Final diagnosis by fine-needle aspiration biopsy for definitive operation in breast cancer

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.

Changes in thyroid fine needle aspiration practice during the COVID-19 pandemic

Purpose

To investigate the diagnostic accuracy of a different sample preparation protocol for fine needle aspiration cytology (FNAC) of thyroid nodules established during the COVID‐19 pandemic.

Methods

From April 2020, conventional smears during FNAC were ceased according to World Health Organization recommendations due to the increased infection risk for operators, and a new protocol using only liquid‐based cytology (LBC) was adopted. FNACs performed between April and July 2020 (COVID‐19 group) were retrospectively compared with those from December 2019 through March 2020 (Pre‐COVID‐19 group). The distribution of diagnoses based on SIAPEC‐IAP categories and the concordance between cytological and histological results were compared using the chi‐squared test.

Results

Categories based on FNAC for 90 and 82 thyroid nodules in the Pre‐COVID‐19 and COVID‐19 groups showed no significant difference in distribution (P = .081), with the following respective cases (and percentages): TIR1, 7 (8%) and 8 (10%); TIR1C, 0 (0%) and 6 (7%); TIR2, 59 (66%) and

55 (67%); TIR3A, 8 (9%) and 5 (6%); TIR3B, 1 (1%) and 2 (3%); TIR4, 5 (6%) and 1 (1%); and TIR5, 10 (12%) and 5 (7%). Among patients with potentially malignant lesions, surgery was performed for 12/16 (75%) nodules in the Pre‐COVID‐19 and 7/8 (88%) nodules in the COVID‐19 groups, with no significant differences between cytological and histological diagnoses (P = .931).

Conclusion

The new LBC‐only protocol provided similar diagnostic accuracy in comparison with conventional smears, and can be effectively applied during a viral pandemic improving operator safety.

COVID-19 and breast fine needle aspiration cytology method: What should we change?

INTRODUCTION

Air-dried slide preparation for fine needle aspiration cytology procedures is currently considered unsafe because of the risk of infectious aerosols of coronavirus 19. This study compares the safety and accuracy of two different protocols, one with and one without air-dried slides.

METHODS

Starting from 3 March 2020, we discontinued the use of air-dried slides during breast fine needle aspiration procedures. We selected cases collected during two periods: 2 months before and 2 months after 3 March. In both groups, the number of procedures was recorded together with the distribution of the diagnostic categories and the concordance between cytological and histological results on surgical specimens for lesions suggestive of malignancy, using the chi-squared test.

RESULTS

Of the 100 procedures performed during the pre-COVID-19 period, 55% were negative (C2), 3% were non-diagnostic (C1) and 40% were positive (C4 or C5). Of the 75 procedures obtained during the COVID-19 period, 44% were negative (C2), 2.7% were non-diagnostic (C1) and 52% were positive (C4 or C5). Despite the use of a new protocol during the COVID-19 period, we observed concordance between cytological and histological results for lesions suggestive of malignancy. There was no statistically significant difference concerning the distribution of the diagnostic categories in the two groups.

CONCLUSIONS

Taking into account the slightly lower number of procedures being analysed during the COVID-19 period, the introduction of a new protocol that does not include air-dried slides is safe and reliable.

Ultrasonographic Elasticity Contrast Index of Palpable Breast Lumps

INTRODUCTION

Elastrography used in addition to grey scale sonography increases its specificity. Elasticity contrast index (ECI) is based on strain elastrography and being a quantitative parameter, maybe more easy to obtain and reproducible while researches has been done in ECI in thyroid lesions, this is the first study, to the best of our knowledge to evaluate in breast lesions. This study was done to evaluate the diagnostic accuracy of Elasticity Contrast Index (ECI) in differentiating benign from malignant lesions of breast and to determine its cutoff value.

METHODS

This is a descriptive cross-sectional study done at tertiary health care centre, which involved retrospective evaluation of data collected from September 2016 to March 2017. Conventional sonography was done followed by elastography on commercially available ultrasound machine. ECI was calculated in thyroid protocol available in the unit. Histopathological diagnosis was obtained for all the lesions and taken as gold standard.

RESULTS

A total of 89 breast lumps were evaluated, of which was 61 (69.3%) were benign and 27 (30.7%) malignant on histopathology. Independent t test revealed the average ECI value of benign lesions was 2.48 and malignant 5.1. Receiver operating curve showed ECI value of 3.25 as the cutoff, above which the lesions were malignant.

CONCLUSIONS

ECI is a quantitative elastography technique which can be easily used as an adjunct during breast sonography and can increase its specificity for diagnosing a lesion as malignant. This could reduce the number of false positive biopsies.

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.

The Negative Predicative Value of Breast Fine-Needle Aspiration Biopsy: The Massachusetts General Hospital Experience

Breast fine-needle aspiration biopsy (FNAB) has been increasingly accepted as an important triage tool for the evaluation of breast lumps. We examined the clinical utility and diagnostic accuracy of a negative breast FNAB result by studying 450 breast aspirates in 413 patients (average age 45 years) with a "negative" or benign cytologic interpretation performed at Massachusetts General Hospital over a 4-year period. Of these patients, 121 (29%) underwent subsequent biopsy and 17 (4%) were found to have malignancy (3% of total negative FNABs; 14% with histology). None of these 17 patients had a triple negative test. A cohort of 115 patients had documentation of negative physical, radiologic, and cytologic examinations (the triple negative), none of whom were found to have malignancy on histologic or at least 2-year clinical follow-up (negative predictive value [NPV] = 100% with a triple-negative test). Outside of the triple-negative test, the NPV of a negative breast FNAB is reduced with a false-negative rate of 7%. However, in the setting of a triple-negative test, the NPV in our patient population was 100%, reassuring the patient and clinician that clinical follow-up and not surgical intervention was sufficient for proper patient care.

Core biopsy versus FNAC for palpable breast cancers. Is image guidance necessary?

The aim of this study was to assess the efficacy of free-hand percutaneous core biopsy (FHCB) and to determine the role of fine needle aspiration cytology (FNAC) as diagnostic tools for palpable radiologically-suspicious breast lumps. This retrospective study was based on reviewing the clinical records of all patients diagnosed as having breast cancer between January 1999 and December 2000 and patients who had benign lesions, but suspicious breast imaging at triple assessment. Absolute sensitivity of FHCB for diagnosing cancer in palpable lesions was 98.7% compared with 51.3% for FNAC. The difference in the sensitivity of FHCB and FNAC was statistically significant (P<0.005, Wilcoxon matched pair test). Since 94.8% of radiologically-suspicious lumps were shown to be cancers, we advocate FHCB for all patients presenting with radiologically suspicious palpable lumps to our breast clinic. We also conclude that the sensitivity of FHCB for the diagnosis of malignancy in palpable radiologically-suspicious breast lesions is so high that image-guidance is unnecessary.

State of the art of minimally invasive breast biopsy: principles and practice

In the last two decades, the increasing use of screening mammography with the early detection of breast cancer and the newly gained understanding of the biology and changing therapy of breast cancer, emphasizing systemic therapy and minimizing extensive local surgery, has contributed to the increasing development of minimally invasive techniques for the diagnosis of breast lesions. Minimally invasive techniques provide increased patient comfort, excellent cosmetic result and minimal morbidity They are also responsible for decreased costs and better medical care by allowing an informed discussion of breast cancer therapy and planning of surgery with an emphasis on negative margins and the dissection of the sentinel node. Techniques in use include Fine-Needle Aspiration Cytology, Core-Needle biopsy, Vacuum-Assisted Core biopsy (Mammotome) and Large Core biopsy (ABBI, Site-select). We present a balanced, evidence-based approach to the diagnosis of patients with palpable or mammographic abnormalities.

A study on the cost effectiveness of sestamibi scintimammography for screening women with dense breasts for breast cancer

The potential impact of Sestamibi scintimammography (SSMM) on the cost effective management of women with dense breasts is not known. This study addresses this issue quantitatively by examining the impact of SSMM based screening strategies on the approximately 3,000,000 women over 40 with very dense breasts (DY patterns) without palpable masses and who have had one or more prior mammograms, who undergo routine screening each year. Quantitative decision tree sensitivity analysis was used to compare the conventional mammography (MM) strategy (strategy A), which does not subject patients with negative mammograms to any further examination until their next screening, with two decision strategies for screening with SSMM; SSMM after a negative mammogram (strategy B) or SSMM as the only screening test for women already identified as having dense breasts by a previous mammogram (strategy C). Cost effectiveness was measured by calculating the incremental cost effectiveness ratio (ICER) of strategies B and C, which is the cost of achieving an additional year of life in the screening population by choosing a SSMM based decision strategy rather than the conventional strategy. Strategies B and C reduced the number of false negative diagnoses by 62% and 8%, respectively. The ICER was $632,000 and $3.18M per life year for strategy B and C, respectively. To be cost effective, the pre-test probability of cancer in the study population must be greater than 3% for strategy B or the cost of SSMM must be less than $50 for strategy C. These results show the ICER of an SSMM based breast cancer screening strategy in the management of patients with dense breasts is not currently within the range (approximately $50,000 per year life saved) of other commonly performed medical interventions that are considered cost effective.

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

From January of 1990 to December of 1992, 6,954 consecutive cytologic breast fine-needle aspiration biopsies (FNAB) were performed at the Laboratory of Pathology of Sant'Anna Hospital in Turin. Of these cases 62% were solid nodes, 35% were cystic nodes, and 2.7% were nonpalpable breast lesions (stereotaxic or ultrasound guided FNAB). We verified 4,110 cases: 913 cases underwent surgery and 3,197 were evaluated clinically, and/or cytologically, and/or with mammography at least 1 yr after the first diagnosis, or checked with the database of the Tumor Registry of Turin. In our series the FNAB sensitivity was 94.6%, specificity was 99.9%, accuracy was 98.8%, inadequate samples were 6.4%, false-negative rate was 1.4%, and false-positive rate was 0.3%. Our results indicate that the use of cell block improves sensitivity (from 85.2 to 94.6%) and strongly reduces false-negative results (from 3.9 to 1.4%). We conclude that FNAB is a discriminant procedure to the surgical biopsy in cases with clinical, ultrasound, or mammographic low or intermediate suspect, contributing to allow a high malignant/benign surgical biopsy rate and to reduce the need for frozen section diagnosis and medical costs.

Comparison of histologic diagnosis between stereotactic core needle biopsy and open surgical biopsy

BACKGROUND

This study correlates the histologic findings of stereotactic core needle biopsy (SCNB) with open surgical biopsy (OSB) and identifies which lesions can be treated definitively based only on the SCNB histology.

METHODS

Women who underwent SCNB between July 1, 1993, and January 1, 1969, were identified by retrospective chart review. Mammographic (MGM) lesions found by SCNB to be ductal or lobular hyperplasia with atypia, or carcinoma underwent OSB. When the histologic findings by SCNB were inconsistent with the MGM findings, the lesion also underwent OSB.

RESULTS

799 women underwent SCNB with 96 (12%) of these going on to OSB. MGM findings in the 92 who presented without a palpable mass included microcalcifications (MCS) in 39, mass in 47, MCS and mass in 7, and tissue distortion in 3. One hundred one breast lesions biopsied first by SCNB, then by OSB were correlated histologically. Sensitivity of SCNB is 89%, with a specificity of 94%. Eight-four women (88%) were able to have definitive treatment at time of OSB because of prior SCNB, and 703/799 (88%) of women were spared OSB entirely.

CONCLUSION

SCNB accurately identifies benign breast histology and invasive cancers in women with MGM abnormalities, a distinct advantage over fine needle aspiration cytology. SCNB does not reliably identify women with DCIS and invasion. All women with SCNB diagnosis of ductal or lobular atypia should also undergo OSB.

Preoperative prediction of open breast biopsy results

BACKGROUND

The accuracy of a surgeon's clinical judgment dictates the need for interventional diagnostic procedures to identify breast carcinoma patients. Few studies exist in which such accuracy is determined.

METHODS

A series of 2247 consecutive open breast biopsies in newly presenting patients is presented in which the author preoperatively predicted a benign or malignant condition.

RESULTS

Positive predictive values for all patients, patients with breast lumps, and patients with abnormal mammograms were 0.49, 0.68, and 0.39, respectively, with the highest positive predictive value (0.89) found in women 50 years or older with a breast lump. Negative predictive values for all patients, patients with a breast lump, and patients with abnormal mammograms were 0.94, 0.94, and 0.93, respectively, with the highest values found in women younger than 30 years (0.98) and in women younger than 50 years (0.95).

CONCLUSIONS

Negative predictive values are reliable enough in women younger than 50 years to justify initial clinical observation of many benign appearing breast conditions. Minimal interventional procedures and open breast biopsies have a tendency to be overutilized in an effort to avoid any delay in the diagnosis of breast carcinoma. Fear of failure to diagnose breast carcinoma in a "timely fashion" is a driving force for interventional procedures in many situations in which close clinical follow-up alone is justifiable.

A Case of Ductal Carcinoma In Situ (DCIS:noncomedo type)Detected by Ultrasonography: Demonstration of Occult Multiple Foci

We report a case of ductal carcinoma in situ (DCIS) of the breast detected by ultrasonographic mass screening in a 51-year-old woman. In a mass screening program for breast cancer, physical examination with inspection and palpation, and ultrasonography (US) were performed. A hypoechoic mass with a slightly irregular margin was detected by US in the lateral upper quadrant of the right breast, at a distance 2 cm from the edge of the nipple. The mass was not detected by physical examinations or by mammography (MMG). The mass, which measured 0.8 x 0.5 cm and was examined by fine needle aspiration biopsy (FNAB) under US guidance, was cytologically diagnosed as class X. Modified radical mastectomy (Auchincloss method) was performed with the patient's consent. Pathological examination of the resected specimen revealed DCIS (noncomedo type) and occult multiple foci of malignancy which was considered tracking centripetally underneath the nipple. This case suggests that US and FNAB performed under US guidance are useful in the detection and diagnosis, respectively, of a breast mass. We should take multifocality into consideration, particularly with tendency tracking to the nipple, in the treatment of small breast cancers such as DCIS.

Core needle aspiration biopsy of palpable breast masses

The purpose of the present study was to determine the usefulness of core needle aspiration biopsy (CNAB) with an 18-gauge modified menghini needle in the preoperative evaluation of 145 palpable breast masses as the major indicator for definitive treatment by surgery. Of the 145 lesions histologically verified by surgery, 126 were diagnosed as carcinoma, of which 117 were correctly diagnosed by the needle biopsy (93%). CNAB showed a sensitivity of 90% in the diagnosis of breast malignancy and a specificity of 100%. The overall diagnostic accuracy was 91%. There were no false-positive results and after definitive diagnosis with the Menghini needle, a one-stage procedure without frozen sections could be performed for definitive treatment of breast carcinoma.

Management of ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) is an early, localized stage of breast carcinoma that has an excellent prognosis when it is properly treated. The significant increase in the frequency of diagnosis of DCIS in recent years is the result of both better recognition of DCIS among pathologists and widespread use of screening mammography. Multicentricity, bilaterality and histologic subtype are important considerations in the management of this disease. The clinical presentation of DCIS is the presence of either a palpable mass or a mammographic abnormality, most frequently in the form of an area of microcalcifications. For several decades, total mastectomy was considered the appropriate treatment for DCIS, and it should still be considered the standard to which more conservative forms of treatment must be compared. Breast conservation surgery has been used with increasing frequency in the treatment of DCIS but the adequacy of this approach remains subject to controversy. Segmental mastectomy alone may be applied with caution in carefully selected patients, while the rest of the patients undergoing breast conservation surgery should be treated with breast irradiation. Axillary node dissection is generally considered unnecessary in the treatment of DCIS. There is no role for adjuvant chemotherapy in the management of this disease. The role of tamoxifen in the treatment of DCIS is not clearly defined and it should be given only to patients enrolled in clinical trials. Ongoing research should clarify the controversies surrounding DCIS and enable us to define the optimal management for this disease.

Stereotactic core needle biopsy of mammographic breast lesions as a viable alternative to surgical biopsy

BACKGROUND

Stereotactic needle biopsy technique has received considerable attention as a possible alternative to surgical biopsy of nonpalpable breast lesions. The exact role of this procedure in the management of mammographic breast lesions has not yet been accurately defined.

METHODS

Data have been collected prospectively on 416 patients over an 8-month period (January 1992 through August 1992). Of 416, 356 patients underwent only stereotactic breast biopsy with a 14-gauge needle. Sixty patients underwent stereotactic breast biopsy followed by surgical biopsy. Based on mammographic findings before biopsy, lesions were classified as benign (24%), likely benign (49%), malignant (2%), likely malignant (6%), and indeterminate (19%). The number of core biopsy specimens obtained from each patient ranged from one to six.

RESULTS

The specimen was considered adequate in 98% of cases. Complications were minimal. The tissue diagnosis was benign in 92% and malignant in 8% of patients. In those patients undergoing surgical and stereotactic biopsy, 57 of 60 had matching histopathological results, representing an agreement rate of 95% (p < 0.001). The three patients whose histopathological results did not match had malignant diagnoses on stereotactic biopsy that were subsequently not identified in the modified radical mastectomy specimen because the entire focus of malignancy was removed by the several passes made by the core needle during biopsy. No patient had a negative stereotactic biopsy result in whom malignancy was later detected by surgical biopsy.

CONCLUSIONS

This study indicates excellent agreement between surgical and stereotactic needle biopsy findings. Stereotactic biopsy with a 14-gauge needle could obviate the need for surgical biopsy in certain women with radiologically benign, likely benign, and indeterminate lesions.

Triple approach in the diagnosis of dominant breast masses: combined physical examination, mammography, and fine-needle aspiration

In an attempt to reduce the number of breast biopsies done for benign breast disease in patients with breast lumps, we evaluated prospectively the sensitivity and specificity of the combination of three diagnostic modalities: clinical examination, mammography, and fine-needle aspiration cytologic examination (FNA). A total of 234 patients with a breast mass had a physical examination, a mammogram, and FNA, and were listed as malignant/suspicious or benign. All patients underwent a subsequent biopsy: 110 were found to have breast cancer, and 124 had a benign lesion. The sensitivity and specificity of the individual tests were as follows: 89% and 73%, respectively, for mammographic examination; 93% and 97% for FNA cytologic examination; and 89% and 60% for physical examination. For the combined triad of tests, the sensitivity was 100% and specificity 57%. All patients who had breast cancer had positive findings for malignancy in one or more of the diagnostic tests, i.e., 100% sensitively. All patients who had negative findings for malignancy in all three diagnostic tests had benign lesions, i.e., a negative predictive value of 100%. We conclude that breast masses can be diagnosed with a high degree of accuracy by combined physical, mammographic, and fine-needle aspiration cytologic examination. Patients in whom physical examination, mammography, and FNA were negative for malignancy can be safely observed, obviating the need for an open biopsy.

Overview of the biology and management of ductal carcinoma in situ of the breast

Ductal carcinoma in situ of the breast (DCIS) is an early, noninvasive stage of breast malignancy that arises from ductal epithelium and has an especially favorable prognosis. Its biologic characteristics are consistent with a direct precursor to invasive carcinoma, which develops in the majority of cases if left untreated, generally within 10 years of diagnosis. Mammography has resulted in a substantial increase in its diagnosis, as well as a change in its presentation from large, palpable masses to nonpalpable lesions manifested primarily as microcalcifications. The same treatment options are available for DCIS as for invasive breast carcinoma, and there is also a limited role for wide local excision alone in incidental lesions. Most cases of DCIS currently are treated effectively by lumpectomy and radiation therapy, although the fact that 50% of all local breast recurrences are invasive lesions may affect survival adversely. Mastectomy is associated with the best survival rates and should be performed on any patient with factors known to pose a high risk of locoregional recurrence. There are still many outstanding issues to be resolved by further study before the intriguing potential of this disease can be realized fully.

Stereotactic cytology in a regional breast-screening programme

Stereotactic localization and fine-needle aspiration are new procedures for the management of non-palpable mammographic abnormalities. In this prospective study, stereotactically guided cytology with immediate reporting was performed before biopsy in a consecutive series of 166 patients with screen-detected non-palpable abnormalities. All specimens were obtained by multiple stereotactically guided passes with a 22-G Franzén needle and graded as: 1, acellular or inadequate; 2, benign; 3, atypical, probably benign; 4, probably malignant; or 5, malignant. After definitive surgery all tumours were staged according to the Union Internacional Contra la Cancrum classification. Of 71 patients with malignancy, 56 were correctly diagnosed by cytology before operation. Twelve patients with malignancy had grade 1 cytology and 50 of the 52 with grade 2 cytology had benign disease. This study confirms that stereotactic cytology is a valuable diagnostic test in a breast-screening programme.

Ultrasonographically guided fine needle aspiration cytology and core-needle biopsy in the diagnosis of breast tumors

The present study was designed to assess the performance of fine needle aspiration cytology (FNAC) and core-needle biopsy (CNB) of breast lesions when these procedures are performed under sonographic guidance. The results obtained in 1142 FNAC procedures and 180 CNB procedures were analysed. The study took place in a University Hospital and a private practice clinic. The patients eligible for this study were a series of women, in whom at least one hypoechoic, limited mass was found at breast ultrasonography. Cystic masses were excluded from the study. Each individual mass was investigated using either FNAC or CNB under sonographic guidance. Accuracy characteristics to suspect or diagnose malignant and pre-malignant breast lesions, such as sensitivity and specificity, were calculated. The cytological results were classified into four categories according to standard criteria: benign; atypical and/or suspicious for cancer (hyperplasia with atypia); malignant; and unsatisfactory for diagnosis specimen. Tissue specimens were classified according to the W.H.O. The 1142 lesions submitted to FNAC included 66 invasive carcinomas, 4 intraductal carcinomas, and 4 atypical hyperplasias. FNAC led to 6 false-negative examinations, equally distributed between small (volume < or = 1 cm3), and larger lesions, and 1 false-positive examination. There were 12.9% (147/1142) inadequate smears. Only 3 inadequate samples were obtained in the presence of a discrete pathologic lesion (3/363, or 0.1%). All 3 corresponded to invasive carcinomas. The majority of inadequate samples (144/147, or 98.0%) were obtained in the normal/dystrophic group. Overall, the sensitivity is 92.1%, and the specificity is 84.8%. The 180 lesions submitted to CNB included 31 invasive carcinoma, 5 intraductal carcinomas, and 17 atypical hyperplasias. CNB, in this series, had an accuracy rate of 100%. In conclusion, US guidance increases the accuracy of breast tissue sampling procedures. This is of particular importance as the number of suspicious images to be investigated steadily increases, as the result of mass screening.

Aspiration biopsy cytology of malignant papillary breast neoplasms

Papillary carcinoma of the breast is a rare neoplasm characterized by a low grade of malignancy. From the files of the Department of Histopathology of Conegliano Veneto City Hospital, Conegliano Veneto, Italy, 16 cases of papillary breast carcinoma diagnosed by fine-needle aspiration cytology have been selected. A multiparametric morphologic study has been performed in order to contribute to the cytologic characterization of this rare group of breast malignancies. The authors believe that aspiration biopsy cytology is able to provide an accurate preoperative diagnosis.

Evaluation of a palpable breast mass

A palpable mass in a woman's breast represents a potentially serious lesion and requires evaluation by history taking, physical examination, and mammography. The initial objective is to distinguish simple cysts from solid lesions, which can be accomplished with needle aspiration (Fig. 2). A solid lesion requires a firm diagnosis, and this usually calls for removing the lesion for histologic examination. A positive result on cytologic examination after aspiration is sufficiently accurate to justify one-stage diagnosis and treatment, with confirmation by examination of a frozen section obtained during the procedure. A negative or suspicious finding on cytologic evaluation is inconclusive, and outpatient biopsy is indicated. Perfection in diagnosis will require the removal of every solid mass. This can be expected to result in the biopsy of many benign lesions, but removal of many of them is desirable on other grounds. Although in some instances the probability of cancer may be exceedingly small, it is never zero. If biopsy is not recommended, the probability of cancer should be estimated so that the patient can decide whether the level of risk is acceptable to her.

Cytologic differentiation between proliferative and nonproliferative breast disease in mammographically guided fine-needle aspirates

Fine-needle aspiration biopsy (FNAB) is considered a valid diagnostic procedure in management of patients with breast lesions. It is also important to differentiate benign nonproliferative change from proliferative breast changes, since the risk of development of breast carcinoma in patients with atypical hyperplasia is 4-5 times that of general population. Therefore, the recognition of proliferative breast disease with atypia significantly impacts on the patient's subsequent management. To assess the feasibility of a cytologic grading system to further characterize benign breast lesions, cytologic preparation of 87 mammographically guided FNABs were studied. Cellular aspirates were evaluated for the cellular arrangement, the degree of cellular pleomorphism and anisonucleosis, presence of myoepithelial cells and nucleoli and the status of the chromatin pattern. Values ranging from 1 to 4 were assigned to each cytologic criterion, and a score based on the sum of the individual values was calculated for each case. The minimum score attainable was thus 6. In our chosen criteria cytologic diagnosis of nonproliferative disease was entertained when the total score ranged from 6 to 10. Proliferative disease without atypia was diagnosed with a total score ranging from 11 to 14. Atypical hyperplasia was reported when the total score ranged from 15 to 18. A cytologic diagnosis of malignancy was entertained when the total score ranged from 19 to 24. The cytologic diagnosis was then compared to the reported histologic diagnosis from the excisional biopsies and the data were statistically analysed. A high degree of concordance was found between the cytologic findings and the histologic diagnosis. This study suggests that it is possible to apply a cytologic grading system to further subclassify benign breast disease and distinguish these forms from neoplastic lesions.

Newer developments in the diagnosis and staging of breast cancer

Tremendous changes have occurred in the diagnosis and staging of breast cancer. There are more sophisticated diagnostic techniques available and new developments in prognostic indicators that have altered decisions regarding adjuvant treatment. In the near future, progress in quantity and quality of survival may be linked to early diagnosis and precise staging of the disease.

Percutaneous biopsies of the breast: state of the art

Percutaneous biopsy of nonpalpable breast lesions can be performed using mammographic or ultrasound guidance. Stereotaxy is the only technique applicable to microcalcifications and very small masses. With few exceptions, discrete masses greater than 0.7-0.8 cm can be visualized on high-frequency sonograms. Because of the continuous real-time monitoring of the needle placement and of the sampling procedure, sonography has proved to be highly accurate and safe in experienced hands. In addition to depending on the accuracy of the radiologist in hitting the target and the accuracy of the cytopathologic diagnosis, the success of fine-needle aspiration biopsy depends on successful tissue extraction. The lack of significance of insufficient specimens and the importance of properly recording such results in the calculation of accuracy values for fine-needle aspiration biopsy are emphasized. On the other hand, confidence in a negative cytologic result (i.e., adequate specimen without malignant cells) of a perfectly guided procedure is a prerequisite for the nonsurgical management of nonpalpable breast masses and thus for reducing the number of surgical biopsies.

Survey of aspiration biopsy cytology of the breast

Based on the team approach, the Papanicolaou method, simple equipment, and special criteria of malignancy, aspiration biopsy cytology of the breast is reviewed.

Prospective evaluation of radiologically directed fine-needle aspiration biopsy of nonpalpable breast lesions

The application of fine-needle aspiration biopsy (FNAB) to the diagnosis of nonpalpable breast lesions was evaluated with a new method which uses standard needle localization under mammographic guidance to assure accurate sampling by FNAB. This method was prospectively applied to 100 mammographically detected breast lesions in 100 women (mean age, 53 years). All 100 patients underwent surgical excision of these nonpalpable lesions after cytologic aspiration. Sufficient aspirated material was obtained for cytologic diagnosis from 91 patients (91%). The histologic and cytologic interpretations were then compared. Twenty malignancies were ultimately diagnosed by histology (12 invasive ductal carcinoma, six ductal carcinoma in situ, and two lobular carcinoma in situ), of which 17 had been cytologically diagnosed. There were no false-positive diagnoses of malignancy by FNAB. False-negative readings (3.3%) included two cases of lobular carcinoma in situ and one case of ductal carcinoma in situ. This technique thus demonstrated a sensitivity of 85%, specificity of 100%, and overall diagnostic accuracy of 96.7% for the nonsurgical detection of malignancy in nonpalpable breast lesions. These results suggest that the established safety, reliability, and cost-effectiveness of FNAB can be maintained in this clinical setting. This procedure may obviate the need for open surgical biopsy in those patients with an unequivocal diagnosis of malignancy. It can also be done using standard techniques and equipment available in many community hospitals.

Medullary carcinoma of the breast. An unusual cytologic finding in cyst fluid aspirates

Cystic medullary carcinoma of the breast is unusual. This report describes five patients with medullary carcinoma who presented clinically with a breast cyst. Fine-needle aspiration biopsy (NAB) was performed as part of the initial physical examination and the retrieved cyst fluid was examined cytologically. Four of the five patients were premenopausal, more typical of benign cystic disease and significantly younger than the average (60+ years) for other forms of cystic breast carcinoma. Only three of the five patients demonstrated suspicious findings of hemorrhagic cyst fluid, a residual mass after NAB, or refilling of the cyst. Due to the relatively young age of most patients, the innocuous clinical presentation, and the abundant inflammatory component noted in the aspiration biopsy cytologic study (ABC), misinterpretation as an inflamed cyst is possible. The ABC of cystic medullary carcinoma is presented with histologic correlation.

Monoclonal antibody B72.3. An adjunct for evaluation of suspicious aspiration biopsy cytology from the breast

Monoclonal antibody B72.3 (MoAb B72.3) is a potentially valuable diagnostic adjunct when applied to aspiration biopsy cytology (ABC). In this prospective study, its reactivity was tested on the ABC from 25 breast lesions interpreted as suspicious. The stain was applied directly to the Papanicolaou-stained specimen by the avidin-biotin peroxidase methodology at a concentration of 40 micrograms/ml. In 11 aspirates from invasive carcinomas, the reactivity to MoAb B72.3 was strongly positive in nine cases and weakly positive in two. Ten of these tumors were homogeneous or heterogeneous infiltrating lobular neoplasms, tumors causing special diagnostic pitfalls by ABC. The cells from seven of the nine benign lesions were nonreactive, and in two cases from fibrocystic change, weakly reactive. The ABC from five patients with noninvasive carcinomas or atypical lobular hyperplasia showed a variety of responses. The findings indicate that in select circumstances, MoAb B72.3 used in conjunction with clinical and cytologic findings may be a useful diagnostic adjunct.