Case Study: FNAC: A safe procedure for the diagnosis of hydatid cyst

Summary

Hydatid cyst disease, also known as Echinococcosis, is a zoonotic infection that can affect any organ and tissue but is most often found in the liver or lungs. It is most common in rural areas, where patients have close contact with cattle [1]. Cases are generally asymptomatic and there is nearly always a delay in the diagnosis. An asymptomatic cyst or incidental findings in ultrasonography (USG) are common presentations of the disease. Here I shall describe 20 cases of hydatid cysts of multiple organs that were diagnosed by FNAC. There were no complications, and all of these cases were confirmed by histopathology after radical surgery. All but one patient recovered completely.

Background

Hydatid disease occurs often in India, and is usually caused by larvae of the tapeworm Echinococcus granulosus. The cysts caused by the parasite may appear in nearly any organ, though generally in only one organ at a time. The liver is most commonly involved, and the lungs are involved in 10-30% of cases [2]. USG and CT-scan successfully pick up the entity in the majority of cases, but sometimes they are not able to rule out other possibilities [3, 4]. Complications like rupture with anaphylaxis, neurocerebral symptoms, recurrent infections and digestive problems may occur [5, 6]. So searching with various approaches (imaging, FNAC, serology, etc.) has always been there to confirm the diagnosis before surgery or albendazole-based chemotherapy or steroids. It might be best to avoid aspiration in hydatid disease, since some patients may have allergic reactions, or the disease could be spread further [7], but neither of these problems occurred in these cases studied by me. Previously, in a similar case study series, incidental aspiration of thoracichydatid cyst proved to be safe [7]. As a quick and reliable diagnostic test, FNAC is being practiced widely to diagnose hydatid cyst.
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Case Presentation

The table below describes the presenting features, treatment, and outcomes of all 20 cases:

Serial No. Month and Year of FNAC Site Age Sex Symptoms Confirmation Treatment Follow-up
1. 11/2007 Liver 36 Male Liver cyst with mild jaundice; detected with USG FNAC Radical Surgery Treated. No recurrence reported after 3 years
2. 08/2008 Liver 55 Female Asymptomatic liver enlargement; cyst detected with USG FNAC Radical Surgery Treated. No recurrence reported after 3 years
3. 09/2008 Kidney 32 Male Symptomatic kidney cyst with features of renal failure FNAC and autopsy after death Radical Surgery Died before surgery
4. 12/2008 Ovary 44 Female Painful cyst detected with USG FNAC Radical Surgery Treated. No recurrence reported after 3 years
5. 02/2009 Gluteal region 21 Female Tense painful cystic swelling; detected with USG FNAC Radical Surgery Treated. No recurrence reported after 2 years
6. 02/2009 Liver 26 Male Asymptomatic liver cyst detected with USG FNAC Radical Surgery Treated. No recurrence reported after 3 years
7. 04/2009 Spleen 33 Female Pain left hypochondrium; detected with USG FNAC Radical Surgery Treated. No recurrence reported after 3 years
8. 04/2009 Liver 33 Female Mass right hypochondrium; cyst detected by USG FNAC Radical Surgery Treated. No recurrence reported after 3 years
9. 01/2010 Calf muscle 26 Female Painful cystic swelling FNAC Radical Surgery Treated. No recurrence reported after 2 years
10. 01/2010 Left Lung 62 Male Respiratory distress and recurrent lower respiratory infections FNAC Radical Surgery Treated. No follow up available
11. 08/2011 Right Lung 46 Female Respiratory distress and recurrent lower respiratory infections FNAC Radical Surgery Treated. No follow up available
12. 08/2011 Liver 31 Male Symptomatic liver cyst with indigestion problems detected with USG FNAC Radical Surgery Treated. No recurrence reported after 2 years
13. 10/2011 Breast 34 Female Asymptomatic palpable breast cyst detected with USG FNAC Radical Surgery Treated. No recurrence reported after 1.5 years
14. 12/2011 Liver 38 Male Asymptomatic liver cyst detected with USG FNAC Radical Surgery Treated. No follow up available
15. 12/2011 Lung 42 Male Respiratory distress and recurrent lower respiratory infections FNAC Radical Surgery Treated. No recurrence reported after 1 year
16. 06/2012 Spleen 65 Male Pain left hypochondrium; cyst detected with USG FNAC Radical Surgery Treated. No recurrence reported after 1 year
17. 07/2012 Liver 55 Male Symptomatic liver cyst with gall stones; detected with USG FNAC Radical Surgery Treated. No follow up available
18. 07/2012 Lung 55 Male Respiratory distress and recurrent lower respiratory infections FNAC Radical Surgery Treated. No follow up available
29. 01/2013 Liver 68 Female Asymptomatic liver swelling; cyst detected with USG FNAC Radical Surgery Treated. No recurrence reported after 4 months
20. 03/2013 Liver 34 Male Inflamed mass right hypochondrium; cyst detected with USG FNAC Radical Surgery Treated. No recurrence reported after 3 months

Investigations

  1. Routine blood examination revealed leucocytosis with eosinophilia of varied degrees in all cases
  2. X-ray, Ultrasonography and CT-scan to assess the cyst, its contents, and extension
  3. Serological tests (enzyme-linked immunosorbent assay, indirect hemagglutination and immunoblot techniques, Monteux, HIV, VDRL, etc.)
  4. Elevated serum IgE
  5. Liver function tests and pulmonary function tests as applicable
  6. Aspiration cytology (FNAC) along with culture sensitivity studies from the aspirate
  7. Z-N stain of the smears that highlighted the membranes and hooklets

Differential Diagnosis

  1. Parasitic cysts
  2. Cystic tumors
  3. Abscess
  4. Malignant tumors
  5. Developmental cysts

Treatment

As described above in the table

Outcome and Follow-Up

As described above in the table

Discussion

Hydatid cysts may appear similar to benign cysts on a sonogram, except with a thicker and more laminated wall. Both types would appear as a well-defined lobulated mass. Ultrasonography may also show floating membranes, daughter cysts, and vesicles [1]. Hydatid cysts can be confirmed using serologic tests, including enzyme-linked immunosorbant assays, indirect hemagglutination, or immunoblot techniques [1]. A comparison of serum-specific immunoglobulin has been published in Parasite Immunology recently [8].
hydatid cyst Fig1
Hydatid cysts can be diagnosed before operating, based on imaging, clinical, and FNAC results. According to Cancelo et al., a laminated wall with parallel striations dispersed retractile hooklets, granular debris, and multinucleated giant cells are signs of a hydatid cyst [1]. (See Figures 1 and 2: Laminated membranes with parallel striations, dispersed glistening hooklets and granular debris are characteristic features of hydatid cyst in cytology (MGG, 100X))

hydatid cyst Fig2In these 20 cases, FNAC was a fast, inexpensive, and safe method of diagnosis before surgery. Cystectomy was performed, often with portions of affected native tissue, in order to keep the risk of rupture to a minimum. None of the patients had allergic reactions, and no patients who could be reached for later follow-ups have reported any recurrence.

Learning Points/Take Home Messages

FNAC has been a safe and accurate diagnostic technique, and by confirming the diagnosis before surgery, it can allow patients with a high surgical risk to avoid complications [1].

About The Author

Dr-Swapan-Samanta-64x80
Dr. Samanta, MBBS, MD is currently a consultant at Suraksha diagnostic PVT. LTD. Kolkata, India for histopath, cytopath and hematology. His other interests are: oncopathology, bone marrow and neuropathology.

 

References (click to show/hide)

  1. Maria Jesus Cancelo, Maria Martín, Nicolas Mendoza. Preoperative diagnosis of a breast hydatid cyst using fine-needle aspiration cytology: a case report and review of the literature. Journal of Medical Case Reports 2012, 6:293. http://www.jmedicalcasereports.com/content/6/1/293
  2. Debabani Biswas, Atin Dey, Saurabh Biswas, and Mukul Chakraborty. It’s easy to miss complicated hydatid cyst of lung. Lung India. 2010 Jul-Sep; 27(3): 164–166.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2946721/?report=classic
  3. Brunetti E, Junghanss T (2009) Update on cystic hydatid disease. Curr Opin Infect Dis 22: 497–502.
  4. Saint Martin GA, Larrieu E, Chiesa JC, Dapcich C, Martinez E (1988) Ultrasound scanning as a screening technique for hydatidosis in developing countries. J Clin Ultrasound 16: 233–37.
  5. Kulpati DD, Hagroo AA, Talukdar CK, Ray D. Hydatid disease of lung. Indian Chest Dis.1974;16:406–10.
  6. Reddy CR, Narasiah IL, Parvathi G, Somsundra RM. Epidemiology of hydatid disease in Kurnool.Indian Med Res. 1968;56:1205–20.
  7. McCorkell SJ. Unintended percutaneous aspiration of pulmonary echinococcal cysts. AJR Am J Roentgenol. 1984; 143(1):123-26.
  8. Marinova I, Nikolov G, Michova A, Kurdova R, Petrunov B. Quantitative assessment of serum-specific IgE in the diagnosis of human cystic echinococcosis. Parasite Immunol 2011, 33:371-376.


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