|Year : 2015 | Volume
| Issue : 3 | Page : 7-9
Comparative analysis of detecting cervical lymph node metastasis with fine needle aspiration cytology
Mohammed Kamran Shakeel, Mariappan Jonathan Daniel, Subramaniam Vasudevan Srinivasan, Ramadoss Koliyan, Jimsha Vannathan Kumar
Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of Dental Sciences, Puducherry, India
|Date of Web Publication||28-Sep-2015|
Dr. Mohammed Kamran Shakeel
Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of Dental Sciences, Puducherry
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: We correlated the results of cervical lymph node (LN) status by T-tumor size, N-nodal metastasis, M-distant metastasis (TNM) staging, and fine needle aspiration cytology (FNAC) in oral cancer patients to assess the discrepancy index (DI) between nodal metastasis (N) and FNAC results of cervicofacial LNs. Materials and Methods: A total of 63 patients (29 females and 34 males) aged from 30 to 85 years were included in our study. Cervical LN status through TNM staging and FNAC results were matched and DI was calculated. Results: DI in case of nodal status was 64.10% and 43.47% for TNMN1 and N2, respectively, indicating that tendency for observation of positive result on FNAC increased from N1 to N2. Conclusion: Hence, we suggest that relying solely on clinical examination and routine diagnostic tests like FNAC may not be appropriate and additional diagnostic imaging modalities should be considered.
Keywords: Carcinoma, cervical lymph node, discrepancy index, metastasis
|How to cite this article:|
Shakeel MK, Daniel MJ, Srinivasan SV, Koliyan R, Kumar JV. Comparative analysis of detecting cervical lymph node metastasis with fine needle aspiration cytology. J Nat Sc Biol Med 2015;6, Suppl S1:7-9
|How to cite this URL:|
Shakeel MK, Daniel MJ, Srinivasan SV, Koliyan R, Kumar JV. Comparative analysis of detecting cervical lymph node metastasis with fine needle aspiration cytology. J Nat Sc Biol Med [serial online] 2015 [cited 2020 Aug 10];6, Suppl S1:7-9. Available from: http://www.jnsbm.org/text.asp?2015/6/3/7/166050
| Introduction|| |
Oral squamous cell carcinoma (OSCC) is a common malignant tumor in the head and neck region.  OSCC constitutes 95% of oral cavity cancers and predominantly spreads to the lymph nodes (LNs) of the neck.  The presence of positive LNs is a significant adverse prognostic factor for survival. , The rate of metastases to cervical LNs probably reflects the aggressiveness of the primary tumor. Between 10% and 52% of clinical LN negative (cN0) in neck are pathological LN positive (pN+). Due to this high proportion of occult metastases, radical neck dissection or selective neck dissection are traditionally used for treatment of cN0 as well as clinical LN positive (cN+) in neck. However, the proportion of occult metastases depends on the sensitivity of the initial diagnostic methods employed, example, palpation and imaging. 
The course of OSCC is unpredictable, but the T-tumor size, N-nodal metastasis, M-distant metastasis (TNM) stage of the primary tumor correlates well with the survival rate. The prognosis is best when the primary tumor is small and there is no evidence of regional LN involvement or distant metastasis. In fact, the 5-year survival rate of persons with early stage oral SCC according to the TNM staging system may reach 80% to 90%, whereas the 5-year survival rate for advanced-stage oral SCC is about 40%.  Hence, we correlated the results of cervical LNs status by TNM staging with fine needle aspiration cytology (FNAC) in oral cancer patients to assess the discrepancy index (DI).
| Materials and Methods|| |
The study group comprised of 63 patients (29 females and 34 males) aged from 30 to 85 years, who reported to Mahatma Gandhi Postgraduate Institute of Dental Sciences, Puducherry for treatment. Patients with clinically diagnosed oral cancer with enlarged cervicofacial LNs were included in the study. Subjects with other known causes for cervicofacial lymphadenopathy such as oral infection, tuberculosis, sarcoidosis, etc. were excluded from the present study. For every subject, thorough clinical examination was performed, history of any harmful habit such as tobacco chewing, smoking, alcohol consumption, was recorded and the exact location of all lesions were recorded in a case sheet. Panoramic radiograph was also performed to screen bony changes due to carcinomatous lesion. TNM staging  was also performed for all the study subjects. The following clinical criteria were used for differentiating malignant LNs:
- LN with approximate size larger than 1 cm in diameter; and
- LN with hard or indurate consistency.
Following informed written consent from the subjects, FNAC procedure for cervical LN was performed.
Cervical LN status through TNM staging and FNAC results were matched and DI (DI = the number of negative results of LN through FNAC/the number of total patients ×100) was calculated. In addition, the epidemiological parameters were also recorded. The data obtained in the study were subjected to descriptive and analytical statistical analysis.
| Results|| |
In our study subjects, males had higher prevalence of oral cancer in sixth decade or older age group while among female patients prevalence of oral cancer had equal distribution in sixth and seventh decades. Habit of smoking and chewing tobacco was most common among females and males, respectively. Metastatic malignant squamous cells were detected in the LN smears [Figure 1]. The distribution of cancer patients based on LN staging and FNAC findings are presented in [Figure 2]. We observed that from N1 to N2 to N3, the tendency for observation of positive result on FNAC increased. DI was observed to be 64.10% (=[25/39] × 100) and 43.47% (=[10/23] × 100) for LN status N1 and N2, respectively. It was not feasible to calculate the DI for nodal status N3 as the there was only one study sample with nodal status N3.
|Figure 2: Distribution of oral cancer patients based on lymph node staging and fine needle aspiration cytology results|
Click here to view
| Discussion|| |
Cancers of the oral cavity and oropharyngeal region are the sixth most common cancers globally.  OSCC continues to affect more males than females with a ratio of 1.5:1 ,, which is consistent with our observations in this study. High proportion of cases among males may be due to high prevalence of tobacco consumption habits in them, coupled with smoking whereas in our society females less commonly indulge in tobacco smoking.  Diagnosis of OSCC is usually at the fifth or sixth decade of life, although there is increase in the trend (~6%) of oral cancer affecting young people under the age of 45 years. In the Asian population, the buccal mucosa is commonly affected due to betel quid/tobacco chewing habits. , In our study, chewing tobacco habit was most prevalent in male patients while smoking tobacco was most common in female patients.
The current TNM classification  is the widely used system for predicting the clinical prognosis of OSCC. In our study, N1 tumors lacking distant metastasis, showed significant cervical LNs metastasis (35.89%) on FNAC. However, a higher percentage (56.52%) of patients with N2 had shown the cervical LNs metastasis through FNAC. These findings suggest that the percentage of FNAC results increases with increase of LN status (N2 > N1). The findings of the present study are in accordance with previous report.  Although the TNM system includes acceptable prognostic parameters however, the biological properties of the tumor cannot be predicted. Hence, the fixity of LNs and the sentinel node biopsy should also be assessed. Fixity of the LN is usually suggestive of malignancy,  while sentinel node biopsy enhances the chances of detecting the nodal metastasis and improves the accuracy of staging. 
In our study, DI in case of N1 nodal status patients was 64.10%, which suggests a significant discrepancy between the nodal status of TNM staging and FNAC results of cervical LN metastasis. With similar previous reports,  its reasonable to suggest that conventional FNAC technique is unreliable method for detecting cervical LN metastasis, which necessitates use of additional imaging techniques (computed tomography [CT], magnetic resonance [MR] imaging, and ultrasonography) to improve reliability of detecting metastasis. In our study, in case of N2 nodal status patients DI was 43.47%, which is suggestive of increase of sensitivity of method to diagnose cervical LN metastasis with increase of nodal size (N2 > N1) and its correlation with TNM staging.
We also emphasize that deep-seated LNs may be difficult to access using FNAC and can be confused with complex anatomical structures in the head and neck because of the lack of accuracy in needle tip localization and possible risk of injury to surrounding vital tissues. Nevertheless, FNAC can be performed under imaging guidance to improve outcomes. ,, However, despite its limitations and pitfalls, FNAC appears to be a good first line method for investigating the cases of cervical lymphadenopathy in oral cancer patients because FNAC has proved to be a quick, relatively easy, safe, and repeatable method of obtaining tissue for microscopic examination and allows rapid interpretation of the specimen. This procedure can be performed as an office procedure with or without the use of a local anesthetic, thus relieving the patient's anxiety, and it permits an early and efficient treatment planning process. , We concluded that reliance solely on clinical examination and routine diagnostic test like FNAC in assessment of OSCC may not be appropriate and other diagnostic modalities should be considered. Although histopathological examination is the gold standard, use of additional imaging modality (CT, MR imaging, and/or ultrasound scanning) can increase the accuracy of detecting LN metastasis.
| References|| |
Wang B, Zhang S, Yue K, Wang XD. The recurrence and survival of oral squamous cell carcinoma: A report of 275 cases. Chin J Cancer 2013;32:614-8.
Omar EA. The outline of prognosis and new advances in diagnosis of oral squamous cell carcinoma (OSCC): Review of the literature. J Oral Oncol 2013;2013:519312.
Cohen JM, Wenig BM. General principles of head and neck pathology. In: Harrison LB, Sessions RB, Hong WK, editors. Head and Neck Cancer: A Multidisciplinary Approach. 3 rd
ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 3-50.
Saafan ME, Elguindy AS, Abdel-Aziz MF, Younes AA, Albirmawy OA, Mandour M, et al
. Assessment of cervical lymph nodes in squamous cell carcinoma of the head and neck. Surg Curr Res 2013;3:145.
Norling R, Buron BM, Therkildsen MH, Henriksen BM, von Buchwald C, Nielsen MB. Staging of cervical lymph nodes in oral squamous cell carcinoma: Adding ultrasound in clinically lymph node negative patients may improve diagnostic work-up. PLoS One 2014;9:e90360.
Feller L, Lemmer J. Oral squamous cell carcinoma: Epidemiology, clinical presentation and treatment. J Cancer Ther 2012;3:263-8.
Greene FL, Page DL, Fleming ID, Fritz AG, Balch CM, Haller DG, et al
., editors. AJCC Cancer Staging Manual. 6 th
ed. New York, NY: Springer; 2002.
Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol 2009;45:309-16.
Jerjes W, Upile T, Radhi H, Petrie A, Abiola J, Adams A, et al.
cTNM vs. pTNM: The effect of not applying ultrasonography in the identification of cervical nodal disease. Head Neck Oncol 2012;4:5.
Khandekar SP, Bagdey PS, Tiwari RR. Oral cancer and some epidemiological factors: A hospital based study. Indian J Community Med 2006;31:157-62.
Agar NJ, Patel RS. Early detection, causes and screening of oral cancer. JSM Dent 2014;2:1039.
Sundar SB, Rao NR, Faheem MK. Epidemiological and clinico pathological study of oral cancers in a Tertiary care hospital. Int J Biol Med Res 2012;3:2376-80.
Bundgard T, Bentzen SM, Wildt J. The prognostic effect of tobacco and alcohol consumption in intra oral squamous cell carcinoma. Eur J Cancer B Oral Oncol 1994;30B:323-8.
John P, John PR. Lymphatic drainage of the head and neck region differential diagnosis of cervical lymphadenopathy. In: John P, John PR, editors. Textbook of Oral Medicine. 3 rd
ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2014. p. 116-22.
Borle RM, Arora A, Bhola N. Oral cancer. In: Borle RM, editor. Textbook of Oral and Maxillofacial Surgery. 1 st
ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2014. p. 693-744.
Onofre MA, Sposto MR, Navarro CM, Motta ME, Turatti E, Almeida RT. Potentially malignant epithelial oral lesions: Discrepancies between clinical and histological diagnosis. Oral Dis 1997;3:148-52.
Witcher TP, Williams MD, Howlett DC. "One-stop" clinics in the investigation and diagnosis of head and neck lumps. Br J Oral Maxillofac Surg 2007;45:19-22.
He Y, Zhang Z, Tian Z, Zhang C, Zhu H. The application of magnetic resonance imaging-guided fine-needle aspiration cytology in the diagnosis of deep lesions in the head and neck. J Oral Maxillofac Surg 2004;62:953-8.
Ebenezer V, Balakrishnan R, Padmanabhan PA. Efficacy of fine needle aspiration cytology in lesions of head and neck region: A review. Indian J Multidiscip Dent 2013;3:802-9.
Orell SR, Sterrette GR, Walters NI, Whitaker D. Manual Atlas of Fine Needle Aspiration Cytology. 2 nd
ed. Edinburgh: Churchill Livingstone; 1992. p. 37-61.
Wakely PE Jr, Kneisl JS. Soft tissue aspiration cytopathology. Cancer Cytopathol 2000;90:292-8.
[Figure 1], [Figure 2]