|Year : 2015 | Volume
| Issue : 2 | Page : 125-128
Role of fine needle aspiration cytology in the diagnosis of hepatic lesions
Subhan R Ali, Leena Jayabackthan, Sanila Rahim, Mendonca Bryne Sharel, Krishna Prasad, Namita Hegdekatte
Department of Pathology, Father Muller Medical College, Mangalore, Karnataka, India
|Date of Web Publication||13-Jul-2015|
Dr. Leena Jayabackthan
Department of Pathology, Father Muller Medical College, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Objective: To evaluate the role of Fine needle aspiration cytology(FNAC) as a first line of investigation in space occupying lesions of liver and to study the various cytological patterns in hepatic lesions, categorizing them into non-neoplastic and neoplastic lesions. Materials and Methods: Retrospective study of a total of 138 guided Fine needle aspirations was done at Father Muller Medical College Mangalore, during the period of Jan 2011 to Dec 2013. Papanicolaou (Pap) and May-Grunwald-Giemsa (MGG) stained smears was reviewed and analysed under the microscope. Results: Age ranged from 22 to 85 yrs. 122 out of 138 were conclusive. 17 out of 122 were benign lesions, 8 cases were reported as negative for malignancy, 2 suspicious for malignancy, 95 were malignant cases of which 40 were primary in the liver. Metastatic lesions were 55 including squamous cell carcinoma, adenocarcinoma, malignant melanoma, neuroendocrine and small cell carcinoma. One case of spindle cell neoplasm was reported the histopathology of which was inconclusive. Conclusion : Guided FNA is a first line of investigation in space occupying lesions of liver as the procedure is safe, simple, rapid, effective and minimally invasive.
Keywords: Guided FNAC, Liver, Hepatocellular carcinoma
|How to cite this article:|
Ali SR, Jayabackthan L, Rahim S, Sharel MB, Prasad K, Hegdekatte N. Role of fine needle aspiration cytology in the diagnosis of hepatic lesions. Muller J Med Sci Res 2015;6:125-8
|How to cite this URL:|
Ali SR, Jayabackthan L, Rahim S, Sharel MB, Prasad K, Hegdekatte N. Role of fine needle aspiration cytology in the diagnosis of hepatic lesions. Muller J Med Sci Res [serial online] 2015 [cited 2020 Jun 3];6:125-8. Available from: http://www.mjmsr.net/text.asp?2015/6/2/125/160679
| Introduction|| |
Fine needle aspiration cytology (FNAC) has been proven to be a very effective means of obtaining tissue from many different body sites for diagnosis. It was applied in liver as early as 1985. 
FNAC is a rapid, less invasive method that can be employed for pathological evaluation of both benign and malignant hepatic lesions. Inflammatory lesions and diffuse liver diseases may mimic mass like lesions or appear as non homogeneous lesions on radiographs. Such lesions can also be sampled by FNA to rule out neoplasms and differentiate it from other diagnosis. 
It can be used to detect malignancy in different zones of liver for example in the area of portahepatis where trucut biopsy would be dangerous. Ultrasonography (USG) or Computed tomography (CT) guided FNAs of liver lesions increase the accuracy of sampling for deep seated lesions. Accuracy of FNAC is higher since multiple samples can be obtained and hence the chance of obtaining a representative sample is enhanced. 
Accurately sampled, well prepared and stained cytological samples along with cell block preparations and correlation with clinical and radiological findings yield the best results.
| Materials and Methods|| |
A retrospective study of a total 138 guided FNACs performed on liver lesions diagnosed clinically or radiologically with normal range of coagulation profile at Father Muller Medical college, Mangalore over a period of three years from Jan 2011 to Dec 2013 was done. Both wet fixed and air dried smears were reviewed and confirmed with cell block or histopathology wherever possible.
| Results|| |
Fine needle aspiration of a total of 138 cases were studied during three years [Figure 1]. Age group ranged from 22 to 85 yrs with maximum cases in the range of 40-55 yrs. The chief complaints were pain in right upper quadrant of abdomen, weight loss, anorexia, abdominal mass and hepatosplenomegaly. Some of the patients presented with fever, pruritis and jaundice, abdominal distention with ascites. The study showed 122 conclusive results out of 138 cases in which 17 cases (12%) were benign, and 95(69%) were malignant [Table 1]. Out of total 17 benign lesions, 5 were benign cytic lesions, 4 infectious, 4 regenerative nodules, 3 hepatic adenomas and one hemangioma. In 4 infectious lesions 2 cases of tubercular abscess were seen. Of 95 malignant cases diagnosed, 40(42%) were primary of the liver and 55(58%) were secondaries. The most important cytomorphological features of primary tumors were cellularity, architectural patterns, cytological features of individual cells and background material [Figure 2]. The main architectural pattern seen was broad trabecule with transgressing blood vessels, cohesive clusters and endothelial wrapping. Cytologically the diagnosis of malignancy included Adenocarcinoma (81%), Squamous cell carcinoma (13%), one each of malignant melanoma, small cell carcinoma and neuroendocrine carcinoma [Figure 3].
| Discussion|| |
Guided FNAC is a very useful procedure for the diagnosis of various neoplastic and non-neoplastic hepatic lesions. It is a minimal intervening procedure at low cost and without major complications.  It offers high accuracy with diagnostic sensitivity of around 90% (range 67-100%) in malignancy. , The only contraindications are suspected vascular lesions and marked hemorrhage. During this study no complications were encoutered. The chief complaints of the patients were vague abdominal pain, majority of them presented with right upper quadrant pain, fatigue, weight loss, anorexia, mass per abdomen and hepatomegaly. The appropriate management of various hepatic lesions depends on accurate diagnosis.  The differential diagnosis include congenital or acquired cyts, inflammatory abscess such as tuberculosis or hydatid cyst, metastatic deposits and primary liver malignancy. The imaging techniques' helps, but some overlap between the radiologic features of liver abscess, Hepatocellular Carcinomas (HCC) and metastases are seen. Tumour either primary or secondary, can undergo extensive necrosis, and present radiologically as cavitary neoplasms mimicking abscess and similarly absesses with accompanied proliferative reactive changes mimic neoplastic process radiologically. In these situations guided FNAC plays an important complementary role for the accurate cytological diagnosis of various liver lesions. ,, In focal liver lesions multiple aspirates can be done replacing core needle biopsy to a larger extent. 
It helps to categorise liver malignancies into primary, metastatic or non-neoplastic. However histopathological examination is required for classification of HCC. But with the use of cell blocks there is improved diagnostic accuracy as it facilitates study of multiple sections, use of special stains and immunohistochemistry (IHC). 
In our study a total of 17 benign lesions were seen, 5 were benign cytic lesions, 4 infectious, 4 regenerative nodules, 3 hepatic adenomas and one hemangioma. In the 4 infectious lesions 2 cases are of tubercular abscess. Smears of inflammatory lesions showed inflammatory cells, necrosis and debris. Those with tubercular eitiology showed caseous necrosis and granulomas with positive special stain for acid fast bacilli. In one of the study in India showed that 68% of granulomas in liver biopsies were of tubercular eitiology. ,
FNAC can accurately distinguish non-neopastic from neoplastc hepatic lesions and categorize neoplastic lesions in to primary or metastatic as concluded by Swamy et al. 
The primary liver malignancy in our study seen was only HCC. Individual cells were polygonal with irregular nuclear contours and single or multiple macronucleoli, abundant eosinophilic granular cytoplasm. Intranuclear cytoplasmic inclusions and bile plugging were seen. Background showed singly dispersed atypical stripped nuclei and bile pigment. Cohen et al.  concluded that the most important helpful cytological features were trabacular pattern, irregular granular chromatin, multiple nucleoli and atypical stripped nuclei which was similar to our study.The atypical naked nuclei were included as one of the important crietaria for the diagnosis of HCC by Pedio et al. as these were rarely seen in benign and metastatic conditions.  One case reported to be benign cytologically turned out to be clear cell variant of HCC in biopsy. This could be due to unawareness of the cytomorphology of rare variant of the HCC or inadequate cytological material. So in difficult cases a stepwise logistic regression analysis has to done.  Serological findings like alpha feto protein was available for most cases however six cases had a normal level of the marker with classical cytological features on FNAC.
Most common metastatic malignancy was adenocarcinoma from lung, GIT and breast. The common cytological pattern observed was malignant columnar cells in palisaded rows or microglandular groups in a background of necrotic debris often with evidence of mucin secretion. In our study majority of them were unknown primary. The special stains like Periodic acid shiff (PAS) and mucicarmine was complimentary to diagnosis as seen in other studies. ,
Squamous cell carcinoma (SCC) is relatively easy to diagnose when it is well differentiated enough to produce keratinized cells that stain orangeophilic with Pap stain. Less well differentiated tumors in which keratin are not apparent is diagnosed on the basis of nuclear and cytoplasmic features. One case of neuroendocrine tumor showed the characteristic nuclear moulding, salt and pepper chromatin.
| Conclusion|| |
Guided FNAC is useful in diagnosis of various neoplastic and non-neoplastic lesions of Liver as it is simple, safe, quick, economical and accurate. Early diagnosis decreases the length of stay in hospital and minimizes further ancillary investigations. As diagnostic accuracy of FNAC is high enough, early management can be initiated and prognosis can be predicted with certainty. In correlation with clinical, radiological and accurate sampling, well prepared FNAC smear, in conjunction with cell-block preparation, special stain/IHC where ever required yields the best results.
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[Figure 1], [Figure 2], [Figure 3]