100 cases of Soft tissue lesions were studied by Fine Needle Cytology (FNAC) and subsequently correlated by Histopathological examination and Immunohistochemical staining. The study revealed that 55% of the cases were benign soft tissue tumour masses, 34% were benign soft tissue tumour like masses and 11% were malignant soft tissue lesions. The accuracy determined by the histopathological examination for benign soft tissue masses was 94.38% and in 100%malignant soft tissue lesions. The discordance of 5.62% in the benign soft tissue masses was due to aspiration of inadequate material and loss of architectural pattern. Hence, excision with histopathological examination is mandatory in such cases

Baba Khalil

Bhat ML

Rasool Zubaida

Reshi Ruby

Rumana M

Samoon Nuzhat

Shafi M

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GLOBAL JOURNAL OF MEDICINE AND PUBLIC HEALTH        1  www.gjmedph.com Vol. 2, No. 2  2013                                                                                                                                                                       ISSN#- 2277-9604  Utility of Fine Needle Aspiration Cytology in Diagnosis of Soft Tissue Lesions with Histopathological Correlation  Rasool Zubaida*, Bhat ML+, Samoon Nuzhat**, Baba Khalil++, Rumana M***, Reshi Ruby+, Shafi M+++  ABSTRACT 100 cases of Soft tissue lesions were studied by Fine Needle Cytology (FNAC) and  subsequently  correlated  by  Histopathological  examination  and Immunohistochemical staining. The study revealed that 55% of the cases were benign soft tissue tumour masses, 34% were benign soft tissue tumour like masses and 11% were malignant soft tissue lesions. The accuracy determined by  the  histopathological  examination  for  benign  soft  tissue  masses  was 94.38% and in 100%malignant soft tissue lesions. The discordance of 5.62% in the benign soft tissue masses was due to aspiration of inadequate material and  loss  of  architectural  pattern.  Hence,  excision  with  histopathological examination is mandatory in such cases.   Keywords: Soft tissue tumours, FNAC, Histopathological examination  INTRODUCTION Soft tissue is represented by the voluntary muscles, fat and fibrous tissues along with the vessels serving these tissues. It also includes the Peripheral Nervous Systems  because  tumours  arising  from  Nerves present as soft tissues masses1. The true frequency of soft tissue lesions is difficult to estimate, as most of  non-neoplastic  and  benign  lesions  are  not removed.  A  conservative  estimate  is  that  benign tumours  outnumber  their  malignant  counterparts by ratio of about 100:1 in hospital population and their  annual  incidence  is  approximately  300  per 1,00,000  population 2,  8,  9,  10.Soft  tissue  sarcomas can  occur  anywhere  in  the  body.  Approximately, 40%  of  soft  tissue  sarcomas  occur  in  lower extremity,  30%  in  trunk/retro  peritoneum,  20%  in upper  extremity  and  10%  in  head  and  neck.  Soft tissue sarcomas occur more commonly in males in comparison  to  female  (1.4:1)  but  sex  and  age incidences vary among different histological types, approximately  40%  develop  in  middle  aged  and elderly. There is no proven racial variation even   though  the  annual age  adjusted, incidence  rates  have been  reported  to  be higher for blacks than Whites in United States3  The role of FNAC in diagnosis   of soft tissue lesions is one  of  the  difficult  areas in  surgical  pathology. The  relative  absence  of  recognizable  tissue architectural  pattern  in  cytological  preparation makes  diagnosis  by  FNAC  even  more  difficult. However, it provides predictive  diagnosis  of benign  or malignant  neoplasm, or  even  in  some  case  specific  tumour  type. Also, if the lesion is benign and  the  patient  is  elderly,  risk  of  surgery  can  be avoided.  In  case  of  recurrences  of  malignancy  a cytological diagnosis can help in the administration of palliative treatment4.  GJMEDPH 2013; Vol. 2, issue 2 *Assistant Professor, **Research Scholar ***Associate Professor ++Professor, Department of Pathology Sher-i-Kashmir Institute of Medical Sciences Soura-190011. J&K, India + Professor, Department of Pathology, Government Medical College, Srinagar-190001. J&K. India +++ Professor, Department of Surgery, Government Medical College, Srinagar-190001, J&K, India  *Corresponding Author Zubaida Rasool Department of Pathology, SKIMS,  Soura, Srinagar, India  Conflict of Interest—none   Funding—none         2  www.gjmedph.com Vol. 2, No. 2  2013                                                                                                                                                                       ISSN#- 2277-9604  Articles This  study  has  been  undertaken  to  increase  our understanding  about  the  soft  tissue  tumours,  the accuracy of FNAC in diagnosing soft tissue tumours, its cyto-architectural features and to compare these findings with histopathological diagnosis11.  MATERIALS AND METHODS  The FNAC was conducted on 100 patients of which 59  were  males  and  41  were  females  in  the Department  of  Pathology,  Government  Medical College, and Srinagar on patients having soft tissue lesions  anywhere  in  the  body.  Special  stains, Histopathological  examination, Immunohistochemistry  were  employed  wherever necessary,  to  arrive  at  the  final  diagnosis.  Aspiration was done with Franzen’s handle, in which 20  ml  disposable  syringe  was  fixed  with  20-25 gaugeneedles.  Fixation  of  smears  was  done depending  upon  the  type  of  stain  needed.  For Haematoxylin  and  Eosin  and  Papnicolaou  stains, smears were wet fixed. Smears, which were to be stained  by  May-Grunwald  Geimsa,  were  air-dried. Fixative  used  was  equal  parts  of  Ether  and  95% Ethanol, 100% methanol or 85% Isopropyl alcohol. Fixation time was 10-15 minutes.       RESULTS A total of 100 cases were included in the study on patients who presented with soft tissue masses on different  sites  of  the  body,  superficial  as  well  as deep.  These  hundred  cases  were  evaluated cytologically for the cytomorphological nature of      the lesion and comprised of benign and malignant lesions  including  metastatic  deposits.  Out  of  100 soft  tissue  masses,  89  cases  were  benign  which comprised  of  55  soft  tissue  tumour  masses,  34 tumour like masses and 11 were malignant lesions. These Soft tissue masses appeared in Head & Neck (43%),  Lower  limb  (16%),  upper  limb  (15%), Abdomen  and  Thorax  (14  and  12%)  respectively (Table 1).   Table 1 Site-wise Distribution of Benign and Malignant Tumors Tumours / Site Head & Neck Upper Limb Thorax Abdomen Lower Limbs Total Cases Benign Soft Tissue Tumour Masses  17  10  8  10  10  55 Benign Soft Tissue Tumour Like Masses  19  5  2  2  6  34 Malignant Masses  7  -  2  2  -  11 Total Cases  43  15  12  14  16  100     Among 55 cases of benign soft tissue masses 56% were lipomas, which were present mostly in head and neck region (Table 2).  Out  of  34  benign  soft  tissue  tumour  like  masses, 76% were non neoplastic and 24% were Neoplastic masses.  In  non-neoplastic  masses,  47%  were Keratinous cysts and mostly occurred in head and neck  region  whereas  in  neoplastic  masses,  out  of 24% cases, adnexal tumour (11.5%) represented in head and neck region only (Table 3).        3  www.gjmedph.com Vol. 2, No. 2  2013                                                                                                                                                                       ISSN#- 2277-9604  Articles   Table 2 Site-wise Distribution of Benign Soft Tissue Tumour Masses Tumour Masses/ Site Head & Neck Upper Limb Thorax Abdomen Lower Limbs Total Cases %ages Lipoma  12  3  7  9  2  33  60 Schwannoma  1  4  1  1  2  9  16 Haemangioma  2  2  -  -  1  5  9 Neurofibroma  1  1  -  -  -  2  4 Pseudosarcomatous Proliferations -  -  -  -  2  2  4 Angio-fibromyxoma  -  -  -  -  1  1  2 Cellular Fibroma  -  -  -  -  1  1  2 Giant Cell Tumour of T.S.  -  -  -  -  1  1  2 FibromatosisColli  1  -  -  -  -  1  2 Total Cases  17 (31%) 10 (18%) 8  (15%) 10 (18%) 10 (18%) 55     Table 3 Site-wise Distribution of Benign Soft Tissue Tumour-like Masses Tumours / Masses Site  Head & Neck Upper   Limb Thorax Abdomen Lower Limb Total Cases %ages Keratinous cyst Non-neoplastic 8  2  2  2  2  16  47 Thyroglossal cyst  4  -  -  -  -  4  11.5 Ganglion cyst  -  3  -  -  -  3  9 Calcinosis  -  -  -  -  2  2  6 Chronic Sialadentis  1  -  -  -  -  1  3 Adnexal Tumour Neoplstic 4  -  -  -  -  4  11.5 Pleomorphic Adenoma  2  -  -  -  -  2  6 Hamartoma  -  -  -  -  2  2  6 Total Cases  7(63%)  0  2 (18%)  2(18%)  0  34         4  www.gjmedph.com Vol. 2, No. 2  2013                                                                                                                                                                       ISSN#- 2277-9604  Articles  Among  11  malignant  lesions,  45%  cases  were sarcomas present at various sites of the body and 55% were metastatic deposits of which 27% were present  in  lymph  nodes  which  include  Duct  cell carcinoma,  medullary  carcinoma  and  mucin secreting carcinoma (9% each); and 27% occurred in subcutaneous tissue of various sites which included malignant  melanoma,  basal  cell  carcinoma  and squamous cell carcinoma (Table 4).   Table 4 Site-wise Distribution of Malignant Tumours Tumours / Masses Site  Head & Neck Upper Limb Thorax Abdomen Lower Limb Total Cases %ages EmbryonalRhabdomyo-sarcoma Sarcoma 1          1  9 Alveolar Rhabdomyo-sarcoma        1    1  9 Spindle cell sarcoma (Int Grade)      1      1  9 Clear Cell Sarcoma   1          1  9 Liposarcoma        1    1  9 Malignant Melanoma Metastatic Deposits 1          1  9 Basal cell carcinoma   1          1  9 Squamous Cell Carcinoma      1      1  9 Mucous Secreting Carcinoma  1          1  9 Medullary Carcinoma of Thyroid  1          1  9 Duct cell carcinoma  1          1  9 Total Cases   7 (63%)  0  2 (18%)  2 (18%)  0  11    DISCUSSION This study was conducted on one hundred patients attending  SMHS  and  associated  hospitals  of Government Medical College, Srinagar.  The study was clinically evaluated and divided into two groups, benign and malignant. Among benign lesions,  89  cases  were  benign  soft  tissue  masses, which were further categorized as benign soft tissue tumours masses and benign soft tissue tumour like masses (non-neoplastic and neoplastic). Benign soft tissue  tumour  masses  comprised  of  55  cases, whereas  benign  soft  tissue  tumour  like  masses comprised of 34 cases.   The comparative analysis of the benign soft tissue tumour masses as shown in (Table 5) revealed that out of 33 lipomas, (60%) cases of benign soft tissue tumour  masses,  31  were  histologically  correlated and  2  cases  were  found  to  be  fibrolipoma  on histological  diagnosis.  The  probable  cause  for discordance for these two cases was due to lack of spindle cells in the smears which can occur because of insufficient and inappropriate material aspirated during the FNAC. The commonest site involved was head  and  neck  region  in  males  between  the  age group  of  41-50  years  and  the  diagnostic  accuracy was 94%.  Neurilemoma  also  known  as  Schwannoma  (16%) was the second common benign soft tissue tumour mass  in  this  study  and  100%  correlation  was observed  between  FNA  and  histopathology,  thus acquiring  100%  diagnostic  accuracy.  All  the  cases were mostly found in the upper extremity followed by  lower  extremity,  predominantly  in  males between  the  age  group  of  51-60  years. Haemangiomas (9%) were mostly found in males in the age group of 31-40 and the commonest site was head  and  neck  region.  Out  of  5  cases  of haemangioma, 4 cases were diagnosed on FNA and subsequently  confirmed  on  Histopathological examination  and  one  false  negative  diagnosis  of benign  adnexal  lesion  was  diagnosed  as      5  www.gjmedph.com Vol. 2, No. 2  2013                                                                                                                                                                       ISSN#- 2277-9604  Articles haemangioma  on  histopathological  examination. The  disparity  in  diagnosis  was  due  to  hyper cellularity  of  smears  during  aspiration,  which yielded surrounding benign epithelial cells causing the  diagnostic  dilemma.  Thus  the  diagnostic accuracy achieved was 80%.   Table 5 Comparative Analysis of FNAC and Histopathological Diagnosis Concordance between FNAC and HPE  Discordance between FNAC and HPE Type  Diagnosis  No. of Cases FNAC Diagnosis  No. of Cases H/P Diagnosis  No. of Cases Benign Soft Tissue Tumour Masses Lipoma  31  Lipoma  2  Fibrolipoma  2 Neurolimoma  9  Benign Adnexal lesions 1  Hemangioma  1 Hemangioma  4  Benign Mesenchymal lesions 1  Cellular fibroma 1 Neurofibroma  2         Pseudosarcomatous lesions   2         Angiofibromyxoma  1         Giant Cell tumour of tendon sheath 1         Fibromatosiscolli  1         Benign Soft Tissue tumour like masses  (Non-neoplastic)  (Neoplastic) Keratinous Cysts  16         Thyroglossal Cysts  4         Ganglion Cysts  3         Calcinosis  1  Lipoma  1  Calcinosis Cutis 1 Chronic Sialadenitis  1         Adnexal Tumours(pilomatricoma) 4                    Pleomorphic adenoma  2           Hamartoma  1         Malignant Lesions              EmbryonalRhabdomyosarcoma  1           Alveolar Rhabdomyosarcoma  1         (Sarcomas)  Intermediate grade spindle cell sarcoma 1           Liposarcoma  1           Clear cell sarcoma  1           Malignant Melanoma  1           Squamous Cell Carcinoma  1           Basal cell carcinoma  1         (Metastatic Deposits Lymphnode) Duct cell carcinoma  1         Medullary carcinoma thyroid  1         Mucous secreting adenosarcoma 1          One  case,  which  was  diagnosed  as  benign mesenchymal lesion on FNAC, proved to be cellular fibroma  on  histopathology.  This  false  negative diagnosis  was  due  to  loss  of  proper  architectural pattern  of  the  lesion,  which  is  essential  in diagnosing  the  cellular  fibroma.  Neurofibroma,      6  www.gjmedph.com Vol. 2, No. 2  2013                                                                                                                                                                       ISSN#- 2277-9604  Articles Pseudosarcomatous proliferations (Nodular Fasciitis and  Proliferative  Myositis),  Angio-fibromyxoma, Giant  cell  tumour  of  Tendon  sheaths  and fibromatosis colli were histologically correlated and the diagnostic accuracy achieved was 100%.   The  comparative  study  revealed  that  out  of  34 benign  soft  tissue  tumour  like  masses,  33  cases (97%) were diagnosed on FNAC and subsequently confirmed on Histopathology; only one case (3%), which was diagnosed as Lipoma on FNAC proved to be Calcinosis cutis. The discordance in the diagnosis occurred due to aspiration of mature adipose tissue only and no calcific material was aspirated.(Table 5)  Out of 100 cases, eleven (11%) malignant soft tissue masses  were  diagnosed,  which  were  categorized into sarcomas (5 cases) and metastatic deposits in lymph nodes (3 cases) and subcutaneous tissue (3 cases). All eleven cases were correlated with HPE and proved to be diagnosed correctly on FNAC.  CONCLUSION In  this  study,  correlation  of  94%  was  observed  in benign soft tissue lesions, and 100% in malignant lesions. 6% discordance in the diagnosis was due to inability to aspirate enough material on FNAC, on which  observer  interpretation  varies.  So  it  is obligatory,  that  enough  material  should  be aspirated for interpretation of soft tissue lesions and an index of suspicion should always be kept in mind while dealing with larger masses in advance aged patients. In malignant lesions, whether primary or secondary,  often  moderately  cellular  smears  can arrive  at  suspicious  or  confirmatory  diagnosis compared from benign soft tissue lesions where it is at  times  difficult  to  report  correct  diagnosis.  It  is impressed here that excision of the lesion should be done where diagnostic dilemma arises on FNAC, so that  on  Histopathological  Examination  exact diagnosis is confirmed.  In the study of Akerman et al5, 85% benign tumours were reported as benign and 89% of sarcomas were classified  as  malignant  soft  tissue  tumours.  The results of Brosjo et al6 were also similar. Wakely et al7  found  96%  accuracy  in  FNAC.  Layfield  LJ  et al12presented FNAC study of 136 primary soft tissue tumours with comparative histopathology results in 58 malignant and 42 benign lesions. They showed diagnostic  sensitivity  of  FNAC  for  malignant neoplasm as   95%. There was approximately 20% of  false  positive  and  false  negative  rate.  Similar study of FNAC of soft tissue tumours in correlation with histopathology was done by Kulakarni DR et al13.  FNA  is  an  accurate,  cost  effective,  and  well tolerated procedure in well trained and experienced hands11.  It  is  concluded  that  accuracy  rate  of  our study  is  at  par  with  the  available  references  and studies.  REFERENCES 1.  Enzinger and Weiss.  Soft tissue tumours, Scand Edition; Benign Tumours of peripheral nerves, 1988; (735).    2.  Tim D  Pencavel, Dirk  C Strauss, Greg  P  Thomas, J Meirion Thomas, and Andrew J Hayes Ann R CollSurg Engl. 2010 July; 92(5): 417–421.  3.  Cutler, S. J. & Young, J. L. (1975) Third National Cancer Survey: Incidence Data (National  Cancer  Institute  Monograph  No.  41), Washington, DC, US Government Printing Office  4.  Roy S, Manna A K, Pathak S, Guha D.  Evaluation of fine needle aspiration cytology and its correlation  with  histopathological  findings  in  soft tissue tumours. J Cytol 2007;24:37-40  5.  Akerman M, Rydholm A.  Surgery  based  on  fine  needle  aspiration  cytology. ActaOrthopScandSuppl 1994; 65: 256  6.  Brosjo O, Bauer HCP, Kreicbergs A, et al.  Fine needle aspiration biopsy of soft tissue tumours, ActaOrthopScandSuppl 1994; 65 : 256  7.  Wakely PE, Rowers CN, Frable WJ.  Metachronous  soft  tissue  masses  in  children  and young  adults  with  cancer  :  correlation  of  histology      7  www.gjmedph.com Vol. 2, No. 2  2013                                                                                                                                                                       ISSN#- 2277-9604  Articles and aspiration cytology. Hum Pathol 1990; 21: 669-77.   8.  MarkkuMiettinen, Sharon, W. Weiss:  In Soft tissue tumours. Anderson’s pathology 10th edition 1996; Vol 2: pp480.  9.  Gonzalez-  Compora  R,  Munoz-  Arias  G,  Otal- Solaverri C.  Fine needle aspiration cytology of primary soft tissue tumours.Morphologic  analysis  of  the  most  frequent types.ActaCytologica 1992;36:905-17.  10. Bennert KW, Abdul-Karim FW.  Fine needle aspiration cytology vs. needle core biopsy of soft tissue tumours: a comparison. ActaCytologica 1994;38:381–4.  11.  Ackerman M. Idvall J, Anders R.  Cytodiagnosis of soft tissue tumours and tumour like conditions by means of fine needle aspiration biopsy. Arch Orthop Trauma Surg 1981;96:61-7.  12. Layfield LJ, Anders KH, Glasgow BJ, Mirra JM.  Fine needle aspiration of primary soft tissue lesions. Arch. Pathol lab med 1986;110:420-4.  13. Kulkarni D R, Hemant R, Kokandaker et al.  Fine needle aspiration cytology of soft tissue tumours in  correlation  with  histopathology.  Indian  J  pathol, Microbiol.2002;45:45-8.  

Utility of Fine Needle Aspiration Cytology in Diagnosis of Soft Tissue Lesions with Histopathological Correlation

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