Fine needle aspiration cytology for parotid neoplasms: risk of malignancy through inconclusive results and lower grade tumors

  • Andrea Galli
  • Michele Tulli
  • Leone GiordanoEmail author
  • Matteo Biafora
  • Davide Di Santo
  • Stefano Bondi
  • Lucia Oriella Piccioni
  • Mario Bussi
Head and Neck



Fine needle aspiration cytology (FNAC) is a commonly performed procedure for parotid masses, although its accuracy in detecting malignancies widely varies through different series. We evaluated our single-center cohort of parotidectomies to highlight possible limitations of preoperative FNAC.


Seven hundred and eighteen consecutive patients submitted to parotid surgery at San Raffaele Scientific Institute (Milan) were retrospectively evaluated (2002–2018). Five hundred and fifty four FNAC were analyzed. FNAC accuracy was assessed with and without inclusion of “inconclusive” results. The peculiar role of lower grade primary parotid cancers was investigated.


FNAC reports were “diagnostic” in 502 cases (90.4%) and “inconclusive” in 52 (9.6%). Histopathology revealed 488 benign lesions (88.1%) and 66 malignancies (11.9%). FNAC sensitivity, specificity, PPV, NPV and accuracy in detecting malignancies were 59%, 99%, 89%, 95%, and 95%, respectively. Sensitivity fell to 48%, when “inconclusive” FNAC was computed. Within 66 parotid cancers, FNAC could discriminate malignancy in 32 cases (48.5%), provide proper grading in 21 (31.8%), and precise histopathological diagnosis in 15 (22.7%). Malignancy was more likely in patients with “inconclusive” FNAC than in those with “diagnostic” cytologies (23.1% vs 10.8%, p = 0.003). Low-intermediate-grade primary parotid cancers were associated to a higher rate of FNAC failure in comparison with high-grade ones (86.4% vs 19.0%; p < 0.001).


FNAC is an important tool for preoperative assessment of parotid masses, though its sensitivity in detecting malignancy remains poor. “Inconclusive” FNAC results could further jeopardize FNAC accuracy and should elicit resorting to additional tests, especially when a lower grade parotid cancer is suspected.


Parotid Salivary glands Head and neck Fine needle aspiration cytology Malignancy 


Compliance with ethical standards

Conflict of interest

None of the authors has potential conflicts of interest to disclose.

Research involving human participants and/or animals

All performed procedures and retrospective data management were in accordance with the ethical standards of our institutional and national research ethical committee and with the principles stated in the Declaration of Helsinki “Ethical Principles for Medical Research Involving ‘Human Subjects”, adopted by the 18th World Medical Assembly (Helsinki, Finland, June 1964) and as amended most recently by the 64th World Medical Assembly (Fortaleza, Brazil, October 2013).

Informed consent

Informed consent for retrospective data management was obtained for all subjects.


  1. 1.
    Liu CC, Jethwa AR, Khariwala SS, Johnson J, Shin JJ (2016) Sensitivity, specificity, and posttest probability of parotid fine-needle aspiration: a systematic review and meta-analysis. Otolaryngol Head Neck Surg 154(1):9–23. CrossRefPubMedGoogle Scholar
  2. 2.
    Frable MA, Frable WJ (1991) Fine-needle aspiration biopsy of salivary glands. Laryngoscope. 101(3):245–249. CrossRefPubMedGoogle Scholar
  3. 3.
    O'Brien CJ (2003) Current management of benign parotid tumors–the role of limited superficial parotidectomy. Head Neck 25(11):946–952. CrossRefPubMedGoogle Scholar
  4. 4.
    Suzuki M, Kawata R, Higashino M, Nishikawa S, Terada T, Haginomori SI et al (2019) Values of fine-needle aspiration cytology of parotid gland tumors: a review of 996 cases at a single institution. Head Neck 41(2):358–365. CrossRefPubMedGoogle Scholar
  5. 5.
    Zbaren P, Schar C, Hotz MA, Loosli H (2001) Value of fine-needle aspiration cytology of parotid gland masses. Laryngoscope 111(11 Pt 1):1989–1992. CrossRefPubMedGoogle Scholar
  6. 6.
    Zbaren P, Vander Poorten V, Witt RL, Woolgar JA, Shaha AR, Triantafyllou A et al (2013) Pleomorphic adenoma of the parotid: formal parotidectomy or limited surgery? Am J Surg. 205(1):109–118. CrossRefPubMedGoogle Scholar
  7. 7.
    Piccioni LO, Fabiano B, Gemma M, Sarandria D, Bussi M (2011) Fine-needle aspiration cytology in the diagnosis of parotid lesions. Acta otorhinolaryngol Ital 31(1):1–4PubMedPubMedCentralGoogle Scholar
  8. 8.
    Rossi ED, Faquin WC (2018) The Milan system for reporting salivary gland cytopathology (MSRSGC): an international effort toward improved patient care-when the roots might be inspired by Leonardo da Vinci. Cancer Cytopathol. 126(9):756–766. CrossRefPubMedGoogle Scholar
  9. 9.
    Wu M (2011) A comparative study of 200 head and neck FNAs performed by a cytopathologist with versus without ultrasound guidance: evidence for improved diagnostic value with ultrasound guidance. Diagn Cytopathol. 39(10):743–751. CrossRefPubMedGoogle Scholar
  10. 10.
    El-Naggar AK, Chan JKC, Grandis JR, Takata T, Slootweg PJ (2017) WHO classification of head and neck tumours, 4th edn, IARC, LyonGoogle Scholar
  11. 11.
    Carrillo JF, Ramirez R, Flores L, Ramirez-Ortega MC, Arrecillas MD, Ibarra M et al (2009) Diagnostic accuracy of fine needle aspiration biopsy in preoperative diagnosis of patients with parotid gland masses. J Surg Oncol 100(2):133–138. CrossRefPubMedGoogle Scholar
  12. 12.
    Eytan DF, Yin LX, Maleki Z, Koch WM, Tufano RP, Eisele DW et al (2018) Utility of preoperative fine needle aspiration in parotid lesions. Laryngoscope. 128(2):398–402. CrossRefPubMedGoogle Scholar
  13. 13.
    Tryggvason G, Gailey MP, Hulstein SL, Karnell LH, Hoffman HT, Funk GF et al (2013) Accuracy of fine-needle aspiration and imaging in the preoperative workup of salivary gland mass lesions treated surgically. Laryngoscope. 123(1):158–163. CrossRefPubMedGoogle Scholar
  14. 14.
    Zbaren P, Nuyens M, Loosli H, Stauffer E (2004) Diagnostic accuracy of fine-needle aspiration cytology and frozen section in primary parotid carcinoma. Cancer 100(9):1876–1883. CrossRefPubMedGoogle Scholar
  15. 15.
    Que Hee CG, Perry CF (2001) Fine-needle aspiration cytology of parotid tumours: is it useful? ANZ J Surg. 71(6):345–348CrossRefGoogle Scholar
  16. 16.
    Zbaren P, Zbaren S, Caversaccio MD, Stauffer E (2008) Carcinoma ex pleomorphic adenoma: diagnostic difficulty and outcome. Otolaryngol Head Neck Surg 138(5):601–605. CrossRefGoogle Scholar
  17. 17.
    Fundakowski C, Castano J, Abouyared M, Lo K, Rivera A, Ojo R et al (2014) The role of indeterminate fine-needle biopsy in the diagnosis of parotid malignancy. Laryngoscope 124(3):678–681. CrossRefGoogle Scholar
  18. 18.
    Feinstein AJ, Alonso J, Yang SE, St John M (2016) Diagnostic accuracy of fine-needle aspiration for parotid and submandibular gland lesions. Otolaryngol Head Neck Surg 155(3):431–436. CrossRefGoogle Scholar
  19. 19.
    Badlani J, Gupta R, Balasubramanian D, Smith J, Luk P, Clark J (2018) Primary salivary gland malignancies: a review of clinicopathological evolution, molecular mechanisms and management. ANZ J Surg. 88(3):152–157. CrossRefPubMedGoogle Scholar
  20. 20.
    Espinoza S, Malinvaud D, Siauve N, Halimi P (2013) Perfusion in ENT imaging. Diagn Interv Imaging. 94(12):1225–1240. CrossRefPubMedGoogle Scholar
  21. 21.
    Schmidt RL, Hunt JP, Hall BJ, Wilson AR, Layfield LJ (2011) A systematic review and meta-analysis of the diagnostic accuracy of frozen section for parotid gland lesions. Am J Clin Pathol 136(5):729–738. CrossRefPubMedGoogle Scholar
  22. 22.
    Cibas ES, Ali SZ (2017) The 2017 Bethesda system for reporting thyroid cytopathology. Thyroid 27(11):1341–1346. CrossRefPubMedGoogle Scholar
  23. 23.
    Sood S, McGurk M, Vaz F (2016) Management of salivary gland tumours: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 130(S2):S142–S149. CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Nishikawa S, Kawata R, Higashino M, Lee K, Terada T, Kurisu Y et al (2015) Assessing the histological type and grade of primary parotid carcinoma by fine-needle aspiration and frozen section. Auris Nasus Larynx 42(6):463–468. CrossRefPubMedGoogle Scholar
  25. 25.
    Nagao T, Sugano I, Ishida Y, Hasegawa M, Matsuzaki O, Konno A et al (1998) Basal cell adenocarcinoma of the salivary glands: comparison with basal cell adenoma through assessment of cell proliferation, apoptosis, and expression of p53 and bcl-2. Cancer 82(3):439–447CrossRefGoogle Scholar
  26. 26.
    Tabatabai ZL, Auger M, Kurtycz DF, Laser A, Souers RJ, Laucirica R et al (2015) Performance characteristics of adenoid cystic carcinoma of the salivary glands in fine-needle aspirates: results From the College of American Pathologists Nongynecologic Cytology Program. Arch Pathol Lab Med. 139(12):1525–1530. CrossRefPubMedGoogle Scholar
  27. 27.
    Lombardi D, McGurk M, Vander Poorten V, Guzzo M, Accorona R, Rampinelli V et al (2017) Surgical treatment of salivary malignant tumors. Oral Oncol. 65:102–113. CrossRefPubMedGoogle Scholar
  28. 28.
    Mantsopoulos K, Koch M, Klintworth N, Zenk J, Iro H (2015) Evolution and changing trends in surgery for benign parotid tumors. Laryngoscope 125(1):122–127. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of OtorhinolaryngologySan Raffaele Scientific InstituteMilanItaly

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