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Year : 2012  |  Volume : 8  |  Issue : 4  |  Page : 626-629

Fine needle aspiration cytology of oral and oropharyngeal lesions with an emphasis on the diagnostic utility and pitfalls

1 Department of Cytology and Gynaecologic Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Otolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication29-Jan-2013

Correspondence Address:
Nalini Gupta
Department of Cytology and Gynecologic Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.106581

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 > Abstract 

Aim: This study was undertaken to evaluate the diagnostic utility and pitfalls of fine needle aspiration cytology (FNAC) in oral and oropharyngeal lesions.
Materials and Methods: This was a retrospective audit of oral and oropharyngeal lesions diagnosed with FNAC over a period of six years (2005-2010).
Results: Oral/oropharyngeal lesions [n=157] comprised 0.35% of the total FNAC load. The age ranged 1-80 years with the male: female ratio being 1.4:1. Aspirates were inadequate in 7% cases. Histopathology was available in 73/157 (46.5%) cases. Palate was the most common site of involvement [n=66] followed by tongue [n=35], buccal mucosa [n=18], floor of the mouth [n=17], tonsil [n=10], alveolus [n=5], retromolar trigone [n=3], and posterior pharyngeal wall [n=3]. Cytodiagnoses were categorized into infective/inflammatory lesions and benign cysts, and benign and malignant tumours. Uncommon lesions included ectopic lingual thyroid and adult rhabdomyoma of tongue, and solitary fibrous tumor (SFT), and leiomyosarcoma in buccal mucosa. A single false-positive case was dense inflammation with squamous cells misinterpreted as squamous cell carcinoma (SCC) on cytology. There were eight false-negative cases mainly due to sampling error. One false-negative case due to interpretation error was in a salivary gland tumor. The sensitivity of FNAC in diagnosing oral/oropharyngeal lesions was 71.4%; specificity was 97.8% with diagnostic accuracy of 87.7%.
Conclusions: Salivary gland tumors and squamous cell carcinoma (SCC) are the most common lesions seen in the oral cavity. FNAC proves to be highly effective in diagnosing the spectrum of different lesions in this region. Sampling error is the main cause of false-negative cases in this region.

Keywords: Fine needle aspiration cytology, oral cavity, oropharyngeal lesions

How to cite this article:
Gupta N, Banik T, Rajwanshi A, Radotra BD, Panda N, Dey P, Srinivasan R, Nijhawan R. Fine needle aspiration cytology of oral and oropharyngeal lesions with an emphasis on the diagnostic utility and pitfalls. J Can Res Ther 2012;8:626-9

How to cite this URL:
Gupta N, Banik T, Rajwanshi A, Radotra BD, Panda N, Dey P, Srinivasan R, Nijhawan R. Fine needle aspiration cytology of oral and oropharyngeal lesions with an emphasis on the diagnostic utility and pitfalls. J Can Res Ther [serial online] 2012 [cited 2022 Jun 30];8:626-9. Available from: https://www.cancerjournal.net/text.asp?2012/8/4/626/106581

 > Introduction Top

Fine needle aspiration cytology (FNAC) is an important diagnostic tool for the lesions of the head and neck region especially for swellings in the thyroid gland, salivary gland, and lymph nodes. It helps in avoiding surgical procedures in conditions like non-neoplastic or inflammatory lesions and metastatic tumors. [1] However, its use is limited in the oral and oropharyngeal lesions. Preoperative aspiration cytology can be practiced on almost any anatomic region evident visually, for example, skin or subcutis of the face, pinna, external nose or the reachable nasal cavity, floor of mouth, tongue, palate, tonsils, and the posterior pharyngeal wall. [2],[3],[4] There have been a few previous studies evaluating the role of FNAC in the intraoral lesions with variable outcome. The present study was undertaken to assess the accuracy of FNAC in the intraoral lesions, as well as to identify the common causes of misinterpretation and fallacies of the technique.

 > Subjects and Methods Top

An audit of all intraoral and oropharyngeal lesions diagnosed by FNAC was performed over a period of six years (2005-2010). The cases were retrieved from the records of the department of cytology and gynecological pathology in a tertiary care centre in North India. Aspirations were performed by consultant cytopathologists or trainee residents in the department. The aspiration samples were taken in supine or in sitting position with head support. FNAC was performed without radiological guidance using a 22-23 G needle and 20 cc disposable syringe, fitted on Cameco's handle. Air-dried smears were stained with May-Grünwald Geimsa (MGG) stain and smears fixed in 95% ethanol were stained with hematoxylin and eosin (H& E)/ Papanicolaou (PAP) stains. Special stains like Ziehl-Neelsen and periodic acid-Schiff (PAS) were performed in relevant cases. On-site assessment of the aspirates was not done and ancillary techniques were not used for cytological diagnosis. Procedure-related minor complications in the form of prolonged bleeding were noted in a few of the patients; however, no major complications were seen. Cytological diagnosis was correlated with histological diagnosis, wherever available.

 > Results Top

Out of a total of 45,196 FNACs performed over a period of six years, 157 (0.35%) cases of intraoral/oropharyngeal lesions could be retrieved. Male: female ratio was 1.41: 1. The youngest patient was a one-year-old female child with an inflammatory swelling in the buccal mucosa and the oldest patient was an 80-year-old male with a non-Hodgkin s lymphoma (NHL) of the tonsil. There were 11/157 (7%) cases with inadequate aspirates for a definitive opinion. Histopathology was available in 73/157 (46.5%) cases. The most common site was the palate comprising 66/157 cases (42%), followed by tongue 35 cases (22.3%), buccal mucosa 18 cases (11.5%), the floor of the mouth 17 cases (10.8%), tonsil 10 cases (6.4%), alveolus 5 cases (3.2%), retromolar trigone three cases (1.9%), and posterior pharyngeal wall three cases (1.9%).

Cytological diagnoses were categorized into infective/ inflammatory lesions and benign cysts, benign neoplasms, malignant neoplasms, and inadequate for opinion.

Lesions of the palate

Palatal lesions comprised infective/ inflammatory lesions and benign cysts (24 cases), benign salivary gland tumors (20 cases), malignant tumors (18 cases), and three cases had inadequate aspirates. Histopathology was available in 32/66 cases (48.5%). One false-negative case was of polymorphous low-grade adenocarcinoma (PLGA) reported as pleomorphic adenoma (PA) on cytology [Table 1]; [Figure 1]a and b. One case of adenoid cystic carcinoma (ACC) was reported as PLGA on cytology [Figure 1]c and d. Two of three cases with inadequate aspirates had follow-up excision and were confirmed to be ACC. One case was missed on aspiration due to the lesion being located in the distal portion of the soft palate [Figure 1]e and f and the other had cystic areas [Table 1]. The malignant palatal tumors included mucoepidermoid carcinoma (4), adenocarcinoma (3), ACC (2), squamous cell carcinoma (SCC) (1), PLGA (1), nasopharyngeal carcinoma (NPC) (1) [Figure 2]a, poorly differentiated carcinoma (1), NHL (3) [Figure 2]b, and plasmacytoma (2). A case of Langerhans cell histiocytosis (LCH) was diagnosed from palatal swelling on FNAC in a one-year-old female child [Figure 2]c.
Figure 1: Paired cytology-histopathology of intraoral (palatal) lesions; (a) polymorphous low-grade adenocarcinoma (PLGA) reported as pleomorphic adenoma on fi ne needle aspiration cytology (FNAC) (MGG × 40X); (b) the corresponding histopathology of PLGA (H&E × 40X); (c) adenoid cystic carcinoma (ACC) reported as PLGA on FNAC (MGG × 20X); (d) the corresponding histopathology of ACC (H&E × 40X); (e) ACC missed on FNAC due to sampling error (MGG × 40X); 1(f) the corresponding histopathology of ACC (H&E × 40X)

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Figure 2: A panel of microphotographs of intraoral lesions; (a) nasopharyngeal carcinoma (MGG × 40X); (b) Non-Hodgkin's lymphoma (MGG × 40X); (c) Langerhans cell histiocytosis (MGG × 40X); (d) epithelioid cell granuloma in leprosy (H&E × 40X); (e) adult rhabdomyoma (H&E × 20X); (f) leiomyosarcoma of the buccal mucosa (MGG × 20X)

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Table 1: Summary of discrepant cases

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Lesions of tongue

Histopathology was available in 11/35 cases. Inflammatory lesions of the tongue [n=11] included cysticercosis (3 cases) and leprosy (1 case) [Figure 2]d. Another interesting case was a 15-year-old girl with ectopic lingual thyroid. One false-negative case was ACC reported as inflammation on cytology [Table 1], due to inadequate sampling (ulcerated lesion associated with inflammation). Benign neoplasms (7 cases) included neurofibroma, schwannoma, and adult rhabdomyoma [Figure 2]e. Two-third of the cases with inadequate aspirates had follow-up biopsy and were confirmed to be SCC and hemangioma.

Lesions of buccal mucosa

Histopathology was available in 10/18 cases. There were inflammatory lesions/benign cysts (10 cases). A case of sol = itary fibrous tumor (SFT) was reported as PA on cytology. Collagenous eosinophilic matrix material and bland oval to spindle cells of SFT were misinterpreted as chondromyxoid material and myoepithelial cells of PA, respectively. Malignant tumors included malignant melanoma and leiomyosarcoma [Figure 2]f. Three cases had inadequate aspirates.

Lesions in the floor of the mouth

Histopathology was available in 8/17 cases. One false-positive case was inflammation with squamous cells misinterpreted as SCC on cytology [Table 1]. This emphasises that a diagnosis of SCC in the presence of inflammation should be offered with extreme caution. Another false-negative case was an inflammatory variant of malignant fibrous histiocytoma (pleomorphic sarcoma) reported as inflammatory granulation tissue on cytology [Table 1]. This was due to abundant inflammation and scattered atypical spindle cells interpreted as fibroblasts with reactive changes. In addition, inflammatory/ benign cystic lesions (9 cases), a case each of mucoepidermoid carcinoma, SCC, and ACC were also seen.

Lesions of the tonsil

The tonsillar lesions included inflammatory lesions (3 cases) and malignant tumors including SCC, poorly differentiated carcinoma, and lymphoblastic lymphoma, and 7/10 cases had follow-up histopathology. Two false-negative cases included SCC and diffuse large B cell lymphoma (DLBCL) reported as negative on cytology [Table 1]. This was due to difficulty in sampling, highlighting the fact that deeply situated intraoral lesions may be very difficult to approach, and improper sampling leads to false-negative results.

Lesions of the alveolus/retromolar trigone/posterior pharyngeal wall

These included inflammatory/benign cystic lesions (6 cases), benign tumors (1 case), and malignant tumors including SCC (2 cases), adenocarcinoma (1 case), and metastatic carcinoma (1 case). Of these, 5/11 cases had follow-up histopathology.

There were a total of eight false-negative and a single false-positive case in the present series. Six of these eight cases were due to sampling error, highlighting the fact that intraoral sampling on FNAC poses problems and can lead to false-negative results. The sensitivity of FNAC in diagnosing oral/ oropharyngeal lesions in our series was 71.4%, and specificity 97.8% with a diagnostic accuracy of 87.7%.

 > Discussion Top

A variety of non-neoplastic and neoplastic lesions can involve the oral and oropharyngeal cavity and these are common lesions encountered in clinical practice. Although FNAC is used increasingly in the evaluation of lesions of the neck and head region, [1],[2],[3] experience remains limited in the aspiration of intraoral masses. [4],[5],[6],[7],[8] FNAC can provide helpful information about these lesions and may help in avoiding hasty or unnecessary surgical biopsy. FNAC could avoid excision or surgery in over 50% cases in the present study. FNAC in intraoral lesions is less sensitive and specific than that of superficial lesions. [9] This may be due to the small size and deep location of the lesions as well as by the limited space for maneuvering the needle, with difficulty in fixing the intraoral lesion for adequate aspiration rather than to interpretation or inherent limitations of the technique itself. [10] There are previous studies in the literature exploring the potential of FNAC in the diagnoses of oral and oropharyngeal lesions. [9],[10],[11],[12],[13],[14] The present study was an attempt to determine the efficacy and reliability of FNAC in the diagnosis of these lesions.

Minor salivary gland tumors in the oral cavity account for about 15% of all salivary gland tumors. [15],[16],[17] The majority of palatal neoplasms in the present series were minor salivary gland tumors, PAs, and ACCs being the common ones, which corroborates with previous studies. [15],[18] One case of PLGA was misdiagnosed as PA on cytology. PLGA is seen almost exclusively in the minor salivary glands. [19] Gibbons et al. [20] described this tumor as having architectural diversity but cytological uniformity. Two cases of PLGA were misdiagnosed as ACC and PA in their study initially. It is important to differentiate PLGA from more aggressive tumors like ACC. Differentiation of PA from ACC may pose problems at times in cytology.

SCC is the most common malignancy followed by salivary gland tumors and NHL represents the third common malignancy of the oral cavity. [21],[22] Oral manifestations are present in only 3-5% of the cases of NHL. [23] There were three cases of palatal NHL including a mucosa-associated lymphoid tissue (MALT) lymphoma in the present study. Two false-negative cases with sampling error in the present study highlight the difficulties in approaching the posterior soft palate lesions for FNAC.

Three cases of cysticercosis in the tongue were seen in the present study. Oral cysticercosis is rare, [24],[25],[26] with the most favorable sites being the tongue, lips, and buccal mucosa. This needs to be distinguished from mucocele, benign mesenchymal tumors like, lipoma, fibroma, hemangioma, granular cell tumor, or minor salivary gland tumors. [27] The tongue is a common site for granular cell tumor. [28] Rhabdomyoma occurs almost exclusively in the head and neck region. [29] Apart from salivary gland tumors and SCC, a few uncommon lesions were noted in the present series. These included ectopic lingual thyroid, adult rhabdomyoma and schwannoma in tongue, SFT, malignant melanoma, and LMS in buccal mucosa and pleomorphic sarcoma in the floor of the mouth.

Diagnostic accuracy in the present series was 87.7% with eight false-negative and one false-positive case. False-negative cases were mainly sampling errors with a single case of interpretation error in salivary gland tumor. Gunhan et al. [13] experienced high accuracy in diagnosing oral cavity and jaw bone lesions by FNAC. Scher et al. [8] had no false-positive diagnosis in malignant lesions. FNAC was unsatisfactory in 16% cases [8] as compared to 7% in the present series. They emphasized the need for repeating the FNAC or recommending biopsies in negative and unsatisfactory FNACs. [8] The diagnostic accuracy of FNAC in a study done by Singh D et al. (2008) [12] was 93.75% with a sensitivity of 97.87% and specificity of 88.35%. Shah et al. (1999) [11] had a sensitivity of 93.9% and specificity of 85.7% in their study. The sensitivity and specificity of different studies vary because of selection bias of the cases, whereas we have included all intraoral FNAC cases, and therefore the main problem with our cases was sampling error.

 > Conclusion Top

The present study illustrates the role of FNAC in the diagnosis of a variety of benign as well as malignant lesions of the oral cavity and oropharynx. The deeply situated oral/oropharyngeal lesions are sometimes difficult to aspirate. FNAC saved over 50% of patients from surgery/excision biopsy in the present series. FNAC is highly accurate for the malignant lesions which can be of great help in early planning of the definitive course of management.

 > References Top

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