carcinoma of the gallbladder ( ca gb ) is the most common malignancy of the biliary tract . it affects women 2 - 6 times more commonly than men and its incidence steadily increases with age . rarely it is discovered at a dissectible stage and the mean 5-year survival is about 1% despite surgical intervention . a quick and cost effective fine - needle aspiration cytology ( fnac ) procedure of mass lesion of the gallbladder ( gb ) discovered by imaging techniques speeds up the diagnosis and thus , avoids the unresectable stage of tumor . in the present study in this prospective study of 57 image - guided fine - needle aspirations ( fnas ) were performed from mural thickening of the gb in a tertiary care hospital over a period of 4 years . out of 57 cases , 51 all 57 cases were advised ultrasonography ( usg)/computed tomography ( ct ) scan of the hepatobiliary tract for their chronic complaints of upper abdominal pain , jaundice , dyspepsia , nausea , or vomiting . these cases were subjected to imaging and on discovery of mural thickening of the gb wall , fnac was performed under image guidance . after obtaining written consent , the patients were scanned to identify the lesion and access site . percutaneous transhepatic aspiration was performed using 23 - 27 g needle and 10 ml disposable syringe . air - dried smears were stained with leishman geimsa and alcohol - fixed smears were stained with papanicolaou ( pap ) stain . diagnostic criteria laid down by g. kocjan et al . , 2010 were utilized while analyzing smears . multiple passes were made under radiological guidance to increase the adequacy rate of the sample . the presence of five or six groups of cells deemed to represent the lesion was considered as adequate for reporting . all the analyses were carried out by using stata 8.0 version ( statacorp lp , usa ) . all the analyses were carried out by using stata 8.0 version ( statacorp lp , usa ) . a total of 51 cases were included in this study . out of 51 cases , 38 ( 74.5% ) were females and 13 ( 25.5% ) males . the maximum number of cases ( 51.2% ) was in the age group of 61 - 70 years . usg and ct revealed gb mass or mural thickening of the wall with or without hepatic and distant metastasis suggestive of ca gb . the aspirations were categorized into three groups on the basis of adequacy as shown in table 1 : categories of aspiration group i : adequate aspiration where definitive cytological diagnosis was offered . group ii : inconclusive , due to insufficient number of epithelial cells or necrosis was predominant . group iii : inadequate , due to predominance of mucus or hemorrhage and absence of epithelial cells . overall , 84.3% adequate aspirates including neoplastic ( 72.5% ) and nonneoplastic ( 11.8% ) were obtained . the probability of adequacy of aspirated samples was highly significant ( p = 0.0001 ) . the statistical distribution of nonneoplastic lesions is nonsignificant due to very small number of cases ( n = 6 ) . cytological diagnosis offered in adequate fine - needle ( fn ) aspirate is shown in table 2 . adenocarcinoma contributed to the majority of neoplastic lesions  36 of 51 cases ( 70.5% ) . it showed cells in clusters , disorganized sheets , small acini , and single pleomorphic cells . marked nuclear enlargement , nuclear crowding , molding , irregular nuclear membranes , and high nuclear - cytoplasmic ( n : c ) ratio permit a definitive diagnosis of malignancy when there is adequate well - preserved material [ figure 1 ] . adenomatous lesion had papillary configuration with fibrovascular stalk lined by columnar epithelial cells without any of the abovementioned cytological features of adenocarcinoma . cytological diagnosis offered in adequate aspiration ( n = 43 ) ( a and b ) fna smear from gb wall thickening showing a cluster of malignant cells ( leishman geimsa , 400 ) xanthogranulomatous cholecystitis at times mimic well - differentiated adenocarcinoma but cytological features , which clinch the diagnosis include regular arrangement of epithelial cells in sheets and mixed inflammatory cell component with a large number of foamy histiocytes and surrounding capillary blood vessels . chronic cholecystitis demonstrate scant epithelial cells to sheets of tall columnar cells , nuclei oval and basal with fine nuclear chromatin and inconspicuous nucleoli in pap stain , often described as  matchstick  cells in cytology textbooks . thirty - six cases out of a total of 37 neoplastic cases diagnosed as malignant on cytology had a concordant histopathological diagnosis . the only case , which was reported as suspicious of malignancy , turned out to be xanthogranulomatous cholecystitis on histopathology . the study revealed an overall sensitivity and specificity of 94.7% and 98.6% , respectively , and diagnostic accuracy for adequate aspiration of 95.3% . fnac , being a safe , superior to open biopsy , rapid , cost - effective , and nonsurgical intervention and a daycare investigation procedure , is gaining popularity as a diagnostic modality for gb mass lesions and intraabdominal lesions . diffuse mural thickening and single / multiple lesions detected by usg and ct scan are primary indications for fnac . precise radiological localization with novel techniques , multiple passes , and well - defined cytological criteria increases the sensitivity of the test to arrive at a definitive diagnosis . krishnani et al . have reported an adequacy rate of 62.7% from a single puncture . repeat aspirations performed by experienced hands and better angle on imaging after initial report of inconclusive or inadequate aspiration increases the sensitivity of the test . in the present study , repeat aspiration was performed in 11 cases to obtain adequate material . four of these aspirations were repeated thrice , three aspirations were repeated four times , and single aspiration was repeated five times . usg / ct - guided percutaneous fna of mural thickening of the gbis a safe procedure and no major complication was reported in any of the 57 cases , which is comparable with other studies . the overall diagnostic accuracy of preoperative usg - guided fna of the gb lesion has been reported to be up to 97% . in our study , the accuracy for adequate aspiration in relation to usg and ct findings was 95.3% , which is comparable with other studies . in a prospective study of cytopathological diagnosis of xanthogranulomatous cholecystitis of 31 cases by krishnani et al . , the overall possibility of missing carcinoma was 12.01% , whereas in our study two cases showed adenocarcinoma of the gb , which was inadequate or insufficient for reporting on cytology . however , sensitivity for the adequate aspirations was 100% in this study and no case was missed on cytology . the diagnostic pitfalls of this study included necrotic material , hemorrhage , inadequate epithelial cells , and the predominance of mucus flakes . in two cases , reactive hepatocytes were of diagnostic dilemma but repeat aspirate with better precision and angle on imaging confirmed adenocarcinoma on cytology . in the present study , we reported our experience of fnac of mass lesion or mural thickening of gb wall as a diagnostic adjunct to medical imaging in the preoperative evaluation and management of patients . cytological smears interpreted with clinicoimaging findings and reliable diagnostic criteria with repeated aspirations , whenever indicated , will increase the sensitivity and diagnostic accuracy of the test . preoperative usg - guided fnac will offer a speedy diagnosis and urgency of treatment and thus , reduce the incidence of unresectable tumors .
background : image - guided fine - needle aspiration cytology ( fnac ) serves as first - line diagnostic modalities for the assessment of mural thickening of the gallbladder ( gb).aim : the main objective of the present study was to correlate the diagnostic accuracy of preoperative image - guided fnac of the thickened gb wall based on imaging findings to arrive at a final diagnosis in a tertiary care center.materials and methods : fifty - seven image - guided fine - needle aspirations ( fnas ) were performed from mural thickening of the gb over a period of 4 years and the smears prepared were stained with leishman and papanicolaou ( pap ) stain . out of 57 cases , 
 51 were included in the study for which follow - up histopathology was performed.result:out of 51 aspirations , 43 ( 84.3% ) were adequate , 5 ( 9.8% ) were inconclusive , and 3 ( 5.9% ) were inadequate . among the adequate aspirations , the most common was adenocarcinoma36 ( 70.5% ) . 
 the correlation between confirmatory cytological diagnosis and adequacy was significantly high ( p = 0.0001 ) . 
 the overall diagnostic accuracy for adequate aspiration was 95.3% . 
 the common diagnostic pitfalls were necrotic areas , aspiration of reactive hepatocytes adjacent to the gb mass , and mucus islands . 
 no procedural complication was observed in any patient.conclusions:image-guided fnac can be used as a safe , rapid , and successful diagnostic procedure with high sensitivity , specifically for supporting and confirming ultrasonography(usg)/computed tomography ( ct ) diagnosis of gb mass or mural thickening of the wall .