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Affiliation: Instituto de Hematología e Inmunología, Ciudad de la Habana, Cuba. Phone: 578268. Fax: 442334 E-mail: Mailing address: Dr Roberto Silva Aguiar Instituto de Hematología e Inmunología, Dpto de Patología, Calle E y Aldabo, Altahabana, Ciudad de la Habana, Cuba. Apdo postal 8070. CP 10800

Una experiencia de 10 años con 3274 aspiraciones con aguja fina en la edad pediátrica en un hospital docente en la Habana. (A ten-year experience on 3274 pediatric fine needle aspiration cytologies at a Major Teaching Hospital in Havana).

Roberto Silva Aguiar*
* Instituto de Hematologia e Inmunologia CUBA



Objetivos: Describir y validar  una experiencia de 10 años  con citologías aspirativas con aguja fina (CAAF) en niños y adolescentes. Diseño del estudio: La CAAF fue realizada principalmente como citopunción por un patólogo. Los archivos de citopatología del Hospital Pediátrico William Soler fueron revisados y se seleccionó los registros de los pacientes menores de 21 años. Se creó una base de datos con la información usando el programa Excel. Se revisó también los datos clínicos e histopatológicos. La base de datos fue  analizada y se realizó cálculos, gráficos  y tablas. Resultados: 3274 CAAF fueron realizadas con predominio del sexo masculino (55%) y de niños  menores de 7 años.

Los Ganglios linfáticos, Partes blandas , Tiroides y Mama fueron los sitios más frecuentemente puncionados. Hubo 80.9% de diagnósticos  benignos, 6% malignos, 2.4% sospechosos de malignidad  y 10.7% insuficientes para diagnóstico.  630 citologías  fueron correlacionadas: 69 fueron insuficientes, 321 verdaderos negativos, 184 verdaderos positivos, 19 falsos negativos y 37 falsos positivos. La sensibilidad, especificidad,  precisión, valores predictivos positivo y negativo y prevalencia fueron 90.6%,  89.6%, 90%, 83.2% 94.4%, y 36.1% respectivamente.  4 complicaciones de las punciones en órganos profundos fueron observadas y  el índice  de complicaciones fue de 0.01%. Conclusión: La CAAF  es una excelente técnica diagnóstica en niños y adolescentes como en adultos.

(Objectives: To describe and to validate a 10-year experience in pediatric fine needle aspiration citology (FNAC). Study design: FNAC was done mainly in a non aspirating form by  a pathologist. Archives of  cytopathology at William Soler Pediatric Hospital were reviewed  and patients punctured younger than 21 years were selected. A data base was created with patients’ information using Excel program. Histopathology and clinical data were also reviewed. Data  base was analyzed, figures,  graphics and tables were   done as needed.  Results: 3274 fine needle cytologies were done.  There was a predominance of  male patients (55%) and children younger than seven  years. Lymph nodes, soft tissue, thyroid, and breast  were the most frequently   punctured sites. There were 80,9% benign diagnosis, 6% malignant, 2,4% suspicious for malignancy and 10,7% insufficient. 630  cytologies were correlated: 69 were  insufficient, 321 true negative, 184 true positive,  19 false negative,  and  37 false positive. Sensibility, specificity, accuracy, positive and negative predictive values and prevalence were 90.6%,  89.6%,  90%,  83.2%,  94.4%,  and 36.1%. Four deep organ puncture complications were observed and complication rate was 0,1%. Conclusion: FNAC is an excellent diagnostic technique in pediatric age as in adulthood.)




Fine needle aspiration cytology (FNAC) in adult age  is a  well  recognized  diagnostic technique  with accepted value in management of tumoral and pseudotumoral  processes 1-3. Nevertheless its use  in children and teenagers is still underused 4-6.

Some reports  about FNAC employment in the early years  of life  advocate its value  in a very similar way  as in adulthood 7-10 but  many pediatricians reject it  arguing poor child cooperation  during the puncture, the need of sedation, the inability to obtain an adecuate sample and  the intrinsic diagnostic difficulties  of small round blue cell tumors of infancy.

It is our purpose to demonstrate our experience with the use of FNAC in  a  major children hospital and prove its statistical value. We haven’t found any previus  pediatric report  with such a  diversity of sites punctured.


Material y Métodos    


Previous approbation of this research by the local institutional  review board, archives of cytopathology at William Soler  Pediatric Hospital were reviewed   from January 1992 to September 2002. An Excel data base  was made   with  data from all punctured patients younger than 21 years.  Later,   histopathology archives were   reviewed  to correlate  cytology and histology.  Evolutive clinical data (1-118 moths) of  punctured cases  without biopsy were also correlated.  Statistical results were obtained  analyzing   the data base. Figures, tables and graphics were done as needed 11.  The punctures without anesthesia  were mainly done  by a pathologist with experience and special interest  in this area according to established standards 1,3,12.

The  cytologic samples  obtained by puncture  were expelled and  smeared  onto glass slides  and stained  with May Grünwald Giemsa or  Hematoxylin-Eosin. Diagnosis was done knowing  clinical data and  pertinent laboratory and image  information when available. Thoracic and mediastinal  punctures under  thoracoscopic guide were performed  by surgeons under anesthesia. Deep abdominal  tumors were punctured with or without  real time ultrasonography but without guide, sedation or anesthesia.

Cytology diagnoses   were classified  as benign (neoplastic or not), malignant (with or without histogenetic approach), suspected of malignancy (intermediate diagnostic category not enough  to make  a malignant diagnosis of certitude) and insufficient.



During the almost 11 years  that the investigation  last  3274 punctures were done on   3187 patients. A progressive increase in FNAC demand  was observed  during the first years (Figure 1). Later a stabilization in  the number  of punctures per year  was noticed. A decrease  in 2002  is related to the investigation dead-line date investigation in September 2002. 
In figure 2 it is shown  a distribution of punctures  by sex and age. Males were  1815 (55%) and females were  1450 (44%). Sex was unknown in 9 patients.
There  was a mild predominance of  male children  between one and seven years old.  In older ages a discrete  predominance of  female sex was also observed. The youngest patient was 2 days old, the  mean age was 5,9 years and the median age was  10 years. 
Race was stated in  1179 (70%) white patients, 317 (19%)   mestize  and 179 (11%) black children. Race was unknown in 1599 children.
In Table I it is shown  the number of punctures done according to the site. The lymph nodes were  the predominant  organs examined followed by the soft tissue ,  thyroid  and breast.  It is important to notice a predominance in abdominal punctures 119 (3,6%) over thoracic area 37 (1,1%). The abdomen was  punctured 3 times more than the thorax.
We observed four deep FNAC complications: a cardiac tamponade, two hemoperitoneum (only one required surgery and died secundary to sepsis) and a massive digestive bleeding (that also required surgery). The complication rate was 0,1%.
In Figure 3 it is depicted  the number of FNAC  by site according age groups (one to 18 years). Lymph nodes and soft tissue punctures  decreased  with age increase. On a contrary thyroid and breast punctures increased with age. 
From the total of 3274 FNAC done,  353 (10,7%) were insufficient, 2651 (80,9%) were benign, 198 (6%) were malignant, and 72 (2,4%) were suspected of malignancy. Our malignant/benign ratio was 13,3. The most  frequent tumors  were Non Hodgkin lymphoma, Hodgkin lymphoma, leukemia, nephroblastoma, neuroblastoma,  Ewing's sarcoma, osteosarcoma and rhabdomiosarcoma.
In 630 punctures,  cytohistopathological or clinicocytopathological correlation was possible. 69 punctures were insufficient, 321 true negative, 184 true positive, 19 false negative  and 37 false positive.  No patient was oncosurgically treated  without a corroborative biopsy of the malignant nature of the illness. Statistical values calculated  in this series were: sensibility 90.6%, specificity 89.6%, efficacy 90%, positive predictive value 83.2%, negative predictive value 94,4% and prevalence 36,1%.      
  Table I

Distribution of punctures by  organ or site

Organ or site



Organ or site












Soft tissue









Lymph nodes






Salivary glands









Adrenal gland



































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Figure 1 -

Figure 1.

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Figure 2.

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Figure 3 -

Figure 3.



Pediatric FNAC is  nowadays an increasingly used technique. Literature review shows  that pure pediatric  series are rare, some of them covering up to  300 patients  of different ages. It has been our  objective  to analyze  and present  a first  report  with  3274 FNAC done  in  22 sites or organs. 
We had an increasing  FNAC demand in the first years of the study as  Howell LP reported 5  and  most of  our patients  were 7 years old or  younger.  Our  mean  age  was very similar  as that reported by  Orford JE et al 13 but less than the age reported by Gamba PG et al 14. Our  median  age  was   also very close  to  the age reported by Silverman JF et al (10,5 years) 9. The youngest and oldest   patients in this later report  were also as ours: one day  and 18 years 9. Almeida MM et al, Gamba PG et al, Millar AJW  et al, and Smith MB et al  14-17 had a narrower spectrum  of age  than ours as well as Silverman's  9.
 We found a predominance of the male sex in our  study as has been  noticed by other authors 8,14,15,17,18. Half and quarter  of our punctures  corresponded to lymph nodes and soft tissue. Wakely PE et al reported that  their most frequent benign and malignant  diagnosis depended on  these sites and thyroid 8. Eisenhut CC et al had a higher percentage of lymph nodes, breast, thyroid and salivary gland  punctures than ours, but less of soft tissue 18.  We had also the same distribution of punctures by site and  ages 18. Gamba PG et al  had  lymph  nodes,  and head and neck as the most  frequent sites 14.
We punctured 3 times more abdomen sites than  thorax and mediastinum. The incidence of  pediatric abdominal tumors  is higher  than  the incidence of mediastinum and lung  tumors 19.
We had 10,7%  of insufficient  punctures, less than  many authors 7-9,14,15,17,20-30. There is a wide  variation  of percentages of  benign and malignant  diagnosis in pediatric FNAC reports   that depends  on the design and objectives of the study itself. In our series we had  a very  low  percentage  of malignant diagnosis 7-10,13-18,20-30. Only Eisenht CC et al  had a lower percentage  of malignancy 4.5% 18. This difference may be due to the characteristics of  the cases  we punctured:  mainly   ambulatory children  and teenagers  sent from external  medical  services.  A very similar situation was  found in  the  benign  cytologic category. We had  80,9% of  negative punctures, also a very  high  value. Most authors reported values from 81% to 8,6% 9,13-15,20,30. Only Eisenhut  CC et al had a higher value than ours 95,5% 18. Suspicious diagnosis was 2,4%  in our  series. Values of suspicious category oscillate from 0% to 17,5% 8,14,15,20,24,30. Our benign/malignant  rate was high but lower than the figure  reported by Eisenhut CC et al of 22 18. Our most frequent malignant tumors were also reported by  Tayler SR et al and Schaller RT et al 22,25.
Our series had a sensibility of 90,6%. Only Diament MJ et al   reported  a sensibility lower than ours 23. The rest of the authors  had a higher  value up to 100% 7-10,13-18,20-22,24-30. Our specificity  was  89,6%. Verdeguer A et al  reported a value lower than  ours: 80% 20.  The other authors  also reported  higher values , even 100% 7-10,13-18,21-30.
We had  4 important  FNAC complications with a very low  incidence. Geisinger had stated in his cytopathology book the exceedingly low  incidence of FNAC complications in pediatrics 31. The complication rate  of this series was very low at 0,1%. Valkov I et al, Millar AJ  et al, Jereb  B et al, Schaller  RT et al, Gamba PG et al,  and Diament  MJ et al reported no complications in their series composed by 25-96 patients 7,14,16,23,25,26. These reports had 1,8-0,7% of   the number of our punctures, then the probability  of complications would be practically null.




In conclusion: FNAC  can be used in pediatrics  in a similar way  as it  is employed in adult  age.



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- Julia Cecilia Cruz Mojarrieta (02/10/2005 15:47:10)

Dr. Roberto, me satisface mucho ver tu resultados en el virtual, para que lo puedan leer muchos colegas de todo el mundo.
Creo es una muestra de como hacer mucho bien hecho con muy poco. Suerte.

- Santiago Quintero (10/10/2005 22:51:42)

Muy buen trabajo, producto de tu esfuerzo. Mis felictaciones

- JORGE SAINZ BALLESTEROS (20/10/2005 12:26:19)


- Juan Carlos Perez-Cardenas (25/10/2005 3:47:52)

Aprovecho la oportunidad para saludarte pues en persona se me ha hecho muy dificil, pero sigo al tanto de tu situacion.
Como siempre un magnifico trabajo.
Un abrazo Juan Carlos

- Manuel Diaz-Marta Puentes (14/10/2011 5:29:52)


- Manuel Diaz-Marta Puentes (14/10/2011 5:29:53)


- Manuel Diaz-Marta Puentes (14/10/2011 5:29:54)


- Manuel Diaz-Marta Puentes (18/02/2012 6:38:23)


- Manuel Diaz-Marta Puentes (18/02/2012 6:38:23)


- Manuel Diaz-Marta Puentes (18/02/2012 6:38:24)




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