K.J., KO J.S. and WU M.L.: Fine needle aspiration cytodiagnosis of liver tumors. Results obtained with Riu's stain. Acta. Cytol., 42: , EL Zayadi A.R., Badran H.M., Barakat E.M., et al.: Hepatocellular carcinoma in Egypt: A single centre study over a decade. World J. Gastroenterol., 11: , NASUTI J.F., GUPTA P.F. and BALOCH Z.W.: Diagnostic value and cost-effectiveness of on-site evaluation of fineneedle aspiration specimens: Review of 5688 cases. Diagn. Cytopathol., 27: 1-4, LOGRONO R. and WAXMAN I.: Interactive role of cytopathologist in EUS-guided fine-needle aspiration: An efficient approach. Gastrointest Endosc., 54: , 2001.

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