Fine-needle aspiration cytology (FNAC) is a widely used diagnostic technique for the evaluation of palpable and image-guided lesions because it is minimally invasive, economical, rapid, and associated with a low risk of complications. It provides valuable information regarding the nature of a lesion and helps distinguish inflammatory, infective, benign, and malignant conditions, thereby facilitating timely clinical decision-making. FNAC is routinely employed for lesions involving the thyroid, breast, lymph nodes, salivary glands, soft tissues, and other anatomical sites. However, its diagnostic performance is influenced by several factors, including sampling adequacy, lesion characteristics, cytomorphological features, procedural technique, and the experience of the cytopathologist. Consequently, diagnostic accuracy may vary considerably across different anatomical locations [1-3]. Anatomical location is particularly important because tissues differ in their cellular composition, structural organization, vascularity, and patterns of pathological involvement. In a study evaluating FNAC of neck masses, Carr et al. reported diagnostic accuracies of 87% for lymph nodes, 89% for salivary glands, and 69% for thyroid lesions, demonstrating substantial variation in performance according to the site sampled [2]. Such differences indicate that the overall diagnostic accuracy of FNAC may not adequately represent its reliability at individual anatomical locations. Differences in lesion accessibility, depth, cystic or necrotic changes, and the ability to obtain representative cellular material may further contribute to variations in diagnostic outcomes [1, 3]. The diagnostic challenges associated with individual anatomical sites illustrate this variability. In thyroid lesions, FNAC is valuable for identifying suspicious and malignant nodules; however, distinguishing follicular adenoma from follicular carcinoma generally requires histopathological demonstration of capsular or vascular invasion [4]. In breast lesions, cytological interpretation may be complicated by overlapping features among benign proliferative lesions, atypical lesions, and low-grade malignancies. Standardized reporting systems, including the International Academy of Cytology Yokohama System, have been developed to improve diagnostic consistency and communicate the risk of malignancy [5, 6]. Comparative evidence also demonstrates that the performance of FNAC must be interpreted in relation to the diagnostic requirements of individual breast lesions [7]. Similar limitations occur in other anatomical locations. Salivary gland lesions exhibit considerable morphological diversity, with overlapping cytological features, variable stromal components, and occasional sampling-related difficulties that may result in false-positive or false-negative diagnoses [8, 9]. The Milan System for Reporting Salivary Gland Cytopathology provides a standardized framework for categorization and risk stratification [10]. In lymph node lesions, FNAC is useful for detecting metastatic malignancy and evaluating reactive or granulomatous lymphadenopathy; nevertheless, the diagnosis and classification of certain lymphomas may require additional investigations, including flow cytometry, immunophenotyping, or tissue biopsy [11, 12]. Likewise, bone and soft-tissue lesions may pose challenges because of tumour heterogeneity, inadequate cellularity, and overlapping cytomorphological patterns [13]. These examples emphasize that diagnostic discordance may arise from both sampling errors and inherent site-specific limitations of cytological assessment. Clinicopathological correlation is therefore essential for evaluating the diagnostic utility of FNAC. Comparison of cytological findings with corresponding histopathological diagnoses enables assessment of concordance, identification of diagnostic discrepancies, and calculation of sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy [1, 8, 11]. Such an approach can identify anatomical sites with comparatively high diagnostic reliability and those requiring improved sampling techniques, image guidance, repeat aspiration, or ancillary investigations. Despite the established role of FNAC, evaluating its performance across multiple anatomical locations within a common clinical setting is important because differences in case selection, procedural methods, and reporting practices may influence published estimates. Therefore, the present study aims to evaluate the relationship between anatomical location and diagnostic accuracy by correlating cytological findings with histopathological diagnoses.

A hospital-based observational diagnostic-accuracy study was conducted in the Department of Pathology at a tertiary care hospital in Bihar over the period from July 2025 to June 2026. The study evaluated the association between anatomical location and the diagnostic accuracy of fine-needle aspiration cytology (FNAC) by comparing cytological diagnoses with corresponding histopathological diagnoses. Histopathology was considered the reference standard for assessing diagnostic performance. Study Population The study population comprised patients who underwent FNAC for clinically or radiologically detected lesions involving different anatomical locations, including the thyroid, breast, lymph nodes, salivary glands, skin and soft tissues, bone, and abdominal or thoracic masses where image-guided FNAC was available. Patients with a documented cytological diagnosis and corresponding histopathological findings were included in the primary diagnostic-accuracy analysis. Cases with inadequate cytological material, unavailable histopathological confirmation, or incomplete records were excluded from the relevant accuracy calculations; however, inadequate aspirates were considered when assessing the sample inadequacy rate. Sampling Method & Sample Size Consecutive sampling was employed, and eligible patients presenting during the study period were recruited until the required sample size was achieved. The sample size was calculated using the overall diagnostic accuracy of 93.5% reported by Rammeh et al. (2019) [14]. Using the formula n=Z^2 P(1-P)/d^2, where Z=1.96for a 95% confidence level, P=0.935, and an absolute precision (d) of 0.05, the minimum required sample size was calculated to be 93.39, which was rounded up to 94 participants. After adjustment for 10% potentially non-evaluable cases, the final target sample size was 105 patients. Outcome Parameters The primary outcome was the diagnostic accuracy of FNAC across anatomical locations, determined by its agreement with histopathological findings. Secondary outcomes included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), false-positive and false-negative rates, cytopathological–histopathological concordance, and the proportion of inadequate or non-diagnostic aspirates. The distribution of benign, malignant, inflammatory, infective, and other lesions across anatomical sites was also evaluated. Methodology Relevant demographic and clinical information, including age, sex, presenting complaint, anatomical location, lesion characteristics, and available radiological findings, was recorded using a structured data collection sheet. Each lesion was classified according to its principal anatomical site to facilitate site-wise comparisons. Palpable superficial lesions underwent FNAC using standard aseptic precautions and an appropriate needle-and-syringe technique. Ultrasound or computed tomography guidance was used for deep-seated, non-palpable, abdominal, or thoracic lesions when clinically indicated and available. Cytological smears were prepared, stained using routine departmental protocols, and examined by a pathologist. Samples were categorized according to their cytomorphological features and the reporting system applicable to the anatomical site, wherever relevant. Corresponding histopathological reports from biopsy or excision specimens were retrieved for eligible cases. Cytological and histopathological diagnoses were classified into comparable diagnostic categories. Each cytological result was then compared with the reference diagnosis and categorized as a true positive, true negative, false positive, or false negative for the primary analysis of malignancy. Non-diagnostic samples were recorded separately and were not classified as benign or malignant for calculations requiring a definitive cytological result. Discordant cases were reviewed, where records and material permitted, to identify potential sampling-related or interpretative discrepancies. Statistical Analysis Data were entered into Microsoft Excel and analyzed using Jamovi version 2.7.38. Categorical variables were summarized as frequencies and percentages, while continuous variables were expressed as mean and standard deviation or median and interquartile range, as appropriate. Diagnostic sensitivity, specificity, PPV, NPV, and overall accuracy were calculated from two-by-two contingency tables, with corresponding 95% confidence intervals. Associations between anatomical location and categorical diagnostic outcomes were assessed using the chi-square test or Fisher’s exact test, as appropriate. A two-sided p-value of less than 0.05 was considered statistically significant. Ethical Consideration The study was conducted after obtaining approval from the Institutional Ethics Committee. Institutional confidentiality requirements were followed, and patient information was anonymized before analysis. Informed consent was obtained from participants or their legally authorized representatives when required by the approved study protocol. For retrospective record-based components, consent requirements and any waiver were determined by the Institutional Ethics Committee.

Among the 105 study participants, the largest proportion belonged to the 40–59-year age group (42; 40.0%). Males constituted 54.3% (n = 57). The thyroid and lymph nodes were the most frequently sampled anatomical locations, each representing 25.7% (n = 27) of cases, followed by the breast (19.0%; n = 20). Salivary gland and skin/soft-tissue lesions each accounted for 8.6% (n = 9), while abdominal/thoracic masses and bone lesions constituted 7.6% (n = 8) and 4.8% (n = 5), respectively. Table 1. Sociodemographic characteristics and anatomical distribution of study participants (N = 105) Characteristic Frequency (n) Percentage (%) Age group (years) Below 20 7 6.7 20–39 31 29.5 40–59 42 40.0 60 and above 25 23.8 Sex Male 57 54.3 Female 48 45.7 Anatomical location Thyroid 27 25.7 Lymph nodes 27 25.7 Breast 20 19.0 Salivary glands 9 8.6 Skin and soft tissues 9 8.6 Bone lesions 5 4.8 Abdominal and thoracic masses 8 7.6 Total participants 105 100.0 Of the 105 FNAC samples, benign/non-neoplastic lesions constituted the largest diagnostic category (35; 33.3%), followed by malignant lesions (28; 26.7%) and inflammatory/infective lesions (27; 25.7%). Suspicious/atypical lesions accounted for 7.6% (n = 8), while 6.7% (n = 7) of aspirates were inadequate or non-diagnostic. Overall, 93.3% of samples yielded a diagnosis other than an inadequate/non-diagnostic result. Table 2. Distribution of cases according to FNAC cytological diagnosis (N = 105) Cytological diagnosis Frequency (n) Percentage (%) Benign/non-neoplastic lesions 35 33.3 Inflammatory/infective lesions 27 25.7 Suspicious/atypical lesions 8 7.6 Malignant lesions 28 26.7 Inadequate/non-diagnostic aspirates 7 6.7 Total 105 100.0 Among the 105 recruited cases, 7 (6.7%) had inadequate samples, while 4 additional cases (3.8%) had adequate cytological samples but lacked histopathological correlation. Consequently, 94 cases (89.5%) were included in the diagnostic-accuracy analysis. Thyroid and lymph node lesions each contributed 24 evaluable cases out of 27 recruited, corresponding to 88.9%; breast lesions contributed 18 of 20 cases (90.0%). Salivary gland and skin/soft-tissue lesions each contributed 8 of 9 cases (88.9%), while all 8 abdominal/thoracic masses and 4 of 5 bone lesions were included. The overall inadequacy rate was 6.7%, and 10.5% of recruited cases were excluded from the diagnostic-accuracy analysis. Table 3. Adequacy of FNAC samples and availability of histopathological correlation according to anatomical location Anatomical location Cases recruited (n) Inadequate samples (n) Adequate samples without histopathology (n) Cases included in diagnostic-accuracy analysis (n) Thyroid 27 2 1 24 Lymph nodes 27 2 1 24 Breast 20 1 1 18 Salivary glands 9 1 0 8 Skin and soft tissues 9 1 0 8 Bone lesions 5 0 1 4 Abdominal and thoracic masses 8 0 0 8 Total 105 7 4 94 Overall, FNAC demonstrated a sensitivity of 89.5% (95% CI: 75.2–97.1), specificity of 96.4% (95% CI: 87.7–99.6), positive predictive value (PPV) of 94.4% (95% CI: 81.3–99.3), negative predictive value (NPV) of 93.1% (95% CI: 83.3–98.1), and diagnostic accuracy of 93.6% (95% CI: 86.6–97.6). Lymph node lesions showed a sensitivity of 90.9%, specificity of 100.0%, and accuracy of 95.8%, while breast lesions demonstrated a sensitivity of 87.5%, specificity of 100.0%, and accuracy of 94.4%. Thyroid lesions had an accuracy of 91.7%, whereas salivary gland and skin/soft-tissue lesions each showed an accuracy of 87.5%. Bone lesions and abdominal/thoracic masses demonstrated 100.0% sensitivity, specificity, and accuracy; however, these estimates were based on only 4 and 8 cases, respectively, and had wide confidence intervals. Table 4. Diagnostic performance of FNAC according to anatomical location Anatomical location Sensitivity % (95% CI) Specificity % (95% CI) PPV % (95% CI) NPV % (95% CI) Accuracy % (95% CI) Thyroid 85.7 (42.1–99.6) 94.1 (71.3–99.9) 85.7 (42.1–99.6) 94.1 (71.3–99.9) 91.7 (73.0–99.0) Lymph nodes 90.9 (58.7–99.8) 100.0 (75.3–100.0) 100.0 (69.2–100.0) 92.9 (66.1–99.8) 95.8 (78.9–99.9) Breast 87.5 (47.3–99.7) 100.0 (69.2–100.0) 100.0 (59.0–100.0) 90.9 (58.7–99.8) 94.4 (72.7–99.9) Salivary glands 66.7 (9.4–99.2) 100.0 (47.8–100.0) 100.0 (15.8–100.0) 83.3 (35.9–99.6) 87.5 (47.3–99.7) Skin and soft tissues 100.0 (29.2–100.0) 80.0 (28.4–99.5) 75.0 (19.4–99.4) 100.0 (39.8–100.0) 87.5 (47.3–99.7) Bone lesions 100.0 (15.8–100.0) 100.0 (15.8–100.0) 100.0 (15.8–100.0) 100.0 (15.8–100.0) 100.0 (39.8–100.0) Abdominal and thoracic masses 100.0 (39.8–100.0) 100.0 (39.8–100.0) 100.0 (39.8–100.0) 100.0 (39.8–100.0) 100.0 (63.1–100.0) Overall 89.5 (75.2–97.1) 96.4 (87.7–99.6) 94.4 (81.3–99.3) 93.1 (83.3–98.1) 93.6 (86.6–97.6) PPV = positive predictive value; NPV = negative predictive value; CI = confidence interval. The 95% CIs were calculated using the exact binomial method. Among the 94 cases included in the diagnostic-accuracy analysis, FNAC findings were concordant with histopathological diagnoses in 88 cases (93.6%), while 6 cases (6.4%) showed discordance. The highest concordance was observed in bone lesions and abdominal/thoracic masses, with 100.0% agreement (4/4 and 8/8 cases, respectively). Lymph node lesions showed 95.8% concordance (23/24), followed by breast lesions at 94.4% (17/18) and thyroid lesions at 91.7% (22/24). Salivary gland and skin/soft-tissue lesions each demonstrated 87.5% concordance (7/8). Table 5. Association between anatomical location and FNAC–histopathological diagnostic concordance Anatomical location Concordant diagnoses (n) Discordant diagnoses (n) Concordance rate (%) Thyroid 22 2 91.7 Lymph nodes 23 1 95.8 Breast 17 1 94.4 Salivary glands 7 1 87.5 Skin and soft tissues 7 1 87.5 Bone lesions 4 0 100.0 Abdominal and thoracic masses 8 0 100.0 Total 88 6 93.6

The present study evaluated the diagnostic accuracy of fine-needle aspiration cytology (FNAC) across different anatomical locations by correlating cytological findings with histopathological diagnoses. FNAC demonstrated an overall sensitivity of 89.5%, specificity of 96.4%, positive predictive value (PPV) of 94.4%, negative predictive value (NPV) of 93.1%, and diagnostic accuracy of 93.6%. The secondary outcomes revealed an inadequate sample rate of 6.7% and a cytopathological–histopathological concordance rate of 93.6%. Diagnostic performance varied across anatomical locations, with lymph node and breast lesions showing high concordance, whereas salivary gland and skin/soft-tissue lesions demonstrated comparatively lower concordance. Bone and abdominal/thoracic lesions showed 100% accuracy; however, these findings require cautious interpretation because of the small subgroup sizes. The overall diagnostic performance observed in the present study is comparable to that reported in previous investigations. Rammeh et al. (2019), in their retrospective analysis of 1,262 head and neck FNAC specimens, reported a sensitivity of 92%, specificity of 94.4%, and diagnostic accuracy of 93.5% [14]. Similarly, Ahn et al. (2015) reported a diagnostic accuracy of 91.6%, sensitivity of 88.2%, and specificity of 98.2% for head and neck lesions, which broadly agrees with our findings [15]. A systematic review and meta-analysis by Saman et al. (2026), involving 27 studies and 11,284 patients, reported pooled sensitivity and specificity of 91.2% and 95.8%, respectively [16]. Collectively, these findings support the diagnostic utility of FNAC while demonstrating that its performance depends on the clinical and procedural context. Regarding the distribution of cytological diagnoses, benign/non-neoplastic lesions constituted the largest category in our study (33.3%), followed by malignant (26.7%) and inflammatory/infective lesions (25.7%). Suspicious/atypical lesions accounted for 7.6% of cases. These proportions differ from site-specific studies because the present investigation included lesions from multiple anatomical locations. For example, Alhassan et al. (2022) reported that 73.7% of thyroid FNAC specimens were benign/non-neoplastic [17], whereas Ton Eryilmaz et al. (2021) found reactive lymphoid hyperplasia in 61% of lymph node aspirates [18]. Mohanty et al. (2020), in contrast, reported a malignancy prevalence of 57.86% among women presenting with palpable breast lumps [19]. Such differences are expected because disease prevalence and pathological patterns vary according to the anatomical site, referral population, clinical selection criteria, and availability of histopathological confirmation. The overall inadequacy rate of 6.7% observed in our study indicates that most aspirates provided interpretable cytological material. This finding compares favourably with the 8.1% inadequacy rate reported by Ahn et al. (2015) and the 7.4% unsatisfactory rate reported by Alhassan et al. (2022) for thyroid FNAC [15, 17]. It also falls between the inadequate sample rates reported by Saman et al. (2026) for ultrasound-guided FNAC (5.1%) and conventional FNAC (14.2%) [16]. Nevertheless, inadequate cellularity can arise from cystic or necrotic changes, lesion depth, sampling error, and difficulty obtaining representative material. Repeat aspiration, image guidance, and on-site adequacy assessment may help reduce non-diagnostic results in selected cases. Site-specific analysis showed that lymph node lesions had an accuracy of 95.8%, sensitivity of 90.9%, and specificity of 100%, with 95.8% concordance. These findings are comparable to those of Ton Eryilmaz et al. (2021), who reported 94.1% accuracy, 87.9% sensitivity, and 100% specificity [18]. Rammeh et al. (2019) also reported high sensitivity and 100% specificity for lymph node FNAC [14]. The strong performance may reflect the utility of cytomorphological assessment in identifying metastatic malignancy and common inflammatory or reactive processes. For breast lesions, our study demonstrated 94.4% accuracy, 87.5% sensitivity, and 100% specificity. Mohanty et al. (2020) reported higher sensitivity (93.42%) and accuracy (96.19%), with specificity of 100% [19], while Khemka et al. (2008) reported sensitivity of 96% and specificity of 100% [20]. The lower sensitivity in our study may be attributable to the smaller breast-lesion subgroup, differences in lesion characteristics, and sampling or interpretative limitations. Wang et al. (2017) additionally demonstrated that core needle biopsy had greater pooled sensitivity than FNAC for suspicious breast lesions, highlighting the potential need for tissue sampling in selected cases with persistent clinical or radiological suspicion [21]. Thyroid lesions demonstrated 91.7% accuracy in our study, compared with 89.9% reported by Alhassan et al. (2022), 82.52% by Erkinuresin et al. (2020), and 97% cytological–histopathological correlation reported by Sharma et al. (2015) [17, 22, 23]. Follicular-patterned lesions, cystic changes, and multinodular disease are recognised sources of diagnostic difficulty. Salivary gland and skin/soft-tissue lesions each showed 87.5% accuracy, with salivary gland sensitivity of 66.7%. The relatively lower performance is consistent with the diagnostic challenges associated with morphological heterogeneity and overlapping cytological features. Saman et al. (2026) likewise reported lower pooled sensitivity for salivary gland lesions than for thyroid lesions [16]. Finally, bone and abdominal/thoracic lesions demonstrated 100% accuracy in our study. However, these estimates were based on only four and eight cases, respectively, and should not be interpreted as definitive evidence of perfect diagnostic performance. Sumana et al. (2015) and Hemalatha et al. (2013) reported abdominal lesion accuracies of 96.43% and 96.3%, respectively [24, 25], while Chambers et al. (2020) reported pooled sensitivity of 95.6% and specificity of 96.9% for musculoskeletal lesions [26]. The six discordant cases in our study further demonstrate that false-positive and false-negative results remain possible. Overall, our findings support FNAC as a reliable initial diagnostic procedure, while emphasizing the importance of anatomical location, sample adequacy, clinicoradiological correlation, and histopathological confirmation whenever indicated. The study had certain limitations. The relatively small sample size and limited number of cases within individual anatomical subgroups reduced the generalizability of site-specific diagnostic accuracy estimates. Furthermore, variations in lesion characteristics, sampling techniques, and operator experience may have influenced diagnostic performance. The findings should therefore be interpreted cautiously, particularly for anatomical sites represented by few cases, and validated through larger, multicentre studies.

In conclusion, this study demonstrates that fine-needle aspiration cytology (FNAC) is a reliable, minimally invasive diagnostic technique. Diagnostic performance varied across anatomical locations, with lymph node and breast lesions showing high concordance rates of 95.8% and 94.4%, respectively, while thyroid lesions demonstrated 91.7% concordance. The overall sample inadequacy rate was less than 10%, highlighting the importance of adequate sampling and appropriate procedural techniques. These findings emphasize that anatomical location should be considered when interpreting FNAC results and assessing their diagnostic reliability. FNAC remains a valuable tool for the initial evaluation of diverse lesions; however, histopathological confirmation, repeat aspiration, image-guided sampling, or ancillary investigations may be necessary in selected cases with inconclusive or discordant findings.

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