Core needle biopsy versus fine needle aspiration biopsy in breast--a historical perspective and opportunities in the modern era

Interobserver agreement and risk of malignancy using the International Academy of Cytology Yokohama System for reporting breast FNA biopsy in a liquid-based exclusive cohort

BACKGROUND

Per the College of American Pathologist's National Breast Fine Needle Aspiration Biopsy (FNAB) Practice Survey, ∼40% of laboratories use liquid-based cytology (LBC) for breast FNAB. The reproducibility of the International Academy of Cytology Yokohama System (YS) for reporting breast FNAB on LBC was explored.

DESIGN

Breast FNAB specimens submitted as LBC only (all ThinPrep) between January 2017 and January 2021 were retrieved. Cases without histopathologic follow-up were excluded. Clinical and radiologic information was collected. One cytologist and six cytopathologists rendered diagnoses per YS. All reviewers were blinded to the original diagnosis and histopathologic follow-up. The risk of malignancy was calculated. Concordance rates were calculated by a weighted Cohen Kappa score (κ).

RESULTS

Review of 110 cases demonstrated substantial to near-perfect agreement between each reviewer (κ = 0.73-0.91) and follow-up histopathology (κ = 0.66-0.85). The agreement was lowest in the inadequate (κ = 0.05) and atypical (κ = 0.04) categories. The lack of concordance in the atypical category was common in cases with low cellularity or incomplete structural features. The risk of malignancy for inadequate, benign, atypical, suspicious for malignancy, and malignant categories were 12.5% (2/16), 3% (2/65), 67%, (8/12) 100% (1/1), and 100% (16/16).

CONCLUSION

Interobserver agreement is excellent using the five YS categories in LBC. Lack of cellularity and incomplete architectural features were barriers to perfect agreement. Established pitfalls in the interpretation of LBC were cause for atypical diagnoses. Continuous training and education are recommended to avoid misdiagnosis because of the nonconventional cytomorphologic features of LBC and to improve inadequate and atypical rates within YS.

Minimally invasive biopsy-based diagnostics in support of precision cancer medicine

Precision cancer medicine (PCM) to support the treatment of solid tumors requires minimally invasive diagnostics. Here, we describe the development of fine-needle aspiration biopsy-based (FNA) molecular cytology which will be increasingly important in diagnostics and adaptive treatment. We provide support for FNA-based molecular cytology having a significant potential to replace core needle biopsy (CNB) as a patient-friendly potent technique for tumor sampling for various tumor types. This is not only because CNB is a more traumatic procedure and may be associated with more complications compared to FNA-based sampling, but also due to the recently developed molecular methods used with FNA. Recent studies show that image-guided FNA in combination with ultrasensitive molecular methods also offers opportunities for characterization of the tumor microenvironment which can aid therapeutic decisions. Here we provide arguments for an increased implementation of molecular FNA-based sampling as a patient-friendly diagnostic method, which may, due to its repeatability, facilitate regular sampling that is needed during different treatment lines, to provide tumor information, supporting treatment decisions, shortening lead times in healthcare, and benefit healthcare economics.

Needle biopsy accelerates pro-metastatic changes and systemic dissemination in breast cancer: Implications for mortality by surgery delay

Increased breast cancer (BC) mortality risk posed by delayed surgical resection of tumor after diagnosis is a growing concern, yet the underlying mechanisms remain unknown. Our cohort analyses of early-stage BC patients reveal the emergence of a significantly rising mortality risk when the biopsy-to-surgery interval was extended beyond 53 days. Additionally, histology of post-biopsy tumors shows prolonged retention of a metastasis-permissive wound stroma dominated by M2-like macrophages capable of promoting cancer cell epithelial-to-mesenchymal transition and angiogenesis. We show that needle biopsy promotes systemic dissemination of cancer cells through a mechanism of sustained activation of the COX-2/PGE2/EP2 feedforward loop, which favors M2 polarization and its associated pro-metastatic changes but are abrogated by oral treatment with COX-2 or EP2 inhibitors in estrogen-receptor-positive (ER+) syngeneic mouse tumor models. Therefore, we conclude that needle biopsy of ER+ BC provokes progressive pro-metastatic changes, which may explain the mortality risk posed by surgery delay after diagnosis.

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.

A retrospective comparative study on the diagnostic efficacy and the complications: between CassiII rotational core biopsy and core needle biopsy

Accurate pathologic diagnosis and molecular classification of breast mass biopsy tissue is important for determining individualized therapy for (neo)adjuvant systemic therapies for invasive breast cancer. The CassiII rotational core biopsy system is a novel biopsy technique with a guide needle and a "stick-freeze" technology. The comprehensive assessments including the concordance rates of diagnosis and biomarker status between CassiII and core needle biopsy were evaluated in this study. Estrogen receptor (ER), progesterone receptor (PgR), human epidermal growth factor receptor 2 (HER2), and Ki67 were analyzed through immunohistochemistry. In total, 655 patients with breast cancer who underwent surgery after biopsy at Sir Run Run Shaw Hospital between January 2019 to December 2021 were evaluated. The concordance rates (CRs) of malignant surgical specimens with CassiII needle biopsy was significantly high compared with core needle biopsy. Moreover, CassiII needle biopsy had about 20% improvement in sensitivity and about 5% improvement in positive predictive value compared to Core needle biopsy. The characteristics including age and tumor size were identified the risk factors for pathological inconsistencies with core needle biopsies. However, CassiII needle biopsy was associated with tumor diameter only. The CRs of ER, PgR, HER2, and Ki67 using Cassi needle were 98.08% (kappa, 0.941; p<.001), 90.77% (kappa, 0.812; p<.001), 69.62% (kappa, 0.482; p<.001), and 86.92% (kappa, 0.552; p<.001), respectively. Post-biopsy complications with CassiII needle biopsy were also collected. The complications of CassiII needle biopsy including chest stuffiness, pain and subcutaneous ecchymosis are not rare. The underlying mechanism of subcutaneous congestion or hematoma after CassiII needle biopsy might be the larger needle diameter and the effect of temperature on coagulation function. In summary, CassiII needle biopsy is age-independent and has a better accuracy than CNB for distinguishing carcinoma in situ and invasive carcinoma.

Assessing the accuracy of the International Academy of Cytology Yokohama System for reporting breast fine needle aspiration biopsy cytology at a Vietnamese oncology centre

BACKGROUND

Fine needle aspiration biopsy (FNAB), accompanied by classification systems for cytology, can offer a cheap and convenient option for the diagnosis of breast cancer in women with suspicious breast lumps. In this study, we aimed to assess the accuracy of the International Academy of Cytology (IAC) Yokohama system in a Vietnamese oncology centre.

METHODS

A retrospective cross-sectional study was conducted from November 2021 to April 2022 at Vietnam National Cancer Hospital. We included patients with full hospital records regarding breast lesions for which FNAB was indicated. A total of 803 patients' FNAB specimens were assessed according to the IAC Yokohama system. The basic characteristics were summarised using the appropriate summary measurements. The risk of malignancy (ROM) was calculated for each classification category.

RESULTS

The median age was 42.7 years (range: 14-85). The mean size of the lesions was 17.9 mm (range: 4-123 mm). We had 215 histopathological reports. The most common benign and malignant diagnoses were fibroadenoma and invasive carcinoma, respectively. The ROM for categories II, III, IV, and V was calculated as 3.4%, 37.5%, 95%, and 99.2% respectively. The sensitivity, specificity, positive predictive value, and negative predictive value were 96.4%, 97.2%, 98.5%, and 93.2%, respectively.

CONCLUSION

The IAC Yokohama system offers a good option with which to predict underlying breast pathology using a simple and cheap procedure. However, pathologists require continuous training to ensure accurate interpretation of the slides.

Combined Use of Cell Block and Smear Improves the Cytological Diagnosis of Malignancy in Non-Palpable Breast Lesions Screened by Imaging

Background

Currently, core needle biopsy is replacing fine needle aspiration biopsy (FNAB) for pathological diagnosis of breast lesions. However, FNAB is extensively used for diagnosing breast lesions, including screened lesions, at our hospital. Furthermore, direct smears as well as cell blocks (CBs) from the FNAB specimens have been used. To prepare the CBs, hematoxylin and eosin (HE) staining as well as immunostaining with a mixture of p63 and cytokeratin 5/6 antibodies are routinely used. Therefore, in the current study, we sought to assess the efficacy of diagnosing breast lesions using conventional smears and CB immunostaining.

Methods

Breast FNAB reports of direct smears and CBs from The Nagoya Medical Center between December 2014 and March 2020, were reviewed. The efficiency of diagnoses made with direct smears and CBs were compared using histology-based diagnoses.

Results

Among the 169 histologically confirmed malignant lesions, 12 lesions that were reported as unsatisfactory, benign, or atypia probably benign, using direct smears were diagnosed as malignant using CB. Histologically, these lesions were diagnosed as carcinomas with mild atypia or papillary structures. Ten (83.3%) of the twelve lesions were non-palpable and only detected upon imaging.

Conclusion

Combined use of CB and conventional smear leads to the detection of more malignant lesions in breast FNAB specimens, particularly in lesions detected by imaging alone. Immunostaining of CB sections using a mixture of p63 and cytokeratin 5/6 antibodies provides more information than HE staining alone. Breast FNAB with CB preparation can be successfully applied for evaluation of breast lesions in developed countries.

Comparative study of breast core needle biopsy (CNB) findings with ultrasound BI-RADS subtyping

&lt;b&gt; Introduction:&lt;/b&gt; Given the high prevalence of breast cancer, developing quick and accessible diagnostics solutions is critical. The BIRADS classification is a reliable method for assessing and estimating the risk of malignancy in breast lesions. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Aim:&lt;/b&gt; The aim of this study was to compare the results of core needle biopsy of breast lesions and sonographic findings based on the BIRADS category in Yazd. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Materials and methods:&lt;/b&gt; This retrospective analytical study was done on all core needle biopsy specimens referred to Mortaz hospital, Yazd, Iran from 2010 to 2019. Demographic data such as age, laterality of the lesion, BIRADS category, and pathology reports were extracted from patients&apos; hospital folders. Data were analyzed by SPSS version 21. P &lt; 0.05 was considered statistically significant. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Results:&lt;/b&gt; In total, 514 cases with a mean age of 43.9 9.4 years were studied. Among them, 104 cases (20.2%) were malignant and 410 cases (79.8%) were benign. The most common benign and malignant lesions were fibroadenoma (24.9%), and infiltrative ductal carcinoma (83.7%) respectively. The most common BIRADS was class 4A (54.9%). Patients with benign lesions were mostly in the 3rd and 4th decade of life, while malignant lesions were more in the 4th and 5th decades, and this difference was statistically significant (P = 0.001). The correlation between ultrasound diagnoses (BIRADS) and pathology findings was statistically significant (P &lt; 0.001). &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusion&lt;/b&gt;: Based on the results, there is a significant correlation between ultrasound outcomes according to BIRADS and pathology results, and the radiology-pathology accordance, owing to its high accuracy, can be very helpful in correctly diagnosing, monitoring, and managing the lesion.

Immunohistochemistry Applied to Breast Cytological Material

Fine-needle aspiration biopsies (FNABs) of the breast are minimally invasive procedures enabling the diagnosis of suspicious breast lesions. Unfortunately, they are often perceived as inferior to core-needle biopsies, namely because they are supposedly unable to differentiate between high-grade ductal carcinoma in situ and invasive carcinoma or provide material for ancillary testing. Several studies have shown, however, that FNAB samples, when handled properly, are indeed capable of providing sufficient and adequate material for ancillary testing, namely immunocytochemistry (ICC). We reviewed the published literature regarding the use of ICC for both diagnostic and theranostic uses in the different types of cytological samples obtained from FNABs of the breast, including smears, liquid-based cytology samples, and cellblocks. We found that p63 and 34βE12 show promise in aiding in the differential diagnosis between in situ and invasive lesions and that most other diagnostic markers may be used as in tissue. Regarding theranostic ICC markers, results vary between publications, but with care, these can successfully be performed in cytological samples. Air-dried smears should be avoided, and cellblocks are overall more versatile than cytology slides, enabling the evaluation of not only hormonal receptors and HER2 by ICC, but also of Ki-67. Particular attention should be paid to fixation and antigen retrieval procedures in all cases. We recommend that laboratories without experience perform short validation runs before adopting these techniques into clinical practice.

Correlation Between Ultrasound BI-RADS 4 Breast Lesions and Fine Needle Cytology Categories in a Sample of Iraqi Female Patients

Background: Breast cancer is the most common malignancy in female and the most registered cause of women’s mortality worldwide. BI-RADS 4 breast lesions are associated with an exceptionally high rate of benign breast pathology and breast cancer, so BI-RADS 4 is subdivided into 4A, 4B and 4C to standardize the risk estimation of breast lesions.

The aim of the study: to evaluate the correlation between BI-RADS 4 subdivisions 4A, 4B & 4C and the categories of reporting FNA cytology results.

Patients and Methods: A case series study was conducted in the Oncology Teaching Hospital in Baghdad from September 2018 to September 2019. Included patients had suspicious breast findings and given BI-RADS 4 (4A, 4B, or 4C) in the radiological report accordingly. Fine needle aspiration was performed under the ultrasound guide and the results were classified into five categories. The biopsy was performed for suspicious, malignant or equivocal FNA findings.

Results: This study included 158 women with BIRADS 4 breast lesions with the mean age of (44.6 years); There was a highly significant association between BI-RADS 4 breast lesion and FNA results (p<0.001); 51.9% of BI-RADS IV-C had C5 FNA results. There was a highly significant association between BI-RADS 4 lesion and the final diagnosis (p<0.001); 41.2% of BI-RADS 4 B had a malignant breast lesion, while 37.3% of BIRADS 4 C had a malignant lesion.

Conclusion: A clear relationship was observed between BI-RADS 4 subcategories and the fine needle aspiration cytology subgroups. BI-RADS 4-B is helpful in the discrimination between benign and malignant breast lesions; furthermore BI-RADS 4C has more acceptable validity in the diagnosis of breast malignancy. Therefore, BI-RADS subcategories are encouraged to be included and mentioned in the ultrasound report for more accurate estimation of the lesion nature.

New Advances in Tissue Metabolomics: A Review

Metabolomics offers a hypothesis-generating approach for biomarker discovery in clinical medicine while also providing better understanding of the underlying mechanisms of chronic diseases. Clinical metabolomic studies largely rely on human biofluids (e.g., plasma, urine) as a more convenient specimen type for investigation. However, biofluids are non-organ specific reflecting complex biochemical processes throughout the body, which may complicate biochemical interpretations. For these reasons, tissue metabolomic studies enable deeper insights into aberrant metabolism occurring at the direct site of disease pathogenesis. This review highlights new advances in metabolomics for ex vivo analysis, as well as in situ imaging of tissue specimens, including diverse tissue types from animal models and human participants. Moreover, we discuss key pre-analytical and post-analytical challenges in tissue metabolomics for robust biomarker discovery with a focus on new methodological advances introduced over the past six years, including innovative clinical applications for improved screening, diagnostic testing, and therapeutic interventions for cancer.

Performance of Rapid On-Site Evaluation in Breast Fine-Needle Aspiration Biopsies: Identifying Areas of Diagnostic Challenge

INTRODUCTION

Fine-needle aspiration (FNA) is a well-established method for sampling breast lesions with high accuracy and positive predictive value. Despite its decline in recent years relative to the use of core needle biopsies, there are several advantages to FNA which include cost-effectiveness, low complication rate, and the ability to perform rapid on-site evaluation (ROSE). The aim of this study was to evaluate breast FNAs with ROSE to identify diagnostic challenges during ROSE.

MATERIALS AND METHODS

We identified all breast FNAs with ROSE performed at Massachusetts General Hospital from January 2014 to December 2019. From the electronic medical record, clinical, radiological, and follow-up pathology results were recorded. Comparison between the rapid and final cytological diagnosis was made. All discrepancies were documented with major discrepancy defined as a malignant rapid interpretation not confirmed on final diagnosis or a negative rapid interpretation upgraded to suspicious or positive on final diagnosis.

RESULTS

The study cohort consisted of 483 breast FNAs with ROSE. The rapid and final cytological interpretations showed good correlation, with only 6 (1.2%) major discrepancies. Problematic areas included low-grade, lobular, and fibroepithelial lesions with low cellularity being a contributory factor to misclassification.

CONCLUSIONS

FNA remains a highly accurate method for the evaluation of breast lesions with ROSE.

Ultrasonic actuation of a fine-needle improves biopsy yield

Despite the ubiquitous use over the past 150 years, the functions of the current medical needle are facilitated only by mechanical shear and cutting by the needle tip, i.e. the lancet. In this study, we demonstrate how nonlinear ultrasonics (NLU) extends the functionality of the medical needle far beyond its present capability. The NLU actions were found to be localized to the proximity of the needle tip, the SonoLancet, but the effects extend to several millimeters from the physical needle boundary. The observed nonlinear phenomena, transient cavitation, fluid streams, translation of micro- and nanoparticles and atomization, were quantitatively characterized. In the fine-needle biopsy application, the SonoLancet contributed to obtaining tissue cores with an increase in tissue yield by 3-6× in different tissue types compared to conventional needle biopsy technique using the same 21G needle. In conclusion, the SonoLancet could be of interest to several other medical applications, including drug or gene delivery, cell modulation, and minimally invasive surgical procedures.

Correlation of ultrasound, cytological, and histological features of 110 benign BI-RADS categories 4C and 5 nonpalpable breast lesions. The Institut Curie's experience

BACKGROUND

The purpose of this study was to determine the pathological and ultrasound (US) features of benign nonpalpable breast lesions (NPBLs) classified as Breast Imaging Reporting and Data System (BI-RADS) category 4C or 5.

METHODS

Between 2003 and 2007, 849 consecutive NPBLs detected at US and classified as BI-RADS category 4C (505) or 5 (344) initially underwent US-guided fine needle aspiration (FNA) at our institution. Benign diagnoses were established according to surgical excision findings or during a minimal 6-month imaging follow-up (mean, 3.7 years [SD, 2.6 years]). US BI-RADS features were reviewed and compared retrospectively using a chi-square test for the following pathological categories: epithelial and fibrous proliferation (EFP), cystic and papillary lesion (C&P), inflammatory lesion (IL), benign tumor (BT), intramammary lymph node (ILN), intraepithelial proliferative lesion (IPL), and nonspecific morphological alteration (NMA). The performance of FNA in the diagnosis of benignity was assessed.

RESULTS

Of 849 NPBLs, 110 (12.9%) NPBLs were benign: 88 (17.4%) were BI-RADS category 4C, and 22 (6.4%) were BI-RADS category 5. Forty-four (40%) were EFPs, 21 (19%) were C&Ps, 13 (12%) were NMAs, 11 (10%) were ILs, 11 (10%) were BTs, 8 (7%) were IPLs, and 2 (2%) were ILNs. Lesion shape, US pattern distribution, and posterior features showed statistically significant differences between these categories (P < .05): 33 (75%) EFPs exhibited posterior shadowing, 18 (86%) C&Ps were homogenous, 9 (82%) ILs were heterogeneous, 11 (100%) BTs were homogeneous, 9 (82%) BTs were oval, and 6 (75%) IPLs were irregularly shaped. Of the 110 benign NPBLs, FNA diagnosis was falsely positive in 7 (6%), suspicious in 10 (9%), and benign in 90 (82%), and 3 (3%) were inadequate for diagnosis.

CONCLUSION

A diverse array of benign NPBLs can be classified as BI-RADS category 4C or 5 on US, each showing specific imaging presentations.

Breast Fine-Needle Aspiration Practice in 2019: Results of a College of American Pathologists National Survey

CONTEXT.—

The College of American Pathologists surveys provide national benchmarks of pathology practice for laboratories.

OBJECTIVE.—

To investigate breast fine-needle aspiration (FNA) biopsy practice in domestic and international laboratories in 2019.

DESIGN.—

We analyzed data from the College of American Pathologists Breast FNA Practice Supplemental Questionnaire that was distributed to laboratories participating in the 2019 College of American Pathologists Non-Gynecologic Cytopathology Education Program.

RESULTS.—

Sixty-one percent (499 of 816) of respondent laboratories routinely evaluated breast FNAs. Cystic lesions were the most common indication, and radiologists primarily performed FNAs in most settings. Forty-five percent (220 of 491) of laboratories performed ancillary studies on breast FNA samples, but 33.8% (70 of 207) did not report fixation time for breast biomarker studies. Only 54.5% (271 of 497) of laboratories had a standardized reporting system and only 16.8% (82 of 488) were aware of the International Academy of Cytology Yokohama Breast FNA Biopsy Cytology Reporting System. There were significant differences among different types of institutions in several aspects of breast FNA practice, including frequency of concurrent FNA and core needle biopsy for the same lesion, primary personnel who performed the FNA, etc. Significant differences existed between domestic and international laboratories in slide preparation, ancillary studies, fixation time reporting, standardized/descriptive diagnosis, and International Academy of Cytology Yokohama Reporting System awareness.

CONCLUSIONS.—

This is the first survey from the College of American Pathologists Cytopathology Committee to investigate breast FNA practices. The data reveal significant differences in breast FNA practice among different types of institutions and between domestic and international laboratories, and provide a baseline for future breast FNA studies in a variety of practice settings.

The role of breast fine needle aspiration during and post-COVID-19 pandemic: A fast and safe alternative to needle core biopsy

Fine needle aspiration (FNA) may be used to study breast lesions in patients that do not have access to more complex procedures during the COVID‐19 pandemic. Furthermore, FNA can be a helpful screening method in the post‐pandemic era when a greater number of patients than usual with delayed treatment can overburden clinics and hospitals.

How image-guided core needle biopsies altered the treatment of breast disease: Challenges accepted and opportunities taken

The technique of combining stereotactic targeting of breast lesions with an automated spring-loaded needle biopsy gun reported in 1990 by Steve Parker and colleagues not only ushered in the era of diagnosis almost exclusively by image guided core needle biopsy, but also profoundly changed the practice of pathologists, radiologists, surgeons, and medical oncologists and had major effects on the treatment of women with breast cancer. In this special issue of The Breast Journal celebrating 25 years of publication, it is of value to reflect back on these changes, some expected and some unanticipated, which have occurred over the past three decades and to consider the reasons why core needle biopsies should be considered a milestone in breast pathology.

FNAC of Breast Lesions with Special Reference to IAC Standardized Reporting and Comparative Study of Cytohistological Grading of Breast Carcinoma

BACKGROUND

International Academy of Cytology (IAC) has established a process to produce comprehensive and standardized approach to fine-needle aspiration cytology (FNAC) reporting. They have categorized the breast lesions in C1 to C5. (C1-Insufficient material, C2-Benign, C3- Atypical, C4-Suspicious & C5-Malignant).

AIMS AND OBJECTIVES

The aim of study is to classify various breast lesions (C1 to C5) and to grade breast carcinoma on FNAC using Robinson's grading system which is then correlated with modified Bloom-Richardson grading.

MATERIALS AND METHODS

All routine FNAC for breast lump were included in the study during the period from Jan 2016 to Jan 2017. The study was conducted in the Department of pathology and lab medicine of a tertiary care hospital in central India.

RESULTS

A total 225 female patients were included in the study, with an age group ranging from 15 - 79 years, with lesions in breast were taken. C1 lesions were found in 3 cases, C2 in 186 cases, C3 in 13 cases, C4 in 4 cases, and C5 in 19 cases. Correlation of cytohistological grading was obtained in 108 cases.

CONCLUSION

Cytological categorization based on IAC structured reporting will enhance the reproducibility of reports among pathologist & clinicians. With the comparison between cytohistological nuclear grading, the cytoprognostic scores will help in evaluating the aggressiveness of tumor, predicts histological grade and prognosis. It could be a useful parameter for selecting neo-adjuvant chemotherapy.

Needle Biopsy Adequacy in the Era of Precision Medicine and Value-Based Health Care

CONTEXT.—

Needle biopsy of diseased tissue is an essential diagnostic tool that is becoming even more important as precision medicine develops. However, the capability of this modality to efficiently provide samples adequate for diagnostic and prognostic analysis remains quite limited relative to current diagnostic needs. For physicians and patients, inadequate biopsy frequently leads to diagnostic delay, procedure duplication, or insufficient information about tumor biology leading to delay in treatment; for health systems, this results in substantial incremental costs and inefficient use of scarce specialized diagnostic resources.

OBJECTIVE.—

To review current needle biopsy technology, devices, and practice with a perspective to identify current limitations and opportunities for improvement in the context of advancing precision medicine.

DATA SOURCES.—

PubMed searches of fine-needle aspiration and core needle biopsy devices and similar technologies were made generally, by tissue site, and by adequacy as well as by health economics of these technologies.

CONCLUSIONS.—

Needle biopsy adequacy can be improved by recognizing the importance of this diagnostic tool by promoting common criteria for needle biopsy adequacy; by optimizing needle biopsy procedural technique, technologies, clinical practice, professional education, and quality assurance; and by bundling biopsy procedure costs with downstream diagnostic modalities to provide better accountability and incentives to improve the diagnostic process.

Diagnostic Value of Fine-Needle Aspiration in Male Breast Lesions

OBJECTIVE

Differentiation between gynecomastia, a common cause of male breast enlargement, and breast cancer is crucial for appropriate management. Fine-needle aspiration biopsy has been shown to be sensitive and specific in assessing female breast lesions, comparable to core needle biopsy. Few such studies have been conducted in men. We assessed its diagnostic value in a male patient cohort.

STUDY DESIGN

Men who underwent fine-needle aspiration (FNA) for palpable breast lesions at Massachusetts General Hospital from January 2007 to December 2016 were evaluated. Clinical data, radiographic findings, and cytologic diagnoses of 74 breast FNA from 71 men were reviewed. Breast aspirates were classified as nondiagnostic, benign, atypical, suspicious for malignancy, or malignant. Histology was obtained in 37 cases, and clinical and radiological data were used as follow-up in 37 patients.

RESULTS

Most FNA biopsies (73%) were performed by cytopathologists, and 93.2% of the breast FNA in men were adequate; 58% showed benign processes, mostly gynecomastia (n = 22), and 28.4% (n = 21) were malignant, most often ductal carcinoma. No false-positive cytologies were obtained, and there was 1 false-negative cytology. In our study, FNA of palpable male breast lesions was 95.8% sensitive and 100% specific.

CONCLUSIONS

FNA allows sensitive, specific, and safe evaluation and diagnosis of palpable male breast lesions.

Fine-needle versus core-needle biopsy - which one to choose in preoperative assessment of focal lesions in the breasts? Literature review

Aim

The aim of the study was to review two techniques that can be used to verify focal lesions in the breasts: fine-needle aspiration biopsy and core-needle biopsy.

Material and methods

Fifty-five articles (original papers and reviews), half of them published within the past 5 years, were included in the analysis. The authors also took their own experience into account.

Results

Pre-operative assessment of focal lesions in the breasts is crucial in the planning of further therapeutic management. The role of fine-needle aspiration biopsy has been reduced lately due to its low sensitivity and specificity as well as a high rate of non-diagnostic, suspicious and false negative results. This method does not enable one to differentiate between in situ and invasive disease. Currently, fine-needle biopsy is recommended for cystic lesions, suspected of being recurrences in the chest wall, and lymph node metastases. Core-needle biopsy is the basic diagnostic method of breast lesions. According to the recommendations of the Polish Ultrasound Society and American College of Radiology, BIRADS 4 and 5 lesions should be evaluated histopathologically. Core-needle biopsy makes it possible to establish a final diagnosis more frequently than fine-needle biopsy, both in the case of benign and malignant lesions. It delivers more information about the nature of a tumor (mutation of HER-2, estrogen and progesterone receptors and Ki-67 index). Its limitations include: underestimation of invasion and failure to recognize the components of ductal carcinoma in situ in papillary and atypical lesions. Single fine-needle aspiration biopsy is inexpensive, but when considering the cost of further diagnosis due to non-diagnostic, suspicious and atypical results, this method generates high additional costs.

Conclusions

Microscopic verification of focal breast lesions is crucial for further therapeutic decisions. It has been proven that histopathological verification is more accurate and has more advantages than cytological assessment.

Advances in breast intervention: where are we now and where should we be?

In the past four decades, a variety of methods for minimal or non-invasive diagnosis and treatment of breast cancer have been introduced. Although breast imaging has become more and more specific for diagnosis, specimen biopsy with histopathological confirmation is still necessary. Core-needle biopsy under ultrasound guidance is the appropriate first choice for the diagnosis of most lesions. Fine-needle aspiration is of interest for identification of the presence of metastatic disease in abnormal lymph nodes. For microcalcifications, vacuum-assisted biopsy is recommended, especially with stereotactic guidance. In recent years different therapeutic techniques have been developed for the treatment of solid lesions, including breast cancer. Certainly, with the improvement of technology and medical scientific progress, it is becoming more common to use minimal- or non-invasive therapies. The proposed minimally invasive techniques may offer complete treatment of breast cancer, with better cosmetic results, less psychological stress, and shorter hospital stays. In this article, the strengths and weaknesses of the different diagnostic and therapeutic techniques are presented, and promising techniques for the future are discussed.

Breast cancer neoplastic seeding in the setting of image-guided needle biopsies of the breast

PURPOSE

To identify clinicopathologic, technical, and imaging features associated with neoplastic seeding (NS) following image-guided needle breast biopsy.

METHODS

We performed an institutional review board-approved retrospective review of patients presenting with a new diagnosis of breast cancer or suspicious breast findings requiring biopsy with subsequent diagnosis of NS. The time from biopsy to NS diagnosis was calculated. Histology, grade, estrogen receptor (ER) status, progesterone receptor (PR) status, HER2 status, T category, and N category were recorded. Biopsy guidance method, needle gauge, and number of passes were reviewed in addition to the mammographic and sonographic features of the primary tumors and the NS.

RESULTS

Eight cases of NS were identified in 4010 patients. The mean time from biopsy to NS diagnosis was 60.8 days. The most frequent histology was invasive ductal carcinoma (7/8). Six cases were grade 3 (75.0%). Five primary breast cancers were ER, PR, and HER2 negative (62.5%). Seven patients underwent biopsy with ultrasound guidance. Multiple-insertion, non-coaxial ultrasound-guided core-needle biopsy was done in 6 cases. Mammographic presentation of NS was focal asymmetry (3/7 cases), mass (1/7), calcifications only (1/7), or occult (2/7). Sonographic presentation of NS was most often a mass (7/8) with irregular shape (5/7) and without circumscribed margins (6/7) and was occult in 1 case (1/8). NS distribution was subdermal and intradermal.

CONCLUSION

High-grade, triple-negative breast cancers and multiple-insertion, non-coaxial biopsies may be risk factors for NS. NS should be suspected on the basis of the superficial and linear pattern of disease progression in these patients.

Diagnostic Performance of Ultrasound-Guided Fine-Needle Aspiration of Nonpalpable Breast Lesions in a Multidisciplinary Setting: The Institut Curie's Experience

OBJECTIVES

To assess the diagnostic performance of ultrasound-guided fine-needle aspiration (USFNA) in nonpalpable breast lesions (NPBLs) in a multidisciplinary setting.

METHODS

In total, 2,601 NPBLs underwent USFNA by a radiologist-pathologist team. Gold-standard diagnosis was based on surgery, core-needle biopsy, or 1-year imaging follow-up. USFNA's diagnostic performance was analyzed in different clinical and imaging subgroups.

RESULTS

USFNA's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were, respectively, 92.6% (95% confidence interval [CI], 90.8%-94.2%), 96.8% (95% CI, 95.8%-97.6%), 94.8% (95% CI, 93.2%-96.1%), and 95.4% (95% CI, 94.3%-96.4%). The best PPV was achieved in Breast-Imaging Reporting and Data System (BI-RADS) categories 4C and 5 and the best NPV in BI-RADS categories 2, 3, and 4A and in patients younger than 50 years. The mitotic count, BI-RADS categories, associated palpable cancer, and age (<50 or ≥50 years) were statistically independent factors ( P  < .05) between USFNA's false-negative and true-positive results.

CONCLUSIONS

USFNA is a robust diagnostic procedure in NPBLs. Age and the BI-RADS category of the lesion are important factors determining its performance.

Breast fine needle aspiration continues to be relevant in a large academic medical center: experience from Massachusetts General Hospital

Fine needle aspiration (FNA) is increasingly being supplanted by core needle biopsy. However, breast surgeons continue to rely on FNA at our institution. This retrospective study evaluated breast FNA for its diagnostic accuracy and breast cancer biomarker testing utility. All breast FNAs performed at Massachusetts General Hospital 2009-2015 were reviewed. Cytology diagnoses were compared with subsequent tissue or clinical diagnoses. Immunohistochemistry and fluorescence in situ hybridization (FISH) results using formalin-fixed paraffin-embedded (FFPE) cell blocks and histologic tissue blocks were compared. 1654 consecutive breast FNAs were included. Breast FNA demonstrated the following diagnostic performance: positive predictive value of malignant cytology diagnosis 100 %, negative predictive value of benign cytology diagnosis 97.5 %, complete sensitivity 91.6 %, and specificity 95.5 %. Concordance rates for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) immunohistochemistry, and HER2 FISH were 98.2 % (κ = 0.95, p < 0.001), 100.0 % (κ = 1.000, p < 0.001), 83.1 % (κ = 0.69, p < 0.001), and 93.5 % (κ = 0.785, p < 0.001), respectively. Review of consecutive breast FNAs in a large cohort confirmed the excellent accuracy of this biopsy technique for breast lesion diagnosis. FNA FFPE cell blocks collected in the course of routine clinical care are adequate, practical, and reliable for breast cancer biomarker testing.

Quantitative DWI implemented after DCE-MRI yields increased specificity for BI-RADS 3 and 4 breast lesions

PURPOSE

To assess if specificity can be increased when semiautomated breast lesion analysis of quantitative diffusion-weighted imaging (DWI) is implemented after dynamic contrast-enhanced (DCE-) magnetic resonance imaging (MRI) in the workup of BI-RADS 3 and 4 breast lesions larger than 1 cm.

MATERIALS AND METHODS

In all, 120 consecutive patients (mean-age, 48 years; age range, 23-75 years) with 139 breast lesions (≥1 cm) were examined (2010-2014) with 1.5T DCE-MRI and DWI (b = 0, 50, 200, 500, 800, 1000 s/mm² ) and the BI-RADS classification and histopathology were obtained. For each lesion malignancy was excluded using voxelwise semiautomated breast lesion analysis based on previously defined thresholds for the apparent diffusion coefficient (ADC) and the three intravoxel incoherent motion (IVIM) parameters: molecular diffusion (D_slow ), microperfusion (D_fast ), and the fraction of D_fast (f_fast ). The sensitivity (Se), specificity (Sp), and negative predictive value (NPV) based on only IVIM parameters combined in parallel (D_slow , D_fast , and f_fast ), or the ADC or the BI-RADS classification by DCE-MRI were compared. Subsequently, the Se, Sp, and NPV of the combination of the BI-RADS classification by DCE-MRI followed by the IVIM parameters in parallel (or the ADC) were compared.

RESULTS

In all, 23 of 139 breast lesions were benign. Se and Sp of DCE-MRI was 100% and 30.4% (NPV = 100%). Se and Sp of IVIM parameters in parallel were 92.2% and 52.2% (NPV = 57.1%) and for the ADC 95.7% and 17.4%, respectively (NPV = 44.4%). In all, 26 of 139 lesions were classified as BI-RADS 3 (n = 7) or BI-RADS 4 (n = 19). DCE-MRI combined with ADC (Se = 99.1%, Sp = 34.8%) or IVIM (Se = 99.1%, Sp = 56.5%) did significantly improve (P = 0.016) Sp of DCE-MRI alone for workup of BI-RADS 3 and 4 lesions (NPV = 92.9%).

CONCLUSION

Quantitative DWI has a lower NPV compared to DCE-MRI for evaluation of breast lesions and may therefore not be able to replace DCE-MRI; when implemented after DCE-MRI as problem solver for BI-RADS 3 and 4 lesions, the combined specificity improves significantly. J. Magn. Reson. Imaging 2016;44:1642-1649.

The diagnostic and prognostic role of liquid-based cytology: are we ready to monitor therapy and resistance?

Here, we evaluate the diagnostic and prognostic role of liquid-based cytology (LBC) in different body lesions, including thyroid, lung, effusions and malignant breast lesions. LBC has gained consensus after being applied to both non-gynecologic and fine-needle aspiration cytology. Although some remain sceptical regarding the diagnostic efficacy of LBC, mainly when used alone, in recent years, good results have been obtained as long as it showed a high diagnostic accuracy. Here, we discuss the additional possibility of storing material for the application of ancillary techniques (immunocytochemistry-molecular analysis) with several diagnostic and prognostic advantages, which may pave the way for the challenging evaluation of both monitoring responses to treatment and resistance to targeted therapies in thyroid, lung, breast carcinoma or malignant effusions. Furthermore, it provides the use of several molecular spots as specific targets for personalized therapy.

Fine-Needle Aspiration Followed by Core-Needle Biopsy in the Same Setting: Modifying Our Approach

Fine-needle aspiration biopsy (FNAB) is a well-established initial diagnostic tool. However, in some instances limitations and shortcomings arise, making it insufficient for determining a specific diagnosis. Consequently, patients have to undergo another diagnostic procedure. The second procedure is either repeat FNAB, core-needle or open biopsy, and can be inconvenient and costly. In some centers, the FNAB is immediately followed by core-needle biopsy (CNB) in the same setting after assuring adequacy on the initial FNAB utilizing rapid on-site specimen evaluation (ROSE). It is argued that implementing such an approach will eventually have additional critical advantages that include the following: (a) it is more convenient to patients to have both procedures in one visit, (b) the tissue procured by both procedures will be more adequate, enabling cytopathologists to reach an accurate diagnosis, and (c) it is ultimately a cost-effective approach if we take into consideration the avoidance of a potential second more invasive diagnostic procedure. Since we are living in an era of patient-centered medicine coupled with cost-cutting strategies, we present here a brief review of the topic with analysis of this alternative approach, review of the pertinent literature and shed light on a few scenarios that justify this approach.

Estimates of over-diagnosis of breast cancer due to population-based mammography screening in South Australia after adjustment for lead time effects

OBJECTIVE

To estimate over-diagnosis due to population-based mammography screening using a lead time adjustment approach, with lead time measures based on symptomatic cancers only.

SUBJECTS

Women aged 40-84 in 1989-2009 in South Australia eligible for mammography screening.

METHODS

Numbers of observed and expected breast cancer cases were compared, after adjustment for lead time. Lead time effects were modelled using age-specific estimates of lead time (derived from interval cancer rates and predicted background incidence, using maximum likelihood methods) and screening sensitivity, projected background breast cancer incidence rates (in the absence of screening), and proportions screened, by age and calendar year.

RESULTS

Lead time estimates were 12, 26, 43 and 53 months, for women aged 40-49, 50-59, 60-69 and 70-79 respectively. Background incidence rates were estimated to have increased by 0.9% and 1.2% per year for invasive and all breast cancer. Over-diagnosis among women aged 40-84 was estimated at 7.9% (0.1-12.0%) for invasive cases and 12.0% (5.7-15.4%) when including ductal carcinoma in-situ (DCIS).

CONCLUSIONS

We estimated 8% over-diagnosis for invasive breast cancer and 12% inclusive of DCIS cancers due to mammography screening among women aged 40-84. These estimates may overstate the extent of over-diagnosis if the increasing prevalence of breast cancer risk factors has led to higher background incidence than projected.

Clinical audit of ultrasound guided fine needle aspiration in a general cytopathology service

Background:

Studies on ultrasonography (USG) guided fine needle aspiration cytology (FNAC) have been conducted in specialized settings such as thyroid, breast, and intra-abdominal aspirates. There is a paucity of literature on the practices of guided FNAC in a general cytopathology service.

Aim:

The aim was to determine prevailing practices of USG guided FNAC in a general cytopathology service of a teaching hospital.

Settings and Design:

Metropolitan hospital, clinical audit.

Materials and Methods:

Audit of 112 USG guided percutaneous FNAC done over 12 months.

Statistical Analysis:

Data were coded, entered in an excel spreadsheet and analyzed by translating into percentages and proportions.

Results:

The 112 guided FNACs included constituted 36 thyroid (32.14%), 45 intra-abdominal (40.17%), 11 breast (9.82%), 10 superficial lymph node (8.92%) and 10 soft tissue and miscellaneous (8.92%) lesions. Previous freehand FNAC was documented on the requisition forms in 14 cases. The reports were: Inadequate 33 (29.46%), nondiagnostic descriptive 35 (31.25%) or diagnostic 44 (39.28%). Inadequacy rates of aspirates from thyroid were 11 (30.56%) breast were 2 (18.18%), and intra-abdominal lesions were 13 (28.88%). Majority of the reports were nonstructured: 108 (96.42%) and nonrecommendatory: 101 (90.17%).

Conclusions:

Reporting practices varied and did not conform to a uniform structure. The inadequacy rates of breast and thyroid aspirates were comparable to the rates in the literature. Comparable studies were not available for intra-abdominal aspirates.

Beyond isolated cells: microfluidic transport of large tissue for pancreatic cancer diagnosis

For cancer diagnoses, core biopsies (CBs) obtained from patients using coring needles (CNs) are traditionally visualized and assessed on microscope slides by pathologists after samples are processed and sectioned. A fundamental gain in optical information (i.e., diagnosis/staging) may be achieved when whole, unsectioned CBs (L = 5-20, D = 0.5-2.0 mm) are analyzed in 3D. This approach preserves CBs for traditional pathology and maximizes the diagnostic potential of patient samples. To bridge CNs/CBs with imaging, our group developed a microfluidic device that performs biospecimen preparation on unsectioned CBs for pathology. The ultimate goal is an automated and rapid point-of-care system that aids pathologists by processing tissue for advanced 3D imaging platforms. An inherent, but essential device feature is the microfluidic transport of CBs, which has not been previously investigated. Early experiments demonstrated proof-of-concept: pancreas CBs (D = 0.3-2.0 mm) of set lengths were transported in straight/curved microchannels, but dimensional tolerance and flow rates were variable, and preservation of CB integrity was uncontrolled. A second study used metal cylinder substitutes (L = 10, D = 1 mm) in microchannels to understand the transport mechanism. However, CBs are imperfectly shaped, rough, porous and viscoelastic. In this study, fresh/formalin-fixed porcine and human pancreas CBs were deposited into our device through a custom interface using clinical CNs. CB integrity (i.e., sample viability) may be assessed at every stage using an optomechanical metric: physical breaks were determined when specimen intensity profile data deviated beyond x_avg + 2σ. Flow rates for human CBs were determined for several CNs, and microfluidic transport of fresh and formalin-fixed CBs was analyzed.

Main controversies in breast cancer

In this article, we have reviewed available evidence for diagnosis, treatment, and follow-up in female breast cancer (BC). Into daily clinical practice some controversies are occurred. Especially, in the diagnosis field, despite the fact that the optimal age in which screening mammography should start is a subject of intense controversy, there is a shift toward the beginning at the age of 40 although it is suggested that the net benefit is small for women aged 40 to 49 years. In addition, a promising tool in BC screening seems to be breast tomosynthesis. Other tools such as 3D ultrasound and shear wave elastography (SWE) are full of optimism in BC screening although ultrasonography is not yet a first-line screening method and there is insufficient evidence to recommend the systemic use of the SWE for BC screening. As for breast magnetic resonance imaging (MRI), even if it is useful in BC detection in women who have a strong family history of BC, it is not generally recommended as a screening tool. Moreover, based on the lack of randomized clinical trials showing a benefit of presurgical breast MRI in overall survival, it's integration into breast surgical operations remains debatable. Interestingly, in contrast to fine needle aspiration, core biopsy has gained popularity in presurgical diagnosis. Furthermore, after conservative surgery in patients with positive sentinel lymph nodes, the recent tendency is the shift from axillary dissection to axillary conserving strategies. While the accuracy of sentinel lymph node after neoadjuvant chemotherapy and second BC surgery remains controversial, more time is needed for evaluation and for determining the optimal interval between the two surgeries. Additionally, in the decision between immediate or delayed breast reconstruction, there is a tendency in the immediate use. In the prevention of BC, the controversial issue between tamoxifen and raloxifene becomes clear with raloxifene be more profitable through the toxicities of tamoxifen. However, the prevention of bone metastasis with bisphosphonates is still conflicting. Last but not least, in the follow-up of BC survivors, mammography, history and physical examination are the means of an early detection of BC recurrence. ed.

Liquid-based cytology in fine-needle aspiration of breast lesions: a review

OBJECTIVE

Fine-needle aspiration (FNA) is a safe and cost-effective technique for the diagnosis of breast lesions, especially when correlated with clinical and imaging studies. However, the success of breast FNA is highly dependent on the adequate preparation of cytological conventional smears (CS). The liquid-based cytology (LBC) technique consists of an automated method for preparing thin-layer cytological samples from cell suspensions collected in alcohol-based preservative. LBC is designed to improve CS by avoiding limiting factors such as obscuring material, air-drying and smearing artifacts.

STUDY DESIGN

We performed a review of the published literature about LBC applied to breast FNA.

RESULTS

LBC preparations of breast aspirates demonstrated better cellular preservation, less cell overlapping and elimination of blood and excessive inflammation compared to CS. Conversely, alterations in architecture and cell morphology as well as loss of myoepithelial cells and stromal elements have been described in LBC specimens, requiring training before applying this technique for diagnosis. Studies have shown a similar accuracy between LBC and CS for the diagnosis of breast lesions. LBC also permits the use of residual material for ancillary tests, which is an important advantage compared to CS.

CONCLUSIONS

LBC can be safely applied to breast FNA, showing a similar diagnostic accuracy to CS.

Needle core biopsy for breast lesions: An audit of 467 needle core biopsies

Background:

Breast cancer is the commonest cancer among women in urban India. Triple assessment includes clinical, radiological and cytological assessment of breast lesions. Guided core needle biopsy has replaced fine needle aspiration cytology in most of the western countries. In resource poor countries FNAC is still a very valuable and cost effective method to diagnose breast lesions. Pitfalls include increased rates of non diagnostic smears, and inadequate smears. Further procedures may be required and this increases the cost, anxiety and delay in diagnosis.

Aims:

The aim of this study is to analyze the concordance of radiological and histopathology findings in BI-RADS category 3,4,5 lesions following a core biopsy.

Materials and Methods:

Data was retrospectively collected from consecutive symptomatic and opportunistic screen detected patients with abnormalities who underwent ultrasound guided interventional procedures from Jan 2010 to Aug 2011. Symptomatic patients underwent clinical examination, mammogram and breast ultrasound. Women under 35 years of age had only breast ultrasound. Core biopsy was performed under ultrasound guidance or clinically by a breast surgeon/ radiologist for BI-RADS category 3,4,5 lesions.

Statistical Methods:

Chi square test was done to show the strength of association of imaging findings and histopathology results of core biopsy.

Results:

437 patients were symptomatic and 30 patients had screen detected abnormalities. The positive predictive value for BI-RADS 5 lesions for malignancy is 93.25% and the negative predictive value of BI-RADS category 3 lesions for cancer is 98.4%. False negative diagnosis on core biopsy was 0.85%. We were able to defer surgery in 60% of the patients with a clear radiological and pathological benign diagnosis.

Conclusion:

The PPV and NPV for cancer is high with needle core biopsy in BI-RADS 3,4,5 lesions. Where there is no discordance between clinical, radiology and pathology findings, surgery can be avoided in benign lesions. While in resource poor countries FNAC continues to be a valuable method in the diagnosis of palpable and non palpable breast lesions, the practice of needle core biopsy provides the most accurate and optimal diagnostic information.