Fine needle aspiration biopsy in low‐ and middle‐income countries

May combine two claims.

Numerous studies from various hospitals in LMICs document rates of FNAB diagnoses of inflammatory lesions ranging from 8% to 15% and benign lesions ranging from 17% to 52%.

“Numerous studies from various hospitals in LMICs document the rates of FNAB diagnoses of inflammatory lesions ranging from 8% to 15% and the rates of benign lesions ranging from 17% to 52%.17,22,41”

• cites [17] 17. Carrilho C, Ismail M, Lorenzoni C, et al. Fine needle aspiration cytol- ogy in Mozambique: report of a 15-year experience. Diagn Cyto- pathol. 2019;47(3):166-171. doi:10.1002/dc.24062 sourceDisputed

  In “Results and Discussion—The MCH Experience in FNAC” (page unavailable), this Mozambican hospital study reports inflammatory conditions in 22.2% of cases, outside the claimed 8%–15% range. It reports benign tumors in 13.4%, outside the claimed 17%–52% range; the paper lists hyperplastic conditions separately. (LLM, conf=0.88)

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured
• cites [22] 22. Khan S, Liomba G, Rosenberg NE, et al. Utilization of fine needle aspi- ration cytology at Kamuzu central hospital. PloS One. 2018;13(6): e0196561. doi:10.1371/journal.pone.0196561 sourcePartly supported

  The Results report benign lesions in 22.3% of diagnostic FNAC samples, within the claimed 17%–52% range. They also report tuberculosis and other infections at 5.5% each, but do not classify these together as inflammatory lesions. This single-hospital study cannot establish the ranges across various hospitals on its own. (LLM, conf=0.82)

  Experimental — accuracy not yet measured
• cites [41] 41. Abdullahi K, Umar M, Sahabi SM. Utilisation of fine needle aspiration cytology and biopsy in Sokoto, Nigeria: a five-year review. Afr J Lab Med. 2019;8(1):809. doi:10.4102/ajlm.v8i1.809 sourcePartly supported

  The Discussion reports that 740 FNAC cases (51.6%) were benign at the Sokoto hospital, supporting one value within the claimed benign-lesion range. Our copy does not report an 8%–15% rate for inflammatory lesions or establish either range across numerous hospitals. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

May combine two claims.

FNAB in LMICs can provide minimally invasive, cost-effective tissue diagnosis with rapid assessment and specimen triage, which is advantageous in resource-limited settings.

“Fine needle aspiration biopsy (FNAB) in low-and middle-income countries (LMIC), can provide minimally invasive, cost-effective tissue diagnosis with rapid assessment and specimen triage, which is advantageous in these resource-limited settings.”

• cites [1] 1. Thomas J. Role of cytopathology in cancer control in low-resource settings: sub-Saharan Africa's perspective. Int Health. 2011;3(1):3-6. doi:10.1016/j.inhe.2010.09.002 sourceNot checked — no full text of the source
• cites [2] 2. Ng DL, Vuhahula E, Zhang L, et al. Efficacy of an intensive, ultrasound-guided fine-needle aspiration biopsy training workshop in Tanzania. J Glob Oncol. 2018;4:1-9. doi:10.1200/JGO.18.00134 sourceSupported

• AssumptionRests on an assumption: Findings from individual studies conducted in specific LMICs can be generalized to other LMICs.

May combine two claims.

Among those who underwent FNAB in a Tanzanian study, 69.2% received a benign diagnosis, while 30.8% were deemed suspicious for malignancy based on ROSE assessments.

“Among those who underwent FNAB, 69.2% received a benign diagnosis, while 30.8% were deemed suspicious for malignancy based on ROSE assessments.10”

• cites [10] 10. Philipo GS, Vuhahula E, Kimambo A, Mmbaga EJ, Van Loon K, Ng DL. Feasibility of fine-needle aspiration biopsy and rapid on-site evalua- tion for immediate triage in breast cancer screening in Tanzania. JCO Glob Oncol. 2021;7:146-152. doi:10.1200/GO.20.00279 sourceSupported

May combine two claims.

Deep-seated lesions with ultrasound guidance had a higher diagnostic yield than superficial ones, and FNABs from abdomen and head and neck were more diagnostic than those from lymph nodes.

“Deep-seated lesions with ultrasound guidance had a higher diagnostic yield than superficial ones, and FNABs from the abdomen and head and neck were more diagnostic than those from lymph nodes.”

• cites [22] 22. Khan S, Liomba G, Rosenberg NE, et al. Utilization of fine needle aspi- ration cytology at Kamuzu central hospital. PloS One. 2018;13(6): e0196561. doi:10.1371/journal.pone.0196561 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Overall incidence of cancer is lower in LMICs compared to high-income countries, but cancer-related mortality is significantly higher in LMICs and continues to rise.

“while overall incidence of cancer is lower in LMICs compared to high-income countries, cancer-related mortality is significantly higher in LMICs and continues to rise.8”

• cites [8] 8. Shah SC, Kayamba V, Peek RM, Heimburger D. Cancer control in low- and middle-income countries: is it time to consider screening? J Glob Oncol. 2019;5:1-8. doi:10.1200/JGO.18.00200 sourceSupported

May combine two claims.

FNAB can be performed as an outpatient procedure and has proven effective in resource-limited areas.

“It can be performed as an outpatient procedure and has particularly proven effective in resourcelimited areas.1,2”

• cites [1] 1. Thomas J. Role of cytopathology in cancer control in low-resource settings: sub-Saharan Africa's perspective. Int Health. 2011;3(1):3-6. doi:10.1016/j.inhe.2010.09.002 sourceNot checked — no full text of the source
• cites [2] 2. Ng DL, Vuhahula E, Zhang L, et al. Efficacy of an intensive, ultrasound-guided fine-needle aspiration biopsy training workshop in Tanzania. J Glob Oncol. 2018;4:1-9. doi:10.1200/JGO.18.00134 sourceSupported

May combine two claims.

FNAB is the gold standard for evaluation of thyroid nodules in high resource settings, and this method has gained popularity in LMICs.

“As the FNAB is the gold standard for evaluation of thyroid nodules in high resource settings, this method of diagnosis has also gained popularity in LMICs.[36][37][38]”

• cites [36] 36. Jammah AA. Practice of thyroid nodule management in the Gulf cooperation council countries. Saudi Med J. 2021;42(1):66-74. doi:10. 15537/smj.2021.1.25591 sourcePartly supported

  The introductory passage following the Abstract Conclusion (page unavailable) identifies FNA as a thyroid-nodule diagnostic modality and says such modalities have become more available. The Results and Discussion also describe FNA use in the Gulf countries. The paper does not call FNA the gold standard in high-resource settings or establish that it has gained popularity in LMICs. (LLM, conf=0.84)

  Experimental — accuracy not yet measured
• cites [37] 37. Abdullahi IM, Yasin NA, Dirken ES, Mohamoud AM, Guler I, Adani AA. Comparative study of fine needle aspiration cytology and histopathology in thyroid nodules at a tertiary care hospital: first report from Somalia. Asian J Surg. 2023;46(10):4202-4207. doi:10. 1016/j.asjsur.2022.11.097 sourcePartly supported

  The Introduction calls FNA the most appropriate tool for initial evaluation of thyroid nodules, and the Discussion describes FNAC as widely accepted and cost-effective, especially in developing countries (page numbers unavailable). The paper does not establish that FNAB is the gold standard in high-resource settings or that its popularity has increased in LMICs; its Methods instead use histology as the gold standard for assessing diagnostic accuracy. (LLM, conf=0.86)

  Experimental — accuracy not yet measured
• cites [38] 38. Kakudo K, Higuchi M, Hirokawa M, Satoh S, Jung CK, Bychkov A. Thyroid <scp>FNA</scp> cytology in Asian practice-active surveil- lance for indeterminate thyroid nodules reduces overtreatment of thyroid carcinomas. Cytopathology. 2017;28(6):455-466. doi:10. 1111/cyt.12491 sourcePartly supported

  Section 3, “Thyroid FNAC in Asia” (page not provided), describes thyroid FNA practice across Asian countries, and section 2.2 documents its use in India. That supports use in some lower-resource settings, but the paper does not establish that FNAB is the gold standard in high-resource settings or that its popularity in LMICs has increased. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

May combine two claims.

In a South African study, a significant proportion of PLWH with cytology suggestive of lymphoma did not proceed to diagnostic biopsy, resulting in a high mortality rate.

“However, in their study a significant proportion of PLWH with cytology suggestive of lymphoma did not proceed to diagnostic biopsy, resulting in a high mortality rate.”

• cites [27] 27. Vogt SL, Maloma L, Xian RR, et al. Significance of lymph node fine needle aspiration for the diagnosis of HIV-associated lymphoma in a low-resource setting. Aids. 2022;36(10):1393-1398. doi:10.1097/ QAD.0000000000003261 sourcePartly supported

  The Results report that 21 of 45 PLWH with cytology concerning for lymphoma did not proceed to biopsy; 12 of those 21 died within a year. The Discussion describes mortality in this group as 57%–86%, accounting for loss to follow-up. The paper does not establish that failure to undergo biopsy caused the deaths, as “resulting in” implies. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

May combine two claims.

FNAB is a minimally invasive, reliable, and cost-effective method for sampling tissue that requires minimal and affordable equipment.

“Fine-needle aspiration biopsy (FNAB) is a minimally invasive, reliable, and cost-effective method for sampling tissue that requires minimal and affordable equipment.”

• cites [1] 1. Thomas J. Role of cytopathology in cancer control in low-resource settings: sub-Saharan Africa's perspective. Int Health. 2011;3(1):3-6. doi:10.1016/j.inhe.2010.09.002 sourceNot checked — no full text of the source
• cites [2] 2. Ng DL, Vuhahula E, Zhang L, et al. Efficacy of an intensive, ultrasound-guided fine-needle aspiration biopsy training workshop in Tanzania. J Glob Oncol. 2018;4:1-9. doi:10.1200/JGO.18.00134 sourcePartly supported

  The Background describes FNAB as minimally invasive and cost-effective, requiring minimal equipment and laboratory infrastructure. It does not specifically say the equipment is affordable, and it qualifies reliability: diagnostic accuracy depends heavily on operator skill and formal training. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

May combine two claims.

Many tumors in LMICs usually present at an advanced stage, making them much harder to treat.

“In addition, many tumors in these countries usually present at an advanced stage making it much harder to treat.10”

• cites [10] 10. Philipo GS, Vuhahula E, Kimambo A, Mmbaga EJ, Van Loon K, Ng DL. Feasibility of fine-needle aspiration biopsy and rapid on-site evalua- tion for immediate triage in breast cancer screening in Tanzania. JCO Glob Oncol. 2021;7:146-152. doi:10.1200/GO.20.00279 sourcePartly supported

  The Introduction (page unavailable) reports that 63%–91% of women with breast cancer in Tanzania present with advanced-stage disease and notes substantially lower five-year survival than in high-income countries. It does not establish that many types of tumors across LMICs usually present this way, or explicitly say that advanced-stage tumors are harder to treat. (LLM, conf=0.84)

  Experimental — accuracy not yet measured

May combine two claims.

At Kamuzu Central Hospital in Malawi, FNAB utilization increased over time, most results were available within 72 hours, and FNAB became more diagnostic over time.

“The study found that FNAB utilization increased over time, with most results being available within 72 hours and became more diagnostic over time.”

• cites [22] 22. Khan S, Liomba G, Rosenberg NE, et al. Utilization of fine needle aspi- ration cytology at Kamuzu central hospital. PloS One. 2018;13(6): e0196561. doi:10.1371/journal.pone.0196561 sourceSupported

May combine two claims.

FNAB with ROSE by a trained pathologist can distinguish between malignant lesions and inflammatory conditions, such as mycobacterial infections, allowing accurate diagnosis at point of care when treatment may also be offered.

“Indeed, FNAB with ROSE by a trained pathologist can distinguish between malignant lesions and inflammatory conditions, such as mycobacterial infections, allowing for patients to receive an accurate diagnosis at the point of care when treatment may also be offered.5,14,15”

• cites [5] 5. Wright CA, Pienaar JP, Marais BJ. Fine needle aspiration biopsy: diag- nostic utility in resource-limited settings. Ann Trop Paediatr. 2008; 28(1):65-70. doi:10.1179/146532808X270707 sourceNot checked — no full text of the source
• cites [14] 14. Yadav K, Cree I, Field A, Vielh P, Mehrotra R. Importance of cyto- pathologic diagnosis in early cancer diagnosis in resource-constrained countries. JCO Glob Oncol. 2022;8:e2100337. doi:10.1200/GO.21. 00337 sourcePartly supported

  The Results section, “Role of Cytopathology in Excluding the Cancer Diagnosis” (page unavailable), says FNAB can show that a lump suspected to be malignant is tubercular and that outpatient treatment can start immediately after clinical correlation. The Methods section, “Cytopathology Is a Screening and Diagnostic Tool” (page unavailable), separately discusses FNAB with rapid on-site evaluation for breast-mass triage. Our copy does not establish that ROSE by a trained pathologist provides the tuberculosis-versus-malignancy diagnosis at the point of care where treatment is offered. (LLM, conf=0.85)

  Experimental — accuracy not yet measured
• cites [15] 15. Das DK. Fine-needle aspiration cytology: its origin, development, and present status with special reference to a developing country, India. Diagn Cytopathol. 2003;28(6):345-351. doi:10.1002/dc.10289 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Higher cancer mortality is true for all cancer types and seen in many LMICs, which may lack established cancer screening programs such as lung cancer screening.

“This challenge of higher cancer mortality is true for all cancer types and seen in many LMICs, which may lack established cancer screening programs, such as lung cancer screening.11,12”

• cites [11] 11. Sankaranarayanan R. Screening for cancer in low-and middle-income countries. Ann Glob Heal. 2014;80(5):412. doi:10.1016/j.aogh.2014. 09.014 sourcePartly supported

  The Conclusions (page unavailable) state that organized cancer screening programs do not exist in most LMICs. The Abstract and “Screening for Other Cancers” (pages unavailable) say there is insufficient evidence to introduce population-based lung cancer screening. The paper does not establish that mortality is higher for all cancer types across many LMICs. (LLM, conf=0.87)

  Experimental — accuracy not yet measured
• cites [12] 12. Jiwnani S, Penumadu P, Ashok A, Pramesh CS. Lung cancer Manage- ment in low and Middle-Income Countries. Thorac Surg Clin. 2022; 32(3):383-395. doi:10.1016/j.thorsurg.2022.04.005 sourceNot checked — no full text of the source

May combine two claims.

A training workshop in Tanzania showed significant progress in participants' technical competencies related to FNAB, including slide-smearing and palpation/ultrasound-guided techniques, and illustrated potential for transferring knowledge and skills and creating strong interest in FNAB.

“The outcomes of this workshop showed significant progress in participants' technical competencies related to FNAB, including both slide-smearing and palpation/ultrasound-guided techniques and it successfully illustrated the potential for transferring knowledge and skills and creating a strong interest in FNAB as a diagnostic method.”

• cites [2] 2. Ng DL, Vuhahula E, Zhang L, et al. Efficacy of an intensive, ultrasound-guided fine-needle aspiration biopsy training workshop in Tanzania. J Glob Oncol. 2018;4:1-9. doi:10.1200/JGO.18.00134 sourcePartly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

May combine two claims.

In a survey of Gulf Cooperation Council countries, less than 10% of indeterminate thyroid nodules were being sent for molecular testing, but interest for molecular testing was much higher.

“For example, a survey of countries in the Gulf Cooperation Council highlighted that only less than 10% of indeterminate nodules were being sent for molecular testing, however interest for molecular testing for indeterminate thyroid FNAs to supplement diagnosis was much higher.36”

• cites [36] 36. Jammah AA. Practice of thyroid nodule management in the Gulf cooperation council countries. Saudi Med J. 2021;42(1):66-74. doi:10. 15537/smj.2021.1.25591 sourcePartly supported

  The Results report that 27 of 311 respondents (8.6%) would send an indeterminate FNA result for molecular testing, while 174 (55.9%) would prefer testing to be available. The less-than-10% figure describes clinicians’ reported choices, not the proportion of indeterminate nodules actually sent for testing. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

May combine two claims.

In a review of 550 cases of tuberculous lymphadenitis in India, the most common site sampled was a cervical lymph node (70% of cases), and many cases showed caseous necrotic material with degenerated inflammatory cells or epithelioid giant cell granulomas without necrosis.

“One review of 550 cases of tuberculous lymphadenitis in India highlights that the most common site sampled was a cervical lymph node (70% of cases) and many cases showed caseous necrotic material with degenerated inflammatory cells or epithelioid giant cell granulomas without necrosis.44”

• cites [44] 44. Chand P, Dogra R, Chauhan N, Gupta R, Khare P. Cytopathological pattern of tubercular lymphadenopathy on FNAC: analysis of 550 consecutive cases. J Clin Diagn Res. 2014;8(9):FC16-FC19. doi: 10.7860/JCDR/2014/9956.4910 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Training pathologists in FNAB methods allows for empowerment of pathologists to implement this technique in novel ways.

“It also recognizes the benefit that training pathologists in FNAB methods allows for empowerment of pathologists to implement this technique in novel ways.40”

• cites [40] 40. Alele D, Dahn B, Camanor S, et al. Novel use of fine needle aspiration (FNA) biopsy to diagnose cervical cancer in a low-resource setting: a case series Morovia, Liberia. Clin Case Reports. 2020;8(8):1413-1418. doi:10.1002/ccr3.2911 sourcePartly supported

  The Discussion (page unavailable) describes a novel use of FNA for diagnosing cancer in visible cervical lesions and says a pathologist performed all the biopsies. It emphasizes operator experience, but does not say that training pathologists in FNAB empowers them to develop novel applications. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

May combine two claims.

In Liberia, 13 patients with visible cervical lesions underwent pathologist-performed FNAB of the cervix through a speculum, and a pathologic diagnosis was rendered in all cases.

“As a result, 13 patients with visible cervical lesions underwent pathologist performed FNAB of the cervix through a speculum and a pathologic diagnosis was rendered in all cases.”

• cites [40] 40. Alele D, Dahn B, Camanor S, et al. Novel use of fine needle aspiration (FNA) biopsy to diagnose cervical cancer in a low-resource setting: a case series Morovia, Liberia. Clin Case Reports. 2020;8(8):1413-1418. doi:10.1002/ccr3.2911 sourceSupported

May combine two claims.

FNAB can establish a cytologic diagnosis of cancer and enhance cancer registration capabilities.

“This report highlights the ability of the FNAB to establish a cytologic diagnosis of cancer and enhance cancer registration capabilities.”

• cites [40] 40. Alele D, Dahn B, Camanor S, et al. Novel use of fine needle aspiration (FNA) biopsy to diagnose cervical cancer in a low-resource setting: a case series Morovia, Liberia. Clin Case Reports. 2020;8(8):1413-1418. doi:10.1002/ccr3.2911 sourceSupported

May combine two claims. The quote only partly states this claim.

In Kenya, with additional experience, the study highlighted an increase in the number of overall FNABs performed as well as an increase in malignant diagnoses made.

“With additional experience, this study highlighted an increase in the number of overall FNABs performed as well as an increase in malignant diagnoses made.50”

• cites [50] 50. Sayed S, Field A, Rajab J, et al. Task sharing and shifting to provide pathology diagnostic services: the Kenya fine-needle aspiration biopsy cytology and bone marrow aspiration and trephine biopsy training program. J Glob Oncol. 2018;4:1-11. doi:10.1200/JGO.18. 00094 How to cite this article: Khorsandi N, Balassanian R, Vohra P. Fine needle aspiration biopsy in low-and middle-income countries. Diagnostic Cytopathology. 2024;52(8):426-432. doi:10.1002/dc.25317 sourcePartly supported

  The Results section (FNAB and BMAT Biopsy Procedures Performed; page not provided) reports 41% more FNABs in 2016 than in the comparable period in 2015. The Abstract Results reports 139 malignant FNAB diagnoses, but the copy gives no earlier count showing that malignant diagnoses increased; it also does not establish additional experience as the cause of the increase. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

May combine two claims.

The incidence of cervical cancer in Liberia is high with limited ability to make a pathologic diagnosis of malignancy.

“The incidence of cervical cancer in Liberia is high with limited ability to make a pathologic diagnosis of malignancy.”

• cites [40] 40. Alele D, Dahn B, Camanor S, et al. Novel use of fine needle aspiration (FNA) biopsy to diagnose cervical cancer in a low-resource setting: a case series Morovia, Liberia. Clin Case Reports. 2020;8(8):1413-1418. doi:10.1002/ccr3.2911 sourceSupported

May combine two claims.

Challenges such as equipment shortages, reagents, and lack of trained personnel exist in LMICs.

“Nevertheless, challenges such as equipment shortages, reagents, and lack of trained personnel exist.”

• cites [19] 19. Adesina A, Chumba D, Nelson AM, et al. Improvement of pathology in sub-Saharan Africa. Lancet Oncol. 2013;14(4):e152-e157. doi:10. 1016/S1470-2045(12)70598-3 sourceNot checked — no full text of the source

May combine two claims.

When combined with ROSE by a trained pathologist, FNAB provides rapid diagnosis at point of care, allows triage of sample for ancillary testing, and minimizes risk of patient loss to follow up in low resource settings.

“When combined with rapid on-site evaluation (ROSE) by a trained pathologist, FNAB provides a rapid diagnosis at the point of care, allows for triage of the sample for ancillary testing, and minimizes the risk of patient loss to follow up in low resource settings.3”

• cites [3] 3. Schmidt RL, Witt BL, Lopez-Calderon LE, Layfield LJ. The influence of rapid onsite evaluation on the adequacy rate of fine-needle aspiration cytology: a systematic review and meta-analysis. Am J Clin Pathol. 2013;139(3):300-308. doi:10.1309/AJCPEGZMJKC42VUP sourceNot checked — no full text of the source

May combine two claims.

In Nigeria, an FNAB clinic performed 183 FNABs over a 3-year period; approximately one-third were reactive, one quarter TB, and almost 40% malignancies.

“In Nigeria, an FNAB clinic staffed by the Pathology Department performed 183 FNABs over a 3-year period.Approximately one-third of these diagnoses were reactive, one quarter established a diagnosis of tuberculosis (TB), and almost 40% of these biopsies identified malignancies.”

• cites [25] 25. Thomas JO, Adeyi D, Kayamba H. Fine-needle aspiration in the man- agement of peripheral lymphadenopathy in a developing country. Diagn Cytopathol. 1999;21(3):159-162. doi:10.1002/(sici)1097-0339 (199909)21:33.0.co;2-2 sourceNot checked — no full text of the source

May combine two claims.

A significant number of patients receive definitive treatment solely based on FNAB, providing early entry into healthcare system and reducing need for referrals to more expensive and invasive surgical procedures.

“A significant number of patients receive definitive treatment solely based on FNAB providing them with an early entry into the healthcare system as well as significantly reducing the need for referrals to more expensive and invasive surgical procedures.16”

• cites [16] 16. Field AS, Geddie W, Zarka M, et al. Assisting cytopathology training in medically under-resourced countries: defining the problems and establishing solutions. Diagn Cytopathol. 2012;40(3):273-281. doi:10. 1002/dc.21620 sourceNot checked — no full text of the source

May combine two claims.

In a Nigerian study of 157 pathologist-performed FNABs on palpable breast lesions over 2 years, most lesions were benign (71%) and the second most common diagnosis was malignant (24%).

“One study from Nigeria evaluated 157 pathologist-performed FNABs on palpable breast lesions over a 2-year period.In this study, most lesions were diagnosed as benign (71%) with the second most common diagnosis being malignant (24%).”

• cites [29] 29. Mohammed AZ, Edino ST, Ochicha O, Alhassan SU. Value of fine nee- dle aspiration biopsy in preoperative diagnosis of palpable breast lumps in resource-poor countries: a Nigerian experience. Ann Afr Med. 2005;4(1):19-22. https://hdl.handle.net/1807/5042Not checked — no full text of the source

May combine two claims.

Severe shortages of both laboratories and personnel further hinder diagnostic process, potentially resulting in inappropriate treatments.

“However, severe shortages of both laboratories and personnel further hinder the diagnostic process, potentially resulting in inappropriate treatments.19”

• cites [19] 19. Adesina A, Chumba D, Nelson AM, et al. Improvement of pathology in sub-Saharan Africa. Lancet Oncol. 2013;14(4):e152-e157. doi:10. 1016/S1470-2045(12)70598-3 sourceNot checked — no full text of the source

May combine two claims.

In a review of FNABs in children with clinical suspicion for Burkitt's Lymphoma in South Africa, the most frequent diagnosis was normal/reactive tissue, preventing further unnecessary treatment.

“One review of FNABs performed on children with clinical suspicion for Burkitt's Lymphoma in South Africa reports that the most frequent diagnoses made was normal/reactive tissue, preventing further unnecessary treatment in these children.”

• cites [5] 5. Wright CA, Pienaar JP, Marais BJ. Fine needle aspiration biopsy: diag- nostic utility in resource-limited settings. Ann Trop Paediatr. 2008; 28(1):65-70. doi:10.1179/146532808X270707 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

FNAB should be the first step of clinical interrogation for lymphadenopathy in the tropics because of its ability to differentiate between reactive, malignant, and infectious conditions quickly and accurately.

“The authors identified that the FNAB should be the first step of clinical interrogation for lymphadenopathy in the tropics because of its ability to differentiate between reactive, malignant, and infectious conditions quickly and accurately.25”

• cites [25] 25. Thomas JO, Adeyi D, Kayamba H. Fine-needle aspiration in the man- agement of peripheral lymphadenopathy in a developing country. Diagn Cytopathol. 1999;21(3):159-162. doi:10.1002/(sici)1097-0339 (199909)21:33.0.co;2-2 sourceNot checked — no full text of the source

May combine two claims.

Limited resources, shortage of trained personnel who can obtain high quality samples and perform ROSE, and financial constraints pose significant challenges to broad implementation of FNAB.

“However, limited resources, a shortage of trained personnel who can obtain high quality samples and perform ROSE, as well as financial constraints pose significant challenges to broad implementation.”

• cites [1] 1. Thomas J. Role of cytopathology in cancer control in low-resource settings: sub-Saharan Africa's perspective. Int Health. 2011;3(1):3-6. doi:10.1016/j.inhe.2010.09.002 sourceNot checked — no full text of the source
• cites [16] 16. Field AS, Geddie W, Zarka M, et al. Assisting cytopathology training in medically under-resourced countries: defining the problems and establishing solutions. Diagn Cytopathol. 2012;40(3):273-281. doi:10. 1002/dc.21620 sourceNot checked — no full text of the source
• cites [19] 19. Adesina A, Chumba D, Nelson AM, et al. Improvement of pathology in sub-Saharan Africa. Lancet Oncol. 2013;14(4):e152-e157. doi:10. 1016/S1470-2045(12)70598-3 sourceNot checked — no full text of the source

May combine two claims.

When performed specifically by a pathologist, USFNA may yield a higher amount of diagnostic material and lower discordance rates compared to cytopathologist-performed palpation-guided FNAB across various anatomical sites.

“In addition to the general advantages of ultrasoundguided FNAB (USFNA), studies have indicated that when performed specifically by a pathologist, it may yield a higher amount of diagnostic material and lower discordance rates compared to cytopathologistperformed palpation-guided FNAB across various anatomical sites.46”

• cites [46] 46. Conrad R, Yang S-E, Chang S, et al. Comparison of Cytopathologist- performed ultrasound-guided fine-needle aspiration with Cytopathologist-performed palpation-guided fine-needle aspiration: a single institutional experience. Arch Pathol Lab Med. 2018;142(10): 1260-1267. doi:10.5858/arpa.2017-0123-OA sourceNot checked — no full text of the source

May combine two claims.

Our experience demonstrates the effectiveness of online education in resource-limited settings, bridging educational gaps in cytopathology.

“Our experience demonstrates the effectiveness of online education in resource-limited settings, bridging educational gaps in cytopathology.”

May combine two claims.

In under-resourced healthcare settings, FNAB proved to be a valuable procedure, requiring minimal equipment and trained staff, while positively impacting patient management, despite some inherent limitations.

“Overall, in their experience, FNAB proved to be a valuable procedure in under-resourced healthcare settings, as it required minimal equipment and trained staff, while still positively impacting patient management, despite some inherent limitations.45”

• cites [45] 45. Michelow P, Fatman L. Fine-needle aspiration in a low-resource set- ting. Cancer Cytopathol. 2014;122(10):713-714. doi:10.1002/cncy. 21481 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

In resource-limited healthcare landscapes of LMICs, based on above articles and our experiences with pathologists in Tanzania and India, FNAB has proven instrumental as a vital diagnostic tool offering a minimally invasive yet highly effective method for diagnosis, sparing patients from invasive procedures and unnecessary surgeries.

“In the resource-limited healthcare landscapes of LMICs, based on the above articles and our experiences with pathologists in Tanzania and India, the FNAB has proven instrumental as a vital diagnostic tool offering a minimally invasive yet highly effective method for diagnosis, sparing patients from invasive procedures and unnecessary surgeries.”

• AssumptionRests on an assumption: Findings from individual studies conducted in specific LMICs can be generalized to other LMICs.
• AssumptionRests on an assumption: The authors' institutional experiences in Tanzania and India are representative of other LMIC settings.

May combine two claims.

Addition of ultrasound guidance to FNAB allows visualization of targeted lesions and improves accuracy of sample collection by providing information about adjacent anatomy, vascularity, and heterogeneity of lesions.

“The addition of ultrasound guidance to FNAB not only allows for the visualization of targeted lesions but also improves the accuracy of sample collection by providing information about the adjacent anatomy, vascularity, and heterogeneity of lesions, which helps determine the approach for the biopsy.”

• cites [46] 46. Conrad R, Yang S-E, Chang S, et al. Comparison of Cytopathologist- performed ultrasound-guided fine-needle aspiration with Cytopathologist-performed palpation-guided fine-needle aspiration: a single institutional experience. Arch Pathol Lab Med. 2018;142(10): 1260-1267. doi:10.5858/arpa.2017-0123-OA sourceNot checked — no full text of the source
• cites [47] 47. Lynn TJ, Monaco SE. Adding the "US" in FNA: pearls for starting a pathologist-performed ultrasound-guided fine needle aspiration ser- vice (USG FNA). Semin Diagn Pathol. 2022;39(6):410-420. doi:10. 1053/j.semdp.2022.06.007 sourceNot checked — no full text of the source
• cites [48] 48. Wu M, Choi Y, Zhang Z, et al. Ultrasound guided FNA of thyroid per- formed by cytopathologists enhances Bethesda diagnostic value. Diagn Cytopathol. 2016;44(10):787-791. doi:10.1002/dc.23544 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

FNAB is valuable in pediatric cases in triaging treatment and care management.

“Additionally, they found FNAB to be valuable in pediatric cases in triaging treatment and care management.”

• cites [45] 45. Michelow P, Fatman L. Fine-needle aspiration in a low-resource set- ting. Cancer Cytopathol. 2014;122(10):713-714. doi:10.1002/cncy. 21481 sourceNot checked — no full text of the source

May combine two claims.

FNAB can be used to evaluate mycobacterial infections because smears can be stained with special stains such as Ziehl-Neelsen to evaluate for acid-fast bacilli or material can be collected for nucleic acid amplification testing for mycobacterial DNA.

“As mycobacterial infections are a major challenge in developing countries, the FNAB has been employed to further evaluate these lesions as smears created from FNAB can be stained with special stains, such as Ziehl-Neelsen staining, to evaluate for acid-fast bacilli or material can be collected for nucleic acid amplification testing for mycobacterial DNA.42,43”

• cites [42] 42. Gouda K, Das U, Dhangadamajhi G. Utility of fine needle aspiration cytology (FNAC) in the diagnosis of tuberculous lymphadenitis com- pared to GeneXpert in a tertiary health care center in northern Odi- sha, India. Indian J Tuberc. 2021;68(4):437-444. doi:10.1016/j.ijtb. 2021.01.005 sourceNot checked — no full text of the source
• cites [43] 43. Getachew A, Tesfahunegn Z. Is fine needle aspiration cytology a use- ful tool for the diagnosis of tuberculous lymphadenitis? East Afr Med J. 1999;76(5):260-263. http://www.ncbi.nlm.nih.gov/pubmed/10750 505Not checked — no full text of the source

May combine two claims.

Currently, medical practitioners in LMICs are using FNABs for a wide range of organ systems and types of lesions, ultimately improving access to diagnostic material and subsequent medical management for patients.

“Currently, medical practitioners in LMICs are using FNABs for a wide range of organ systems and types of lesions ultimately improving access to diagnostic material and subsequent medical management for patients.”

• AssumptionRests on an assumption: Findings from individual studies conducted in specific LMICs can be generalized to other LMICs.

May combine two claims.

The numerous studies highlighted in this review indicate the versatility and diagnostic accuracy of FNAB.

“The numerous studies highlighted in this review indicate the versatility and diagnostic accuracy of the FNAB.”

• AssumptionRests on an assumption: Findings from individual studies conducted in specific LMICs can be generalized to other LMICs.

May combine two claims.

Lack of trained personnel exists within a larger setting limited by patient financial constraints and limited healthcare resources, further preventing use of cancer screening programming.

“This lack of trained personnel exists within a larger setting limited by patient financial constraints (travel costs, time constraints, and distant healthcare facilities) and limited healthcare resources (difficulties in referrals, limited treatment capacity, and delayed biopsy results), further preventing the use of cancer screening programming.”

• cites [49] 49. Yip CH, Anderson BO. The breast health global initiative: clinical prac- tice guidelines for management of breast cancer in low-and middle- income countries. Expert Rev Anticancer Ther. 2007;7(8):1095-1104. doi:10.1586/14737140.7.8.1095 sourceNot checked — no full text of the source

May combine two claims.

In a South African study, FNAB plays a pivotal role in management of patients living with HIV, particularly in diagnosing extrapulmonary mycobacterial infections, AIDS-related and non-AIDS-related malignancies, and identifying side effects of antiretroviral therapy.

“Another study from the cytopathology unit in South Africa highlights how FNAB plays a pivotal role in the management of patients living with HIV, particularly in diagnosing extrapulmonary mycobacterial infections, both AIDS-related and non-AIDS-related malignancies, as well as identifying side effects of antiretroviral therapy.”

• cites [45] 45. Michelow P, Fatman L. Fine-needle aspiration in a low-resource set- ting. Cancer Cytopathol. 2014;122(10):713-714. doi:10.1002/cncy. 21481 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Diagnostic excellence on the part of the cytopathologist requires considerable skill and technical experience.

“The authors of this study recognize, however, that this diagnostic excellence on the part of the cytopathologist requires considerable skill and technical experience.39”

• cites [39] 39. Sang CK, Sekadde-Kigondu C, Muchiri L. Fine needle aspiration cytol- ogy of thyroid nodules at Kenyatta National Hospital, Nairobi. East Afr Med J. 2008;84(3):117-120. doi:10.4314/eamj.v84i3.9513 sourceNot checked — no full text of the source

May combine two claims.

Formal training significantly enhances diagnostic accuracy, reducing both non-diagnostic rates and necessity for excisions.

“Research has shown that formal training significantly enhances diagnostic accuracy, reducing both non-diagnostic rates and the necessity for excisions.16”

• cites [16] 16. Field AS, Geddie W, Zarka M, et al. Assisting cytopathology training in medically under-resourced countries: defining the problems and establishing solutions. Diagn Cytopathol. 2012;40(3):273-281. doi:10. 1002/dc.21620 sourceNot checked — no full text of the source

May combine two claims.

In a study from Kenya, benign thyroid nodules were accurately distinguished from malignant nodules, while FNAB was best performed by cytopathologists.

“In one study from Kenya, benign thyroid nodules were accurately distinguished from malignant nodules, while the FNAB was best performed by cytopathologists.”

• cites [39] 39. Sang CK, Sekadde-Kigondu C, Muchiri L. Fine needle aspiration cytol- ogy of thyroid nodules at Kenyatta National Hospital, Nairobi. East Afr Med J. 2008;84(3):117-120. doi:10.4314/eamj.v84i3.9513 sourceNot checked — no full text of the source

May combine two claims.

Major barriers to widespread use of FNAB in LMICs include lack of awareness and lack of trained personnel, compounded by sociopolitical factors and poor national planning of healthcare systems.

“The major barriers to the widespread use of FNAB in LMICs include a lack of awareness and lack of trained personnel, compounded by sociopolitical factors and poor national planning of healthcare systems and supports.”

• cites [1] 1. Thomas J. Role of cytopathology in cancer control in low-resource settings: sub-Saharan Africa's perspective. Int Health. 2011;3(1):3-6. doi:10.1016/j.inhe.2010.09.002 sourceNot checked — no full text of the source
• cites [16] 16. Field AS, Geddie W, Zarka M, et al. Assisting cytopathology training in medically under-resourced countries: defining the problems and establishing solutions. Diagn Cytopathol. 2012;40(3):273-281. doi:10. 1002/dc.21620 sourceNot checked — no full text of the source