Fine needle aspiration cytology versus percutaneous biopsy of nonpalpable breast lesions

Receptor Conversion in Distant Breast Cancer Metastases: A Systematic Review and Meta-analysis

Background

In metastatic breast cancer, hormone and/or human epidermal growth factor receptor 2 (HER2)-targeted therapy decision-making is still largely based on tissue characteristics of the primary tumor. However, a change of estrogen receptor alpha (ERα), progesterone receptor (PR), and HER2 status in distant metastases has frequently been reported. The actual incidence of this phenomenon has been debated.

Methods

We performed a meta-analysis including 39 studies assessing receptor conversion from primary breast tumors to paired distant breast cancer metastases. We noted the direction of change (positive to negative or vice versa) and performed subgroup analyses for different thresholds for positivity, the type of test used to assess HER2 receptor status, and metastasis location-specific differences (two-sided tests).

Results

Overall, the incidence of receptor conversion varied largely between studies. For ERα, PR, and HER2, we found that random effects pooled positive to negative conversion percentages of 22.5% (95% confidence interval [CI] = 16.4% to 30.0%), 49.4% (95% CI = 40.5% to 58.2%), and 21.3% (95% CI = 14.3% to 30.5%), respectively. Negative to positive conversion percentages were 21.5% (95% CI = 18.1% to 25.5%), 15.9% (95% CI = 11.3% to 22.0%), and 9.5% (95% CI = 7.4% to 12.1%). Furthermore, ERα discordance was statistically significantly higher in the central nervous system and bone compared with liver metastases (20.8%, 95% CI = 15.0% to 28.0%, and 29.3%, 95% CI = 13.0% to 53.5%, vs 14.3%, 95% CI = 11.3% to 18.1, P = .008 and P < .001, respectively), and PR discordance was higher in bone (42.7%, 95% CI = 35.1% to 50.6%, P < .001) and liver metastases (47.0%, 95% CI = 41.0% to 53.0%, P < .001) compared with central nervous system metastases (23.3%, 95% CI = 16.0% to 32.6%).

Conclusions

Receptor conversion for ERα, PR, and HER2 occurs frequently in the course of disease progression in breast cancer. Large prospective studies assessing the impact of receptor conversion on treatment efficacy and survival are needed. Meanwhile, reassessing receptor status in metastases is strongly encouraged.

Evaluation of the clinical efficacy of minimally invasive procedures for breast cancer screening at a teaching hospital

AIMS

To assess the clinical efficacy of diagnostic procedures for breast cancer at a teaching hospital using internal auditing tools and quality control measures.

METHODS

A retrospective assessment of 500 patients who underwent core needle biopsy (wide-bore needle biopsy; WBN) of palpable or non-palpable breast nodes that were submitted for at least one cytological examination (fine needle aspiration (FNA) cytology and/or imprint of a WBN specimen). For statistical analysis the auditing tool and quality control proposed by the National Health Service breast screening programme was utilised.

RESULTS

For FNA, full specificity, positive predictive value, inadequate rates and suspicious rates were satisfactory while absolute sensitivity, complete sensitivity, false negatives and false positives were unsatisfactory. For imprint, absolute sensitivity, complete sensitivity, inadequate rate from cancers and suspicious rates were satisfactory, and the remaining indicators were unsatisfactory. WBN displayed the best performance with absolute sensitivity, complete sensitivity, false negative, suspicious rates, full specificity and predictive value showing satisfactory results and only one unsatisfactory result (false positive).

CONCLUSIONS

Based on an overall analysis, WBN displayed the highest clinical efficacy compared with FNA and imprint, and demonstrated adequate safety for confirming the appropriate diagnosis and management of patients, ensuring the efficacy of the service.

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

Breast fine-needle aspiration biopsy (FNAB) by palpation is on the decline, due to its limitations in diagnostic accuracy, decreased sensitivity, and its replacement with core needle biopsy (CNB). Despite its decreasing utility, superficial fine-needle aspiration (FNA) in breast is still the main modality for evaluating metastatic lesions, recurrence, and axillary lymph node metastasis. New modalities including proteomic pattern expression and methylation profiling of breast lesions are other promising techniques that can be used as ancillary tests for refining the diagnosis of breast lesions using FNAB. Image-guided breast FNA proves to be a successful alternative with high sensitivity and specificity. In this review, the advantages, disadvantages, and inherent limitations of breast FNA and CNB, and new advanced techniques are discussed.

Multidisciplinary approach of early breast cancer: the biology applied to radiation oncology

Early breast cancer treatment is based on a multimodality approach with the application of clinical and histological prognostic factors to determine locoregional and systemic treatments. The entire scientific community is strongly involved in the management of this disease: radiologists for screening and early diagnosis, gynecologists, surgical oncologists and radiation oncologists for locoregional treatment, pathologists and biologists for personalized characterization, genetic counselors for BRCA mutation history and medical oncologists for systemic therapies.Recently, new biological tools have established various prognostic subsets of breast cancer and developed predictive markers for miscellaneous treatments.The aim of this article is to highlight the contribution of biological tools in the locoregional management of early breast cancer.

Evaluation of accuracy of fine needle aspiration cytology in BI-RADS3 category breast lesions: cytohistological correlation in 337 cases

OBJECTIVE

To evaluate the accuracy of fine needle aspiration cytology (FNAC) in BI-RADS3 breast lesions.

METHODS

Between January 2004 and December 2007, 337 cases from BI-RADS3 lesions underwent FNAC. Three to six needle passes were made on each patient. In 67 cases (20%) a histological biopsy was performed. Cytological and histological interpretations were performed by the same pathologist.

RESULTS

The histological diagnosis showed that 88% (59/67) of BI-RADS3 breast lesions were benign. Only 6% (4/67) were malignant, consisting of ductal carcinoma in situ and infiltrating ductal carcinoma.

CONCLUSION

BI-RADS3 lesions remain disruptive in their management. However, the correlation between cytology and histology showed that most of these lesions were benign and that finally FNAC remains a useful and accurate test in the management of these lesions.

Exonic expression profiling of breast cancer and benign lesions: a retrospective analysis

BACKGROUND

Gene-expression arrays have generated molecular predictors of relapse and drug sensitivity in breast cancer. We aimed to identify exons differently expressed in malignant and benign breast lesions and to generate a molecular classifier for breast-cancer diagnosis.

METHODS

165 breast samples were obtained by fine-needle aspiration. Complementary DNA was hybridised on splice array. A nearest centroid prediction rule was developed to classify lesions as malignant or benign on a training set, and its performance was assessed on an independent validation set. A two-way ANOVA model identified probe sets with differential expression in malignant and benign lesions while adjusting for scan dates.

FINDINGS

120 breast cancers and 45 benign lesions were included in the study. A molecular classifier for breast-cancer diagnosis with 1228 probe sets was generated from the training set (n=94). This signature accurately classified all samples (100% accuracy, 95% CI 96-100%). In the validation set (n=71), the molecular predictor accurately classified 68 of 71 tumours (96%, 88-99%). When the 165 samples were taken into account, 37 858 exon probe sets (5.4%) and 3733 genes (7.0%) were differently expressed in malignant and benign lesions (threshold: adjusted p<0.05). Genes involved in spliceosome assembly were significantly overexpressed in malignant disease (permutation p=0.002). In the same population of 165 samples, 956 exon probe sets presented both higher intensity and higher splice index in breast cancer than in benign lesions, although located on unchanged genes.

INTERPRETATION

Many exons are differently expressed by breast cancer and benign lesions, and alternative transcripts contribute to the molecular characteristics of breast malignancy. Development of molecular classifiers for breast-cancer diagnosis with fine-needle aspiration should be possible.

Breast Cancer in Limited-Resource Countries: Diagnosis and Pathology

In 2002 the Breast Health Global Initiative (BHGI) convened a panel of breast cancer experts and patient advocates to develop consensus recommendations for diagnosing breast cancer in countries with limited resources. The panel agreed on the need for a pathologic diagnosis, based on microscopic evaluation of tissue specimens, before initiating breast cancer treatment. The panel discussed options for pathologic diagnosis (fine-needle aspiration biopsy, core needle biopsy, and surgical biopsy) and concluded that the choice among these methods should be based on available tools and expertise. Correlation of pathology, clinical, and imaging findings was emphasized. A 2005 BHGI panel reaffirmed these recommendations and additionally stratified diagnostic and pathology methods into four levels--basic, limited, enhanced, and maximal--from lowest to highest resources. The minimal requirements (basic level) include a history, clinical breast examination, tissue diagnosis, and medical record keeping. Fine-needle aspiration biopsy was recognized as the least expensive reliable method of tissue sampling, and the need for comparing its clinical usefulness with that of core needle biopsy in the limited-resource setting was emphasized. Increasing resources (limited level) may enable diagnostic breast imaging (ultrasound +/- mammography), use of tests to evaluate for metastases, limited image-guided sampling, and hormone receptor testing. With more resources (enhanced level), diagnostic mammography, bone scanning, and an onsite cytologist may be possible. Mass screening mammography is introduced at the maximal-resource level. At all levels, increasing breast cancer awareness, diagnosing breast cancer at an early stage, training individuals to perform and interpret breast biopsies, and collecting statistics about breast cancer, resources, and competing priorities may improve breast cancer outcomes in countries with limited resources. Expertise in pathology was reaffirmed to be a key requirement for ensuring reliable diagnostic findings. Several approaches were again proposed for improving breast pathology, including training pathologists, establishing pathology services in centralized facilities, and organizing international pathology services.

Imprint cytology from ultrasound-guided core biopsies: accurate and immediate diagnosis in a one-stop breast clinic

AIM

To investigate whether imprint cytology from ultrasound-guided core biopsy specimens was adequate for the National Health Service Breast Screening Programme (NHSBSP) guidelines.

METHODS

We prospectively audited imprint cytology from ultrasound-guided core biopsy specimens. The performance indicators for imprint cytology specimens from 111 consecutive ultrasound-guided core biopsy were compared with standards set by the NHSBSP for fine-needle aspiration cytology (FNAC).

RESULTS

Imprint cytology fulfilled the "preferred" targets for absolute and complete sensitivity, specificity, positive predictive value, false-positive and false-negative rates, inadequate rate and inadequate rate from cancers. It also satisfied the minimum target for suspicious rate. The complete sensitivity was 97%, full specificity 78%, with 100% positive predictive value for C5 cytology and an inadequate rate from cancers of 1.5%.

CONCLUSION

Imprint cytology from ultrasound-guided core biopsy allows same-day diagnosis and the collection of data regarding the grade of the carcinoma for treatment decisions from a single needle test.

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

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

Implementation of a minimally invasive breast biopsy program in countries with limited resources

Minimally invasive breast biopsy techniques, such as core needle biopsy (CNB) and fine-needle aspiration biopsy (FNAB), offer several advantages over surgical biopsy. Patients in whom minimally invasive biopsy techniques are used may undergo biopsy more quickly, are more likely to have only one surgery for treatment of the breast tumor and axillary staging, and are less likely to need reoperation after breast-conserving surgery because of positive margins. Knowledge of a diagnosis of cancer before surgery allows patients to participate in treatment decisions, and compared with surgical biopsy, minimally invasive biopsy has lower costs, produces less scarring, has nearly equivalent diagnostic accuracy, and does not require general anesthesia or sedation. Minimally invasive biopsy can permit accurate diagnosis and prompt intervention in a cost-effective manner, particularly in countries with limited resources, where patients often present with advanced-stage breast cancer. Several events characterize the implementation of a successful program in minimally invasive breast biopsy: public education about the less invasive nature of these techniques, which may encourage women to seek care at earlier stages; a change in the philosophy of medical personnel that favors involving patients in treatment decisions and acceptance of less extensive but accurate methods of diagnosis; education of medical personnel in the selection of patients for minimally invasive biopsy, performance of the biopsy, and interpretation of histologic and/or cytologic samples; quality assessment and use of the triple test (i.e., correlation of clinical, radiologic, and pathologic findings); and economical use of resources, which results from the lower costs of minimally invasive procedures and the avoidance of unnecessary surgery for benign conditions.

Diagnosis of breast cancer in countries with limited resources

Accurate diagnosis is a necessary step in the management of breast cancer. In women with breast cancer, diagnosis can confirm the presence of the disease, reduce treatment delays, and clarify the predictive and prognostic features of the cancer, which help in planning treatment and counseling women. In women with benign breast conditions, accurate diagnosis avoids erroneous treatment for breast cancer, which can have devastating consequences for the woman and unnecessarily consumes resources. The panel distinguishes between a "clinical diagnosis" of breast cancer (one based on signs and symptoms and imaging findings) and a "pathologic diagnosis" of breast cancer (one based on microscopic examination of cellular or tissue samples). The panel agrees that all women should have a pathologic diagnosis of breast cancer before they are given definitive treatment for the disease, no matter how strongly their clinical findings suggest cancer. The tools for clinical diagnosis include history, clinical breast examination, ultrasound, and diagnostic mammography; these tools provide valuable information and play important supplemental roles in ascertaining the presence of breast cancer. Mammography and ultrasound also help determine the extent of disease within the breast, which is essential when breast-conserving therapy can be offered to women. The tools for pathologic diagnosis include fine-needle aspiration biopsy, core needle biopsy, and standard surgical biopsy. The panel noted that each of these tools has potential benefits and limitations in the limited-resource setting, and concluded that the choice among them must be based on the available tools and expertise. The triple test-checking for correlation of pathology findings, imaging findings, and clinical findings-was identified as a critical practice in diagnosing breast cancer. Panelists uniformly agreed that mastectomy should not be used to diagnose breast cancer, noting that accurate diagnosis can be made by less invasive means. Expertise in pathology was identified as a key requirement for ensuring reliable diagnostic findings. Several approaches were proposed for improving breast pathology, including training pathologists, establishing pathology services in centralized facilities, and organizing international pathology services.