경부종괴의 초음파 소견 및 세침흡인생검의 유용성

Abstract

[한글]

경부 초음파술은 경부 종괴의 물리적인 성상, 위치 결정 및 잠재성 병변의 확인을 위해 현재 가장 보편적으로 이용되는 영상 진단술이다. 그러나 다른 영상 진단술과 마찬가지로 경부 초음파술은 병변의 조직학적 확진에 대한 정보를 주지 못하므로 감별 진단을 위

해서는 보다 관혈적인 진단술을 필요로 하게 된다. 이들 중 세침흡인생검에 의한 세포학적 진단(Fine needle aspiration biopsy cytology, FNABC)은 합병증이 없고 간편하며, 비교적 정확한 확진이 가능하여 이미 널리 임상에 응용되고 있다.

저자는 1985년 3월 부터 1991년 5월까지 경부의 종괴를 주소로 내원하여 초음파 유도하에 FNABC를 시행 하였던 252예를 대상으로 첫째, 경부 초음파의 소견으로 조직학적 분류를 예측할 수 있는가, 둘째, FNABC에 초음파 유도를 병행함으로써 영상 진단으로서의 초

음파술과 조직학적 진단으로서의 FNABC가 서로의 한계점을 보완할 수 있는가, 세째, FNABC의 진단이 최종 진단을 위해 외과적 생검술을 대치할 수 있는가에 대하여 검토하였으며 그 결과는 다음과 같다.

1. 최종 진단의 조직학적 분류상 악성 병변이 85예, 양성 병변이 167예였으며 악성 병변 중에는 림프선의 전이암이, 양성 병변 중에는 결핵성 림프선염이 가장 많았다.

2. 종양의 초음파 소견은 hypoechoic한 병변이 98예(78.5%), hyperechoic한 병변이 16 예 (6.4%), 혼합형 병변이 38예(15.1%)였으며, 초음파 소견을 최종진단 결과와 비교한 결

과 hypoechoic하면서 후방 echo 증강을 가지거나 혼합형의 소견을 보이는 경우는 양성 병변을, hyperechoic한 소견을 보인 경우 악성 병변의 가능성이 많았으며 특히 hypoechoic하면서 후방 echo 증강을 가지는 경우 결핵을, 혼합형인 경우는 농양을 의심할 수 있었다.

3. 악성 병변에 대한 세침흡인생검의 세포학 진단의 감수성은 83.5%, 특이성은 98.8%였으며, 진단의 정확도는 93.7%, 위음성율은 16.5%, 위양성율은 1.2%였다.

4. 세침흡인생검의 세포학진단상 위음성이나 위양성 진단이 없었던 경우는 부갑상선 선종, 혈관종, 지방종, 아급성 괴사성 림프선염, 이하선 점액류, 림프관종 및 유방에서 림프선으로 전이한 암 등이었다.

5. 위음성 혹은 위양성 진단이 관찰된 질환들 중 악성 병변에서의 진단 일치율은 림프선의 전이암 중 미분류암이 100%, 선암이 90.9%, 갑상선 암이 84.6%, 편평 상피암이 80.0%, 미분화선암이 66.7% 이었으며, 악성림프종이 60.0%, 타액선 악성종양이 75.O%였다.

양성 병변에서의 진단 일치율은 농양이 95.2%, 타액선 종양이 88.9%,결핵이 77.2%, 신경초종이 75.0%, 반응성 림프절 증식증이 54.5%, 선천성 기형이 22.2%였다.

6. 진단 과정중 세침흡인 후 이에 대한 합병증이나 천자도를 통한 악성 세포의 전이가 있었던 예는 전혀 관찰되지 않았다.

이상의 결과로 보아 경부 초음파의 유도는 세침흡인시 피검물의 양과 질적인 개선을 가능케 하며 진단의 신뢰도를 높이는데 중요한 역할을 하고, 세침흡인생검의 세포학 진단법의 병용이 경부종괴의 매우 유용하며 안전한 검사방법이므로 경부 종괴가 발견되는 경우

우선적으로 시행하여야 한다고 생각된다. 특히, 본 검사기술에 특별한 관심을 가지고 있는 훈련된 방사선 의사 및 세포병리학 의사가 채취, 판독, 진단을 일괄적으로 시행하여야만 가장 좋은 결과를 얻을 수 있을 것으로 사료된다.

Ultrasonographic findings of neck masses and efficacy of fine needle aspiration

biopsy cytology

Hee Kyung Cho

Department of Medical Science, The Graduate School, Yonsei University

(Directed by Associate Professor Jong Tae Lee)

Although ultrasonography(US) is the most popular method for detecting the

physical quality of neck masses and occult lesions, as with other imaging

modalities, it cannot reveal any histologic finding. For the histologic

confirmation of neck masses, variable invasive methods are also necessary. Among

them, the fine needle aspiration biopsy cytoplogic diagnosis(FNABC) has been proved

to be a safe, rapid, and accurate diagnostic modality for the differentiation of

neck masses. In this prospective study of 252 consecutive ultrasono guided FNABC

findings, it was analysed that whether the US findings could predict the histologic

classification, whether ultrasonography and FNABC could be supplimented each other

and whether the FNABC could be substituted fur any surgical biopsy for the final

diagnosis. There were 113 male and 142 female patients and their mean age was 41.9

years. After the detailed US examination of architecture and the presence of

satellite nodules of masses, a 22gauge or 24gauge Chiba needle was percutaneously

introduced into the mass and was aspirated with 20cc syringe attached wish

specially designed aspirator. Specimens were smeared and prepared for cytologic

diagnosis : an air-dry specimen stained with Giemsa method, a formalin-fixed

specimen stained with Papanicolaou's method. When the tuberculosis is suspicious,

the Ziehl-Neelsen stain were added. A preliminary microscopic examination for

adequacy of specimen was performed immediately after the aspiration.

Masses could be divided into five US categories: 1) hypoechoic lesion with

posterior enhancement(n=68, 27.0%) 2) hypoechoic lesion without posterior

enhancement(n= 130, 51.6%) 3) hyperechoic lesion(n=16, 6.4%) 4) mixed lesion(n=38,

15.1%). A statistical significance was observed in the prediction of

benign(hypoechoic with posterior enhancement or mixed lesions) and

malignant(hyperechoic lesions) masses (p<0.05, p<0.01) and it was possible for

hypoechoic lesion with posterior enhancement as a tuberculous one and for mixed one

as an abscess (p<0.01), respectively.

The final diagnosis revealed that there were 85 malignant and 165 benign lesions.

The metastaic lymphadenopathies(76.5%) and tuberculous lymphadenitis(60.5%) were

predominant masses in each group. The sensitivity, specificity, accuracy, false

negativity, and false positivity of FNABC were 83.5%, 98.8%, 93.7%, 16.5% and 1.2%

respectively. Parathyroid adenova(n=4), hemangioma(n=3), lipoma(n=2), subacute

necrotizing lymphadenitis(n= 1) mucocele of parotid(n=1), lymphangioma(n=1), and

metastatic ductal cell carcinoma(n=1) had no false diagnosis. Comparing the FNABC

diagnosis with final ones, the positivity of diagnosis was highest in the

unclassified malignancy(n=1,100%) and was lowest in the malignant lymphoma(n=15,

60.0%). In benign lesion, abscess was highest one(n=20, 95.2%) and congenital

anomaly was lowest(n=2, 22, 2%). Ultrasound guided FNABC seems to be simple,

accurate and safe diagnostic modality fur neck masses, so that experienced

technique with improve the diagnostic accuracy of FNABC in diagnosing neck mass.

[영문]

Although ultrasonography(US) is the most popular method for detecting the physical quality of neck masses and occult lesions, as with other imaging modalities, it cannot reveal any histologic finding. For the histologic confirmation of neck masses, variable invasive methods are also necessary. Among them, the fine needle aspiration biopsy cytoplogic diagnosis(FNABC) has been proved

to be a safe, rapid, and accurate diagnostic modality for the differentiation of neck masses. In this prospective study of 252 consecutive ultrasono guided FNABC findings, it was analysed that whether the US findings could predict the histologic classification, whether ultrasonography and FNABC could be supplimented each other and whether the FNABC could be substituted fur any surgical biopsy for the final diagnosis. There were 113 male and 142 female patients and their mean age was 41.9 years. After the detailed US examination of architecture and the presence of satellite nodules of masses, a 22gauge or 24gauge Chiba needle was percutaneously introduced into the mass and was aspirated with 20cc syringe attached wish specially designed aspirator. Specimens were smeared and prepared for cytologic diagnosis : an air-dry specimen stained with Giemsa method, a formalin-fixed specimen stained with Papanicolaou's method. When the tuberculosis is suspicious, the Ziehl-Neelsen stain were added. A preliminary microscopic examination for

adequacy of specimen was performed immediately after the aspiration.

Masses could be divided into five US categories: 1) hypoechoic lesion with posterior enhancement(n=68, 27.0%) 2) hypoechoic lesion without posterior enhancement(n= 130, 51.6%) 3) hyperechoic lesion(n=16, 6.4%) 4) mixed lesion(n=38, 15.1%). A statistical significance was observed in the prediction of benign(hypoechoic with posterior enhancement or mixed lesions) and malignant(hyperechoic lesions) masses (p<0.05, p<0.01) and it was possible for hypoechoic lesion with posterior enhancement as a tuberculous one and for mixed one as an abscess (p<0.01), respectively.

The final diagnosis revealed that there were 85 malignant and 165 benign lesions.

The metastaic lymphadenopathies(76.5%) and tuberculous lymphadenitis(60.5%) were predominant masses in each group. The sensitivity, specificity, accuracy, false negativity, and false positivity of FNABC were 83.5%, 98.8%, 93.7%, 16.5% and 1.2%

respectively. Parathyroid adenova(n=4), hemangioma(n=3), lipoma(n=2), subacute necrotizing lymphadenitis(n= 1) mucocele of parotid(n=1), lymphangioma(n=1), and metastatic ductal cell carcinoma(n=1) had no false diagnosis. Comparing the FNABC

diagnosis with final ones, the positivity of diagnosis was highest in the unclassified malignancy(n=1,100%) and was lowest in the malignant lymphoma(n=15, 60.0%). In benign lesion, abscess was highest one(n=20, 95.2%) and congenital anomaly was lowest(n=2, 22, 2%). Ultrasound guided FNABC seems to be simple,

accurate and safe diagnostic modality fur neck masses, so that experienced technique with improve the diagnostic accuracy of FNABC in diagnosing neck mass.