Role of fine-needle aspiration biopsy in breast lesions: analysis of a series of 4,110 cases

Real-World Diagnostic Accuracy of the On-Site Cytopathology Advance Report (OSCAR) Procedure Performed in a Multidisciplinary One-Stop Breast Clinic

Fine-needle aspiration (FNA) cytology has been widely used for the diagnosis of breast cancer lesions with the objective of differentiating benign from malignant masses. However, the occurrence of unsatisfactory samples and false-negative rates remains a matter of concern. Major improvements have been made thanks to the implementation of rapid on-site evaluation (ROSE) in multidisciplinary and integrated medical settings such as one-stop clinics (OSCs). In these settings, clinical and radiological examinations are combined with a morphological study performed by interventional pathologists. The aim of our study was to assess the diagnostic accuracy of the on-site cytopathology advance report (OSCAR) procedure on breast FNA cytologic samples in our breast OSC during the first three years (April 2004 till March 2007) of its implementation. To this goal, we retrospectively analyzed a series of 1820 breast masses (1740 patients) radiologically classified according to the American College of Radiology (ACR) BI-RADS lexicon (67.6% being either BI-RADS 4 or 5), sampled by FNA and immediately diagnosed by cytomorphology. The clinicoradiological, cytomorphological, and histological characteristics of all consecutive patients were retrieved from the hospital computerized medical records prospectively registered in the central information system. Histopathological analysis and ultrasound (US) follow-up (FU) were the reference diagnostic tests of the study design. In brief, we carried out either a histopathological verification or an 18-month US evaluation when a benign cytology was concordant with the components of the triple test. Overall, histology was available for 1138 masses, whereas 491 masses were analyzed at the 18-month US-FU. FNA specimens were morphologically nondiagnostic in 3.1%, false negatives were observed in 1.5%, and there was only one false positive (0.06%). The breast cancer prevalence was 62%. Diagnostic accuracy measures of the OSCAR procedure with their 95% confidence intervals (95% CI) were the following: sensitivity (Se) = 97.4% (96.19-98.31); specificity (Sp) = 94.98% (92.94-96.56); positive predictive value (PPV) = 96.80% (95.48-97.81); negative predictive value (NPV) = 95.91% (94.02-97.33); positive likelihood ratio (LR+) = 19.39 (13.75-27.32); negative predictive ratio (LR-) = 0.03 (0.02-0.04), and; accuracy = 96.45% (95.42-97.31). The respective positive likelihood ratio (LR+) for each of the four categories of cytopathological diagnoses (with their 95% CI) which are malignant, suspicious, benign, and nondiagnostic were 540 (76-3827); 2.69 (1.8-3.96); 0.03 (0.02-0.04); and 0.37 (0.2-0.66), respectively. In conclusion, our study demonstrates that the OSCAR procedure is a highly reliable diagnostic approach and a perfect test to select patients requiring core-needle biopsy (CNB) when performed by interventional cytopathologists in a multidisciplinary and integrated OSC setting. Besides drastically limiting the rate of nondiagnostic specimens and diagnostic turn-around time, OSCAR is an efficient and powerful first-line diagnostic approach for patient-centered care.

International Academy of Cytology Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy Cytopathology: A Review of Predictive Values and Risks of Malignancy

OBJECTIVE

We aimed to assess the risk of malignancy (ROM) and predictive values in prior breast cytology studies as a basis for the new International Academy of Cytology (IAC) Yokohama system for reporting breast fine-needle aspiration biopsy (FNAB) cytology, which classifies cytologic diagnoses into 5 categories: (1) insufficient material, (2) benign, (3) atypical, (4) suspicious of malignancy, and (5) malignant.

STUDY DESIGN

Publications between January 1, 1997, and December 31, 2017, that studied the performance characteristics of FNAB from palpable and nonpalpable breast masses were identified through the PubMed database. Data for number of total cases and cases within each diagnostic category, if available, were collected. Performance characteristics, including absolute sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and ROM for each category were recorded or, when possible, calculated.

RESULTS

The literature review resulted in a case cohort of 33,341 breast FNABs, drawn from 27 studies. Pooling these cases together, the ROM for insufficient material, benign, atypical, suspicious, and malignant were 30.3, 4.7, 51.5, 85.4, and 98.7%, respectively. The complete sensitivity and specificity were 96.3 and 98.8%, correspondingly. The PPV and NPV were 98.7 and 95.3%, correspondingly. The false-negative and false-positive rates were 3.7 and 1.0%, respectively.

CONCLUSIONS

This meta-analysis demonstrates that the diagnostic categories of the new IAC Yokohama System each carry an implied ROM, which increases from the benign to malignant categories. This study also shows the high sensitivity and specificity of FNAB for breast lesions.

Fine needle aspiration cytology of lobular breast carcinoma and its variants

OBJECTIVE

To identify associations between cytological criteria in fine needle aspiration (FNA) specimens and histological subtypes of lobular breast carcinoma (classical and other types).

STUDY DESIGN

FNA cytology and mastectomy specimens from 72 cases of invasive lobular breast carcinoma were consecutively retrieved from the files of the Amaral de Carvalho Hospital, Jaú-São Paulo, Brazil. All cases were reviewed regarding five cytological criteria: cellularity, cellular cohesion, presence of inflammation, nucleoli and nuclear atypia. The χ2 test or Fisher's exact tests with 95% confidence intervals (CI) were used.

RESULTS

The classical type showed lower initial cytological diagnosis of malignancy compared to the other variants (p=0.017; odds ratio (OR) 0.26, 95% CI 0.89-0.80). Moderate/intense cellular cohesion (p=0.011; OR 0.18, 95% CI 0.04-0.73) and mild atypia (p=0.000; OR 16.15, 95% CI 3.20-81.48) were significantly associated with the classical type of lobular breast carcinoma, while the absence of inflammation (p=0.082; OR 0.36, 95% CI 0.12-1.15) was marginally associated with the classical type.

CONCLUSIONS

In cytology, the characterization of lobular carcinoma as malignant is difficult, especially the classical type. The association between cell cohesion and the classical type of lobular breast carcinoma may be one of the factors that complicate this diagnosis.

Fine-needle aspiration of gray zone lesions of the breast: fibroadenoma versus ductal carcinoma

While breast lesions have characteristic cytological features, some lesions, particularly adenocarcinoma and fibroadenoma, may present with overlapping features causing erroneous diagnoses. The current study aimed to define significant cytomorphologic features predictive of fibroadenoma and adenocarcinoma, respectively. Further, we intended to evaluate the predictive characteristics for differentiation between gray zone lesions and to identify root causes contributing to misdiagnoses. First, direct smears prepared from 14 histology-confirmed fibroadenomas and 14 adenocarcinomas were reviewed and characteristics of commonly encountered morphologic features were assessed. We then retrospectively and blindly reviewed nine cytohistologic discrepant cases using the significant characteristic as a guideline, in order to assess whether these discrepant cases could be correctly categorized. Morphologic characteristics predictive of fibroadenoma included moderate cellularity, large, folded cellular sheets/aggregates, staghorn projections, smooth and round borders, monolayers, honeycomb arrangement, smaller nuclear size, and background bipolar cells. Predictive characteristics of adenocarcinoma included high cellularity, loose cohesive sheets/aggregates, pointed projections, irregular borders, larger nuclear size, irregular nuclear membrane, prominent nucleoli, and single atypical epithelial cells. Retrospective, blind review correctly re-classified seven out of nine cytohistologic discrepant cases, including five false negative cases and two false positive cases. Root causes contributing to the misdiagnoses were large branching sheets of carcinoma mimicking folded sheets of fibroadenoma; fibroblasts mimicking myoepithelial cells; apocrine cells mimicking carcinoma cells; and not recognizing the loose myxoid matrix presenting as soap bubbles in fibroadenoma. In conclusion, this study identified significant characteristics that can assist in achieving accurate diagnosis in a subpopulation of breast aspirates that present with overlapping features.

Cytologic features of triple-negative breast carcinoma

BACKGROUND

Triple-negative breast cancer (TNBC) is distinct from other breast cancers, because the tumor cells lack estrogen and progesterone receptors (hormone receptors) and also are negative for human epidermal growth factor receptor 2 (HER2). They comprise a heterogeneous group of tumors with various histologic features and clinical behaviors. High-grade, invasive ductal carcinoma not otherwise specified is the most frequent type, and a substantial fraction of TNBCs belongs to the basal-like tumor type. The purpose of this study was to determine whether some cytologic features could predict the triple phenotype of breast carcinoma.

METHODS

Fine-needle aspiration cytology samples of 62 TNBCs were compared with samples of 82 hormone receptor-positive, high-grade, invasive carcinomas (HRBC) and with samples of 33 hormone receptor-negative, HER2 positive, invasive carcinomas (HER2BC) for the following cytomorphologic features: cellularity, necrosis, lymphocytes, syncytial clusters, tubular/ductal-like clusters, large bare nuclei, streaming within the clusters, and calcifications. Moreover, single cell features, such as cellular borders, cytoplasm, cytoplasmic vacuoles, nuclear pleomorphism, nucleoli, and type of chromatin pattern, were evaluated. Descriptive analyses and 2 multivariate regression models were performed to compare TNBC, HRBC, and HER2BC and to identify the cytologic factors that were associated with tumor type.

RESULTS

TNBCs were more likely to have an abundant necrotic background, many lymphocytes, many syncytial clusters, and ill defined cell borders than non-TNBCs. A tubular/ductal pattern was observed only rarely in TNBCs. Multivariate logistic analysis indicated a 90.8% probability of identifying TNBC versus HRBC by the following cytologic variables: lymphocytes, ill defined cell borders and syncytial clusters, tubular/ductal clusters, cytoplasmic vacuoles, and cellular pleomorphism; whereas there was a 77.5% probability of identifying TNBC rather than HER2BC by the following variables: cellularity, ill defined cellular borders and syncytial clusters, and tubular/ductal clusters.

CONCLUSIONS

Although TNBCs embrace a heterogeneous group of tumors, in this study, they exhibited some common cytologic features that can help to distinguish them from other high-grade breast carcinomas in daily practice.

Characteristics and screening outcome of women referred twice at screening mammography

OBJECTIVES

To determine the characteristics and screening outcome of women referred twice at screening mammography.

METHODS

We included 424,703 consecutive screening mammograms and collected imaging, biopsy and surgery reports of women with screen-detected breast cancer. Review of screening mammograms was performed to determine whether or not an initial and second referral comprised the same lesion.

RESULTS

The overall positive predictive value of referral for cancer was 38.6% (95% CI 37.3-39.8%). Of 147 (2.6%) women referred twice, 86 had been referred for a different lesion at second referral and 32 of these proved malignant (37.2%, 95% CI 27.0-47.4%). Sixty-one women had been referred twice for the same lesion, of which 22 proved malignant (36.1%, 95% CI 24.1-48.0%). Characteristics of these women were comparable to women with cancer diagnosed after first referral. Compared with women without cancer at second referral for the same lesion, women with cancer more frequently showed suspicious densities at screening mammography (86.4% vs 53.8%, P = 0.02) and work-up at first referral had less frequently included biopsy (22.7% vs 61.5%, P = 0.004).

CONCLUSIONS

Cancer risk in women referred twice for the same lesion is similar to that observed in women referred once, or referred for a second time but for a different lesion.

KEY POINTS

Cancer risk was 36% for lesions referred twice at screening mammography. The cancer risk was similar for lesions referred only once at screening. Densities at first referral were associated with increased cancer risk at second referral. No biopsy at first referral was associated with increased cancer risk at second referral. Patient and tumour characteristics were similar for women with and without diagnostic delay.

Non-Hodgkin's lymphoma presenting as breast masses: a series of 10 cases diagnosed on FNAC

Primary breast lymphoma (PBL) is a rare disease, which comprises 0.04-0.53% of all primary malignant tumors of the breast. The most frequent histological subtype is diffuse large B-cell type (DLBCL) (40-70%). Differentiation of PBLs from other breast tumors such as poorly differentiated carcinomas and lobular carcinoma may at times be difficult on cytomorphology alone. An audit of breast lymphomas diagnosed on fine needle aspiration cytology (FNAC) over a period of 9 years (2001-2009) was performed. Ten cases were retrieved and the cytomorphology was reviewed along with immunochemistry (IHC), flow cytometry as well as histopathology, wherever available. The age of patients ranged from 17 to 83 years. Eight cases were diagnosed as non-Hodgkin's lymphoma, high-grade on FNAC. Histopathology was available in four of these cases and cell block was available in one case. Lymphoid cells were positive for leukocyte-common antigen (LCA) and CD20 and negative for CD3 in these cases. The same was confirmed by flow cytometry on aspirated material in one case. A diagnosis of DLBCL was offered in these five cases. One case was a low-grade NHL and another case was a young male, a known case of acute leukemia and had leukemic infiltration in the breast lump. We wish to emphasize the potential importance of FNAC in breast lymphoma and the same can be helpful to avoid unnecessary surgery in these cases. The differential diagnostic entities have been discussed. IHC and flow cytometry can be performed on the aspirated material and provide valuable information.

Fine-needle aspiration cytology of the breast

Fine-needle aspiration cytology (FNAC) is an established, highly accurate, and cost-effective method for diagnosing lesions in different organs, including the breast. The method is minimally invasive without unwanted side effects. FNAC forms part of the triple assessment of breast lesions. Despite some shortcomings of the reporting categories, FNAC as part of the triple assessment has proved its value in describing the findings most accurately. The diagnostic impact depends on experience of the operator, quality of preparation, and diagnostic skills of the cytopathologist. The highest accuracy is achieved at centers with a multidisciplinary approach. FNAC is often palpation guided from palpable breast masses, whereas ultrasonography guidance is more widely used on nonpalpable lesions. Inadequate sampling with FNAC is particularly seen in collagenous lesions and in submitted specimens sampled by physicians lacking experience with the FNAC procedure. A diagnostic biopsy is recommended when FNAC provides scant material. FNAC is considered to be a safe method for screening purposes, although moderately less sensitive than core needle biopsy. FNAC is most accurate when experienced cytopathologists are available to assess the adequacy of the aspirated material and advise on additional aspirations for ancillary tests when needed.

Fine needle aspiration cytology of the breast: the nonmalignant categories

Currently, accurate diagnosis of breast lesions depends on a triple assessment approach comprising clinical, imaging and pathologic examinations. Fine needle aspiration cytology (FNAC) is widely adopted for the pathologic assessment because of its accurracy and ease of use. While much has been written about the atypical and maliganant categories of FNAC diagnosis, little covers the non-malignanat category which represents a sheer number in all FNAC cases. Moreover, any false-negative diagnosis of the non-malignant cases may lead to missed diagnosis of cancer. This paper aims to discuss the issues of smear adequacy, the cytologic features of benign breast lesions and the dilemma of a false-negative aspirate. Much has been suggested about the smear adequacy criterion, including quantifying epithelial clusters, whereas others advocate basing adequacy on qualitative quantum of using noncellular features of FNAC. Various benign lesions could be easily diagnosed at FNAC; however, they have cytologic features overlapped with malignant lesions. False negativity of FNAC does occur; this could be caused by either “true” false-negative cases attributed to suboptimal sampling technique, poor localization of the mass or nonpalpable lesions or “false” false-negative cases due to interpretational errors. Though false-positive cases are less commonly found, they will also be discussed briefly.

[The "gray zone" in organized mammography screening: histocytological correlations]

The National Public Health Program has established the organized mammography screening in Hungary. The aim of this study was to conduct an audit of "gray zone" smears of the organized mammography screening in comparison with histopathological diagnoses.

METHODS

Cytology results were rated to C3 atypia probably benign and C4 suspicious of malignancy.

RESULTS

1361 women had aspiration cytology performed from a total of 47,718 mammography non-negative lesions. 105 (7.8%) were diagnosed as C3, whereas 78 (5.7) as C4. Of the 105 patients with C3 diagnosis 61 (58%) patients underwent surgical biopsy. Histology proved malignancy in 20 (32.8%) cases, and benign lesion in 41 (67.2%) cases. All (100%) of the 78 patients with C4 diagnosis had open biopsies; 69 (88.4%) cases were histologically malignant and 9 (11.6%) cases were benign lesions.

CONCLUSION

The auditing results of fine needle aspiration cytology of "gray zone" in organized mammography screening meet the proposed threshold values. Authors conclude that the "gray zone" category in breast cytology is useful and of value if used judiciously.

Cancer size, histotype, and cellular grade may limit the success of fine-needle aspiration cytology for screen-detected breast carcinoma

BACKGROUND

Fine-needle aspiration cytology (FNAC) was adopted as the first-line method to assess breast lesions in the Verona Breast Cancer Screening Program. The radiological and pathological factors relating to the success of FNAC in breast cancer series were evaluated.

METHODS

Between July 1999 and June 2004, 418 breast cancers were submitted to FNAC in the Verona Breast Cancer Screening Program. The results of FNAC diagnoses were compared with final histology. The FNAC sensitivity rate, underestimation of malignancy rate, and inadequacy rate were correlated with histotype, size, grading, and radiologic imaging.

RESULTS

Of the 418 cancers, 95 were in situ, and 323 were invasive. The sensitivity rate was higher in invasive cancers (P < .001), and the underestimation of malignancy rate was greater in in situ cancers (P = .002). Lobular type cancers had a lower sensitivity rate in invasive and in situ cancers. The sensitivity rate was 100% in medullary, mucinous, and papillary cancers, and no case had inadequate sampling. The underestimation of malignancy rate was higher in tubular carcinoma (18.2%); lobular carcinoma showed a higher inadequacy rate (10.4%). The sensitivity rate was lower and the underestimation of malignancy rate was higher in low-grade carcinomas and in lesions <1 cm (P < .001). The performance of FNAC was not significantly influenced by mammographic imaging of lesions.

CONCLUSIONS

Low-grade cancer histotype, cancer size <1 cm, and lobular and tubular histotypes limit the possibility of obtaining positive results by FNAC. Operator experience and multidisciplinary consultation may help in overcoming these limitations. Pathologists must be aware of the limits of FNAC; results must be critically evaluated in light of the triple assessment.

Disease-specific gene repositioning in breast cancer

Genomes are nonrandomly organized within the three-dimensional space of the cell nucleus. Here, we have identified several genes whose nuclear positions are altered in human invasive breast cancer compared with normal breast tissue. The changes in positioning are gene specific and are not a reflection of genomic instability within the cancer tissue. Repositioning events are specific to cancer and do not generally occur in noncancerous breast disease. Moreover, we show that the spatial positions of genes are highly consistent between individuals. Our data indicate that cancer cells have disease-specific gene distributions. These interphase gene positioning patterns may be used to identify cancer tissues.

Rapid cell blocks improve accuracy of breast FNAs beyond that provided by conventional cell blocks regardless of immediate adequacy evaluation

A new "rapid cell block" technique (RCB; the predecessor of Cellienttrade mark Automated Cell Block System) is efficient at recovering sparse material. We previously found that RCBs of breast fine-needle aspirations (FNAs) frequently allow histologic classification of problematic ductal proliferative lesions. Previous studies that did not emphasize cell blocks found that on-site evaluation (OSE) of breast FNAs improves diagnosis. The purpose of this study was to determine if RCB could replace the utility of OSE of breast FNAs. The study included 604 consecutive ultrasound-guided noncyst breast FNAs composed of three cohorts based on the presence or absence of immediate adequacy assessment, conventional (collodion bag) cell blocks (CCB), and RCB. The cohort with OSE together with CCB did not perform as well as the cohort without OSE but with RCB. In a third cohort, performance characteristics of RCBs and CCBs were compared in an independent review by two cytopathologists blinded to the final cytology and follow-up histology diagnosis. By itself, the RCB histologic section was diagnostic 97% of the time, and it provided a diagnostic accuracy superior to CCB by itself and comparable to that provided by the combination of the smears with CCB. Highest accuracy was obtained by combining smears/monolayer preparations and RCB. Replacing OSE with RCBs provided substantial cost savings and savings of time for cytopathologists, radiologists, and their assistants.

Diagnostic accuracy of fine-needle aspiration cytology of palpable breast masses: an SROC curve with fixed and random effects linear meta-regression models

We used various meta-analytic methods to compare 25 studies describing fine-needle aspiration (FNA) cytologic analyses performed from 1984 to 2007 on palpable breast masses. We found that in the 25 studies examined, the sensitivity ranged from 78% to 100%, the specificity ranged from 76% to 100%, and the diagnostic odds ratio (DOR) ranged from 15.83 to 33 198. The overall diagnostic accuracy was found to be as follows: 0.93 (95% CI: 0.92-0.94) for sensitivity, 0.98 (95% CI: 0.97-0.98) for specificity, and 505.209 (95% CI: 273.08-934.95) for the DOR. The overall diagnostic accuracy according to the results of summary receiving operating characteristic (SROC) curve analysis was 0.95 +/- 0.0032, and the overall weighted area under the (receiving operating characteristic [ROC]) curve (AUC) was 0.99 +/- 0.0014. The DOR values did not show a large variation in the various positivity threshold values. However, the results of those studies had some heterogeneity. The four covariates that were added to the standard SROC model to evaluate variations in the results of the studies were the year of publication, the number of aspirations, the percentage of insufficient material, and the study design. The relative diagnostic accuracy of studies performed after 1990 was 3.98 times higher than that of studies performed before 1990. The relative DOR (RDOR) value was also found to be statistically significant (95% CI: 1.22-13.02). That result may be attributed to the technologic improvements in diagnostic tools over the years. Although it was not statistically significant, an increase in the number of aspirations caused an increase in the RDOR of the FNA cytology (95% CI: 0.52-8.11). In contrast, increasing the percent of insufficient material caused a statistically insignificant but clinically significant decrease in the RDOR of FNA (RDOR = 0.79, 95% CI: 0.21-2.98). In conclusion, our meta-analysis has shown that FNA cytologic analysis of palpable breast masses is highly accurate in the diagnostic differentiation of benign from malignant tumors.

Cytologic diagnosis of lobular carcinoma of the breast: experience with 555 patients in the Rene Huguenin Cancer Center

BACKGROUND

Fine-needle aspiration generally produces results that are not as good for lobular carcinoma as the results for ductal carcinoma of the breast. In this study, the authors evaluated their team's performance in cytologic diagnosis of lobular carcinoma over 11 years and analyzed the reasons for diagnostic failure.

METHODS

Cytologic findings were analyzed in 555 consecutive fine-needle cytopuncture specimens from women with palpable, invasive lobular carcinoma of the breast. The authors also examined the influence of the cytologist's experience, the clinical tumor size, the histologic subtype, and the histologic grade on diagnostic performance. All negative samples were re-examined, along with all samples that had been obtained during the last year of the study, to refine the morphologic description of lobular carcinoma.

RESULTS

Malignancy was diagnosed in 68.8% of specimens overall. The individual pathologists diagnosed malignancy in from 44.4% to 81.1% of specimens, depending on their experience. Diagnostic performance was correlated with clinical tumor size, histologic grade, and histologic subtype, and correct diagnoses were significantly more frequent in pleomorphic subtypes than in "classic" types. Re-examination of all 32 negative specimens reduced the false-negative rate from 5.8% to 3.8%.

CONCLUSIONS

Despite the pitfalls associated with lobular carcinoma of the breast, fine-needle cytopuncture remains a useful diagnostic tool before treatment. Failures can be reduced through experience and by better knowledge of cytologic features.

A decade of breast cancer screening in The Netherlands: trends in the preoperative diagnosis of breast cancer

PURPOSE

In a prospective, multi-institutional follow-up study we describe the trends in the preoperative pathologic confirmation of breast cancer of women who underwent breast cancer screening between 1995 and 2005.

METHODS

We included all women aged 50-75 years who underwent biennial screening mammography in the southern breast cancer screening region of the Netherlands between February 13, 1995 and December 22, 2004. Clinical data, breast imaging reports, biopsy results and breast surgery reports were collected of all women with a positive screening result. Follow-up lasted through the next biennial screening examination and was approximately two years for all referred women.

RESULTS

Of 258,900 mammographic screening examinations, 3,064 (1.2%) were positive screens. The majority of women (92%) were analyzed in four regional hospitals and workup yielded breast cancer in 1,332 women. From 1995 to 2005, the percentage of breast cancer cases that underwent percutaneous biopsy prior to surgery, increased from 42.4 to 100%. The proportion of cancers with a preoperative diagnosis of malignancy by percutaneous biopsy, increased from 27.1% in 1995 to 92.7% in 2004. Preoperative breast cancer confirmation by fine needle aspiration cytology (FNAC) gradually decreased from 91.3% to 14.5%, whereas preoperative confirmation by ultrasound guided core biopsy (USCB) or stereotactic core needle biopsy (SCNB) increased from 8.7% to 69.1% and from 0 to 17.4% respectively.

CONCLUSIONS

A preoperative diagnosis of breast cancer is currently obtained in more than 90% of breast cancer patients. The increase in preoperative breast cancer diagnosis through 1995-2004 is correlated with the introduction of SNCB and increased use of USCB at the expense of FNAC.

Cell blocks of breast FNAs frequently allow diagnosis of invasion or histological classification of proliferative changes

Two major limitations of breast fine needle aspiration (FNA) compared with core needle biopsies (CNB) are the inability to determine whether a cancer is invasive and to classify proliferative lesions. We studied 40 consecutive "rapid cell blocks" from breast FNAs with surgical pathology follow-up to test whether cell blocks can overcome these limitations. Of 25 carcinomas, invasion could be identified in the cell block sections in 11 (44%). One cystosarcoma phyllodes was suspected based on the cell block sections. Cell blocks from 12 of 14 benign breast FNAs showed sufficient cells to assign a histologic diagnosis of no hyperplasia (1 case, confirmed on follow-up) and usual hyperplasia (11 cases; confirmed in eight of 11 on follow-up). Specific histologic diagnoses included intraductal papilloma (2 cases), and in situ lobular neoplasia (2 cases). Cell blocks complement smears and monolayers and appear to overcome major limitations of breast FNA.

Role of fine needle aspiration and tru cut biopsy in diagnosis of mucinous carcinoma of breast—from a radiologist's perspective

This study was to assess whether fine needle aspiration (FNA) or core biopsy would allow diagnosis of mucinous carcinoma of breast. In 37 mucinous carcinoma in 34 patients, 20 lesions had FNA and 24 lesions with core biopsy. FNA achieved a sensitivity of 66.7% in diagnosis of malignant lesions and 56% sensitivity in diagnosis of mucinous carcinoma. Core biopsy achieved 100% sensitivity and accuracy in the diagnosis of malignant lesions and mucinous carcinoma.

Fine-needle aspiration biopsy for breast lesions: a comparison between two devices for obtaining cytological samples

CONTEXT AND OBJECTIVE

Fine-needle aspiration biopsy has been accepted worldwide for breast lesions. However, some questions remain, including the appropriateness of the puncture method. The objective of this work was to compare aspirates obtained by the auto-vacuum device and by the syringe pistol holder.

DESIGN AND SETTING

Randomized trial for validation of diagnostic method, at Hospital das Clínicas da Universidade Federal de Goiás and Hospital Araújo Jorge, Goiânia.

METHODS

351 patients presenting breast lumps underwent fine-needle aspiration biopsy, either with the auto-vacuum device or the syringe pistol holder. A single cytopathologist analyzed all of the cytology slides. The rates of insufficient material, cellularity, cell distortion and background hemorrhage were evaluated.

RESULTS

The percentages of insufficient material were 16% and 22% (p = 0.18), for the auto-vacuum and pistol aspirates, respectively. Good cellularity was seen in 34% of auto-vacuum and 29% of pistol samples (p = 0.4). Cell distortion was seen in 31 and 26 cases, respectively (p = 0.7). Background hemorrhage occurred in 63 (35%) and 54 cases (31%) (p = 0.2), for auto-vacuum and pistol. The sensitivity was 88% and 86%; specificity 99% and 100%, positive predictive value 96% and 100%, negative predictive value 96% and 95% and total accuracy 76% and 75% for the auto-vacuum and pistol, respectively.

CONCLUSION

The results obtained from the two fine-needle aspiration biopsy methods were equivalent. Therefore, the auto-vacuum device is a good option for obtaining aspirates for cytology.

Management of Nonpalpable Breast Lesions in a Modern Functional Breast Unit

During the last 20 years an ever increasing number of nonpalpable breast lesions (NPBL) have been identified. A cytohistological definition is required to establish the correct diagnostic classification of these lesions and the suitable therapy to be used. The Fine-Needle Aspiration Cytology (FNAC), the Advanced Breast Biopsy Instrumentation (ABBI) system or the Vacuum Assisted Core Biopsy (VACB) represent valid alternatives to the surgical excision with needle localisation. 591 NPBL have been included in the present study. The suspected grade of each lesion was then assigned according to the Breast Imaging Reporting and Data System (BI-RADS) of the American College of Radiology. All the BI-RADS 4 and 5, and all the BI-RADS 3 lesions, which after 6-month follow-up showed altered morphology, were sampled for cytological and/or histological examinations by FNAC, VACB or biopsy by ABBI system. The diagnostic algorithm used in this study obviated a surgical procedure in 574 women (97.1%), yielding a 73.9% decrease in the cost of diagnosis compared with surgical biopsy, and a 48.1% decrease in cost if all lesions had been histologically tested using ABBI or VACB procedure. Compared to surgical biopsy, VACB and ABBI system are less expensive, and have smaller emotional and aesthetical impact on patients; however they retain the same sensitivity and specificity.

Characterisation of breast fine-needle aspiration biopsies by centrosome aberrations and genomic instability

Recent studies have suggested that aneuploidy in malignant tumours could be a consequence of centrosome aberrations. Using immunofluorescence analysis with an antibody against γ-tubulin and DNA image cytometry, we measured centrosome aberrations and DNA ploidy patterns in fine-needle aspiration biopsies (FNABs) of 58 breast lesions. Benign lesions did not show any centrosome aberrations. DNA diploid carcinomas showed a mean percentage of cells with centrosomal defects of 2.1%. The aneuploid invasive carcinomas could be divided into two subgroups by their significantly (P=0.0003) different percentage of cells with centrosome aberrations (2.0 and 10.3%, respectively) and their significantly (P=0.0003) different percentage of cells with nonmodal DNA content values determined by the Stemline Scatter Index (SSI), a measure of genomic instability. The percentage of cells with centrosome aberrations demonstrated a positive, linear correlation with the corresponding SSI (r=0.82, P<0.0001) and loss of tissue differentiation (r=0.78, P<0.0001). Our results indicate the percentage of cells with centrosome aberrations as being sufficient to divide the investigated tumours into three significantly different groups: benign lesions with no centrosomal aberrations, and two malignant tumour types with mean values of 2.1 and 9.6% of centrosomal defects, respectively. Together, these results demonstrate that centrosome aberrations correlate with genomic instability and loss of tissue differentiation. Furthermore, this study shows the feasibility of centrosomal analysis in FNAB of the breast and suggests centrosomal aberrations as possessing diagnostic and prognostic value.

Approach to Fine-needle Aspiration Cytology-negative Cases of Breast Cancer

OBJECTIVE

To clarify the clinical usefulness of fine-needle aspiration (FNA) cytology of breast tumours and the management of FNA cytology-negative cases suspected of or equivocal for malignancy.

METHODS

FNA cytology was performed in 94 patients between 1995 and 2002. We calculated the sensitivity, specificity and accuracy of FNA cytology for the diagnosis of malignancy. We also compared clinical and radiological findings between false-negative and true-negative cases.

RESULTS

The sensitivity of FNA was 91% (72/79), specificity was 93% (14/15), accuracy was 91% (86/94), positive predictive value was 99% (72/73) and negative predictive value was 67% (14/21). There were seven false-negative cases and one false-positive case. Findings that aroused suspicion of malignancy were more frequent in the false-negative cases, especially from mammography and magnetic resonance imaging (MRI).

CONCLUSION

FNA cytology was an accurate preoperative diagnostic procedure for the evaluation of breast masses. In FNA cytology-negative cases, repeated FNA, core needle biopsy or excisional biopsy needs to be performed based on MRI findings.

Bilateral primary lymphoma of the breast: A case report initially diagnosed by FNAC

Primary lymphoma of the breast (PLB) is a rare disease, representing 0.04-0.5% of all malignant breast neoplasms. We present a patient with bilateral breast involvement by a high-grade diffuse large B-cell lymphoma, which was diagnosed initially by fine-needle aspiration cytology (FNAC). Mammography revealed a diffuse increase in density of the right breast and a large solitary mass on the left breast, suggestive of an inflammatory carcinoma. The patient underwent FNAC and the diagnosis of a non-Hodgkin's lymphoma (NHL) was suggested. Physical examination revealed palpable bilateral axillary lymph nodes but no evidence of concurrent widespread disease. The patient underwent complete staging evaluation. The only positive findings were an elevated lactate dehydrogenase (LDH) and evidence of axillary lymphadenopathy on CT. Excisional biopsy was performed on the left breast. The morphological and immunohistochemical analysis confirmed the diagnosis of a high-grade diffuse large B-cell lymphoma with an immunophenotype suggestive of a germinal center cell origin.

'Atypical' and 'suspicious' diagnoses in breast aspiration cytology

BACKGROUND

In 1996, the National Cancer Institute (NCI) recommended five categories for the diagnosis of breast aspiration cytology: benign, atypical, suspicious, malignant, and unsatisfactory. The authors evaluated the usefulness of separating inconclusive diagnoses into the aforementioned atypical and suspicious categories. The current study examined the correlation between cytologic and histologic findings made in breast aspiration cytology specimens that were categorized in accordance with these NCI guidelines.

METHODS

From 1992 to 2000, 7727 breast aspirations were performed at the University of Miami/Jackson Memorial Medical Center (Miami, FL). Aspirates were classified using criteria similar to the NCI recommendations. Four hundred eighty-nine aspirates (6%) were classified as being cytologically 'atypical' or 'suspicious'. Of those, 225 'atypical' aspirates and 162 'suspicious' aspirates had available histologic follow-up data and were included in the study.

RESULTS

Among the 'atypical' aspirates, 118 (52%) yielded malignant findings on histologic evaluation. Infiltrating ductal carcinoma (n = 87; 74%) was the most common malignant diagnosis, followed by infiltrating lobular carcinoma (n = 12; 10%). Among 'suspicious' aspirates, 135 (83%) yielded malignant findings on histologic analysis. The most common benign diagnosis in both 'atypical' and 'suspicious' aspirates was proliferative fibrocystic changes with or without atypia, followed by fibroadenoma.

CONCLUSIONS

Most aspirates that yielded suspicious findings on cytologic examination proved to be malignant, as did > 50% of aspirates that yielded atypical findings. Infiltrating lobular carcinoma commonly was underdiagnosed as being atypical on cytologic examination. Benign lesions with atypical or suspicious cytologic diagnoses included certain cases of atypical ductal hyperplasia. The authors concluded that the distinction between the atypical and suspicious categories, as recommended by the NCI, is not warranted. Therefore, they suggest the use of a single term, such as 'equivocal', to describe inconclusive diagnoses on breast fine-needle aspiration cytology.

Fine-needle aspiration cytology in nonpalpable mammographic abnormalities in breast cancer screening: results from the breast cancer screening programme in Oslo 1996-2001

Fine-needle aspiration cytology (FNAC) of nonpalpable mammographic lesions has been under attack from two sides for some years. There has been much discussion and controversy as to the ability to differentiate between in situ and invasive carcinomas in cytological material. A further issue is that of optimal sampling to obtain adequate cell material in sufficient quantity. We present the results of FNAC from 832 nonpalpable mammographic abnormalities detected in the course of the breast cancer screening programme in Oslo during 1996-2001. In 11.6% of cases the smears were inadequate, and there were 7% false negatives (FN) and 1.3% false positives. Of the FN, 64% represented microcalcifications and 86% were due to sampling errors. Absolute sensitivity was 74%, complete sensitivity 88% and specificity 88%. In 255 carcinomas a cytological diagnosis of them as in situ or invasive was made. In 93% of the invasive cases (190/205) these had been correctly identified as invasive on FNAC. In 78% of cases proper follow-up could be resolved by cytology/radiology alone. Suboptimal sampling and localization remains the main cause of FN FNAC results. Problems in differentiating between in situ and invasive breast carcinomas can be significantly reduced by applying strict criteria for in situ lesions.

How stereotactic core-needle biopsy affected breast fine-needle aspiration utilization: An 11-year institutional review

To determine the effect of stereotactic core-needle biopsy (SCNB) on the utilization of breast fine-needle aspirate (FNA) biopsy, we retrospectively reviewed 1,568 cases of breast FNAs that were obtained from 1,188 patients between the years 1990 and 2000. There were 378 positive and atypical cases and 497 negative and unsatisfactory cases in the pre-SCNB group (between 1990 and 1996; 7 years); and 225 positive and atypical cases and 468 negative and unsatisfactory cases in the post-SCNB group (between 1997 and 2000; 4 years). The average number of cases per year in the pre- and post-SCNB groups was 125 and 173, respectively. While the average positive/atypical cases per year in both groups remained relatively constant, the average negative/unsatisfactory cases per year were significantly increased in the post-SCNB group (117 in the post-SCNB vs. 71 in the pre-SCNB). The increase in this group was due to a true increase in the negative diagnoses, since unsatisfactory rate decreased in the post-SCNB group (12.6% in the post-SCNB vs. 9.3% in the pre-SCNB). The sensitivity, specificity, positive predictive value, and negative predictive value were 90%, 79%, 92%, and 82% in the pre-SCNB group and 93%, 86%, 91%, and 90% for the post-SCNB group, respectively. In conclusion, the implementation of SCNB did not result in a decrease in the total number of breast FNAs; however, the distribution of cases changed. FNA is increasingly used to complete the triple test in clinically and radiographically negative cases.

Cytologic diagnosis of invasive lobular carcinoma: Factors associated with negative and equivocal diagnoses

Fine-needle aspiration biopsy (FNAB) of invasive lobular carcinoma (ILC) is associated with notoriously high rates of false negative and equivocal diagnoses. To identify causative factors, we reviewed the cytologic features of presurgical FNAB smears of ILC and correlated the cytologic findings with the number of passes, tumor size, mammographic findings, and the histologic characteristics of the tumor. Smear cellularity, presence of single intact epithelial cells, nuclear size, nuclear atypia, palpability of the tumor, and histologic type of ILC (classic versus nonclassic) were statistically significant in establishing an unequivocally positive diagnosis. We also found that the cytologic cellularity of the lesion does not reflect the actual cellularity of the tumor but instead is an indicator of the architectural arrangement of the neoplastic cells; tumors that form epithelial cell groups, such as in nonclassic ILC, tend to yield more cellular aspirates that are diagnostic for carcinoma. In contrast, classic ILC, in which single neoplastic cells are embedded in fibrous stroma, is more likely to yield a paucicellular smear with subtle atypia and rare single intact epithelial cells. As such, an inconclusive diagnosis in a certain percentage of classic ILC cases may be unavoidable.

Fine-needle aspiration cytology vs. core biopsy in the diagnosis of breast lesions

Fine-needle aspiration cytology (FNAC) is an established, highly accurate method for diagnosing breast lesions. However, in recent years there has been increased use of core biopsy (CB) in this setting. The aim of this study was to evaluate the accuracy of FNAC and compare the quality assessment parameters of FNAC and CB in palpable and nonpalpable breast lesions. Data regarding FNAC, CB, and excision biopsy (EB) diagnoses were retrieved from the archives of our department. A total of 4,367 FNAC samples from the years 1999-2001 was reviewed. Of these, corresponding histology results were available for 1,275 lesions, of which 1,248 were primary breast epithelial lesions (788 EB, 199 CB, 261 EB+CB). All cases were analyzed for sensitivity and specificity of FNAC. Cases with both FNAC and CB were compared and quality assessment parameters were calculated using the methodology detailed in the National Health Service Breast Screening Program guidelines. High specificity and sensitivity, as calculated for satisfactory specimens, were achieved with the use of both FNAC and CB. False-positive and false-negative diagnoses were seen in 7/404 (1.7%) and 45/635 (7.1%) of biopsy-proven specimens sampled by FNAC. The corresponding values for CB were 0% and 5.7%, respectively. Inadequate sampling (15.1%) with use of FNAC was particularly seen in collagenous lesions and in submitted specimens sampled by physicians lacking experience with the FNAC procedure. FNAC is a valuable method, although moderately less sensitive than CB. CB is the preferred method for preoperative diagnosis when sampling FNAC provides scarce material and suspicion of a fibrotic and collagenous lesion such as lobular carcinoma and radial scar arises. FNAC is most accurate when experienced cytologists are available and when immediate assessment by professionals is performed for evaluation of material adequacy, so that additional aspirations can be done when needed.

Diagnosis and subclassification of breast carcinoma by fine-needle aspiration biopsy: results of the interlaboratory comparison program in non-gynecologic cytopathology

CONTEXT

The College of American Pathologists Interlaboratory Comparison Program in Non-Gynecologic Cytopathology is a popular educational program for nongynecologic cytology that had 1018 participating laboratories by the end of 2000. Data generated from this program allow for tracking performance on slides in a diverse group of laboratories.

OBJECTIVE

We reviewed the performance of participating laboratories on fine-needle aspiration biopsies of the breast with particular interest in the ability of participants to accurately subclassify breast carcinoma.

DESIGN

We reviewed the responses of participating laboratories for glass slides of breast fine-needle aspiration biopsies for the year 2000. We analyzed benchmarking data provided for each specific diagnosis.

RESULTS

The overall false-negative rate for laboratories was 6.2%, and the overall false-positive rate was 1.1%. Most of the breast carcinomas were correctly identified as malignant on the general diagnosis, but participants had more difficulty subclassifying types of breast carcinoma. The rate of correct exact diagnosis was 65% for ductal adenocarcinoma, 20% for lobular adenocarcinoma, 12% for medullary carcinoma, and 27% for mucinous carcinoma.

CONCLUSIONS

This study shows that fine-needle aspiration biopsy of the breast is a reliable method for the diagnosis of breast carcinoma, but difficulties still exist in our ability to determine tumor subtype.

Intratumoral cancer chemotherapy and immunotherapy: opportunities for nonsystemic preoperative drug delivery

The recent literature documents the growing interest in local intratumoral chemotherapy as well as systemic preoperative chemotherapy with evidence for improved outcomes using these therapeutic modalities. Nevertheless, with few exceptions, the conventional wisdom and standard of care for clinical and surgical oncology remains surgery followed by radiation and/or systemic chemotherapy, as deemed appropriate based on clinical findings. This, in spite of the fact that the toxicity of conventional systemic chemotherapy and immunotherapy affords limited effectiveness and frequently compromises the quality of life for patients. Indeed, with systemic chemotherapy, the oncologist (and the patient) often walks a fine line between attempting tumour remission with prolonged survival and damaging the patient's vital functions to the point of death. In this context, it has probably been obvious for more than 100 years, due in part to the pioneering work of Ehrlich (1878), that targeted or localized drug delivery should be a major goal of chemotherapy. However, there is still only limited clinical use of nonsystemic intratumoral chemotherapy for even those high mortality cancers which are characterized by well defined primary lesions i.e. breast, colorectal, lung, prostate, and skin. There has been a proliferation of intratumoral chemotherapy and immunotherapy research during the past two to three years. It is therefore the objective of this review to focus much more attention upon intratumoral therapeutic concepts which could limit adverse systemic events and which might combine clinically feasible methods for localized preoperative chemotherapy and/or immunotherapy with surgery. Since our review of intratumoral chemoimmunotherapy almost 20 years ago (McLaughlin & Goldberg 1983), there have been few comprehensive reviews of this field; only one of broad scope (Brincker 1993), three devoted specifically to gliomas (Tomita 1991; Walter et al. 1995; Haroun & Brem 2000), one on hepatomas (Venook 2000), one concerning veterinary applications (Theon 1998), and one older review of dermatological applications (Goette 1981). However, none have shed light on practical opportunities for combining intratumoral therapy with subsequent surgical resection. Given the state-of-the-art in clinical and surgical oncology, and the advances that have been made in intratumoral drug delivery, minimally invasive tumour access i.e. fine needle biopsy, new drugs and drug delivery systems, and preoperative chemotherapy, it is timely to present a review of studies which may suggest future opportunities for safer, more effective, and clinically practical non-systemic therapy.

False-positive reports in fine needle biopsy of breast lesions

A review of the literature reveals considerable variations in the diagnostic accuracy of fine needle biopsy (FNB) of breast lesions between series, partly due to different methods of calculation, different definitions, and insufficient numbers of cases with adequate follow-up to provide reliable statistics. The best larger series have a false-positive rate between 0.2 and 0.3%, slightly higher for non-palpable than for palpable lesions. The cytological patterns of a range of benign lesions which may cause diagnostic difficulties and may be misdiagnosed as malignant by FNB are described, and guidelines to reduce the risk of false-positive diagnoses are proposed.

Critical clinicopathologic analysis of 23 cases of fine-needle breast sampling initially recorded as false-positive. The 44-year experience of the Institut Curie

BACKGROUND

Because false-positive cytologic diagnoses in breast tumors are rare, few cases have been reported, although their consequences may be highly detrimental to the patient. The authors report the Institut Curie's experience, by using a multidisciplinary approach.

METHODS

Of 9334 benign breast tumors examined preoperatively for cytologic diagnosis by fine-needle sampling (FNS), the 23 (0.25%) FNS cases considered to be false-positive were retrospectively reviewed and analyzed.

RESULTS

Tumors were situated close to the nipple in 7 cases and away from the nipple in 16 cases. Tumor stage was T0 for 1 case, T1 for 18 cases, and T2 for 4 cases. Radiologically, six tumors were classified as malignant, seven as indeterminate or suspicious, and nine as benign. Three of six tumors studied by flow cytometry were DNA aneuploid. Based on a multidisciplinary clinicopathologic review, 20 FNS cases were finally classified as false-positive, and the remaining 3 tumors with malignant FNS and subsequent benign histology were classified as true-positive, because local and/or metastatic progression was observed in the short term.

CONCLUSIONS

The authors' review suggests two categories of false-positive cases: the first in which cytologic benign patterns are overdiagnosed, and the second in which atypical morphologic criteria were present. Nevertheless, as shown by the malignant course in three cases, patients with malignant preoperative FNS and corresponding benign histology always require close clinical follow-up. Finally, surgical overtreatment rate could be decreased if all radiologically benign tumors with positive/suspicious FNS were subject to intraoperative frozen section examination.

Fine-needle aspiration cytology for diagnosis and management of palpable breast mass

BACKGROUND

The present study aims to clarify the use, in a developing country, of fine-needle aspiration cytology (FNA) instead of open biopsy as a cost-saving, reliable initial diagnostic and management tool for patients with breast mass.

METHODS

A prospective study of 60 patients (71 breast masses) was carried out. The accuracy of physical diagnosis of the mass was compared with that obtained by FNA. The cytological results were analysed with the clinical profiles and pathological results.

RESULTS

Physical examination was unreliable for the diagnosis of breast cyst (61.1% positive predictive value, 73.6% negative predictive value), which accounted for 35% of breast masses studied. Aspiration alone determined the diagnosis and management in 39% of masses. For solid breast masses benign cytological results (class I, II) were proved to be reliable (100% positive predictive value), as were malignant cytological results (class V; 100% positive predictive value). Inadequate cytology was reported for five masses (11.9%).

CONCLUSIONS

Fine-needle aspiration should be routinely performed in all patients with breast masses. This would facilitate prompt diagnosis and treatment in one-third of patients with breast cyst, and the benign cytological result could facilitate definite management in the majority of patients with a low risk of malignancy. This could save cost, time and patient anxiety. For the patients with a high clinical suspicion of breast cancer, the positive cytological result could reliably confirm the diagnosis, while the equivocal result could be combined with mammography or open biopsy. Considering the ease, simplicity and low cost, FNA may be suitable for developing countries where other non-invasive procedures are unavailable or difficult to obtain, and it could replace open biopsy, which is still commonly done.

Undetected invasive lobular carcinoma of the breast: review of false-negative smears

Analysis of a series of 34 fine-needle aspirations (FNA) from 28 patients with invasive lobular carcinoma (ILC) was undertaken. The false-negative smears were reviewed to reveal the cause of such a relatively frequent error. This was a retrospective study and comparison between the cytological and pathological findings in a series of 34 FNA. Three cases were excluded without sufficient material. Twelve cases were positive, nine suspicious of malignancy, and 10 were considered false-negatives. In a second analysis of this later group, one was reclassified as carcinoma, two reconsidered without sufficient material for diagnosis, and the remaining seven, still considered negatives, constituted the core of this study. Of these seven, there were none with hypercellular smears and in six there was a predominance of fat-tissue fragments. The scarce epithelial component showed honeycomb-flat sheets in four, loose clusters in three, small and tight clusters with irregular limits in six, and more than 10% of isolated epithelial cells (noncohesive cells) in one case. "Staghorns" were undetected and myoepithelial cell nuclei were very scarce in all cases. Some nuclear enlargement was detected in one, angulated nuclear contour in three, and nuclear crowding was present in five. All seven had fine, homogeneous chromatin, without prominent nucleoli. Cytoplasmic limits were undefined in all but one (6/7) and occasional cytoplasmic vacuolization was detected in two. Hypocellular smears with few, small, and dense groups (but always with more than 10 groups in at least one smear) can be related with ILC. In these cases, further studies are recommended to exclude malignancy. The loose cluster and flat sheets identified in four cases represent a benign epithelial hyperplasia mixed with the ILC.