Final Version: The Uniform Approach to Breast Fine-Needle Aspiration Biopsy

Development of a novel approach for breast cancer prediction and early detection using minimally invasive procedures and molecular analysis: how cytomorphology became a breast cancer risk predictor

With enhanced public awareness, advances in breast imaging, and emphasis on early breast cancer detection and prevention, more women are seeking consultation to assess the status of their breast health. Risk assessment has become an integral part of established multi-disciplinary breast care, and breast cancer risk reduction interventions have received a great deal of attention. Similarly, interest in identification of high-risk individuals has increased significantly. Atypical proliferative changes in breast epithelial cells are ranked high among various known breast cancer risk factors and, in recent years, have been the subject of several investigations. Breast tissue and fluid in the ductal system provide a rich source of cells and biomarkers that have the potential to aid in the assessment of short-term risk of breast cancer development, and assess responses to interventional prevention efforts. There are three minimally invasive procedures currently being utilized to sample breast tissue in asymptomatic high-risk individuals. These procedures are: fine-needle aspiration biopsy, nipple aspiration fluid, and ductal lavage. In this review article, the merits and limitations of each procedure are presented, and the contribution of cytomorphology and molecular analysis in breast cancer prediction is highlighted. In addition, the role of Masood Cytology Index as a surrogate endpoint biomarker in chemopreventative trials is discussed.

Trucut biopsy of breast lesions: the first step toward international standards in developing countries

The new concept in breast cancer diagnosis and treatment is based on a less invasive, more accurate and effective strategy, with a multidisciplinary approach in a specialised breast unit. When indicated, conservative surgery has replaced mastectomy with sentinel-node biopsy substituting routine axillary dissection. But the key factor in respect of these new standards is to confirm the cancer before going to the operating room. Trucut biopsy is performed instead of incisional or excisional biopsy and frozen section. The technique is reliable, simple, and reproducible, and not at all expensive; it can be adapted even for low-income developing countries.

MATERIALS AND METHODS

Between March 2006 and June 2010, 764 patients under clinical suspicion of cancer and/or with BIRADS (Breast Imaging Reporting and Data System) III-V in imaging in one university and one private hospital in Tehran, Iran underwent trucut biopsy (60% palpable and 40% non-palpable lesions). Cancer was found in 30.8% of the cases. In benign pathology, in concordance with clinical and imaging suspicion, surgery was omitted with short-term follow-up. For palpable symptomatic benign lesions surgery was performed to relieve the patient's symptoms. When the pathology report was not in concordance with clinical/imaging suspicion (1.8%), and in the presence of moderate and severe hyperplasia with or without atypia, in lobular and papillary lesions (4.9%) open biopsy was done to rule out cancer (10 added cancers, 1.3%; total cancers 32.1%). Cancer surgery was done as a single procedure in 89.8% of cases.

CONCLUSION

Trucut biopsy for breast lesion assessment is the first step toward a new concept in breast cancer care. It is simple, reduces the number of surgeries (no surgery for non-symptomatic benign lesions and one surgery for cancer), and avoids diagnostic errors with full respect for the patient's rights. We insist on its routine use to extend international guidelines while decreasing the total cost of this common disease in all low-resource countries.

Core needle biopsy versus fine needle aspiration biopsy: are there similar sampling and diagnostic issues?

Evidence suggests that in experienced hands fine needle aspiration biopsy (FNAB) is highly safe and effective for the evaluation of patients who have palpable breast lesions. In most cases, FNAB leads to an appropriate clinical or surgical management. FNAB can also be effectively used in evaluation of cystic lesions under ultrasound guidance. Other nonpalpable lesions can benefit from image-directed core needle biopsy (CNB). Overall, cost should influence the decision to use FNAB or CNB. FNAB may be the only affordable procedure in developing countries. Breast cancer affects significant numbers of women worldwide. Attempts should be made to take all the measures necessary to consider optimal approaches to breast health care for everyone regardless of age, race, ethnicity, or social status.

Cytomorphology as a risk predictor: experience with fine needle aspiration biopsy, nipple fluid aspiration, and ductal lavage

Primary prevention of breast cancer requires identification and elimination of cancer-causing agents, which is an incredibly difficult task to follow. Secondary prevention involves screening individuals who are at increased risk for breast cancer in hopes that early intervention will affect survival. In the 1980s, chemoprevention received serious attention. This approach was aimed at reducing cancer risk by administration of natural or synthetic clinical compounds that prevent, reverse, or suppress carcinogenesis in individuals at increased risk for cancer. It was not until 1998, however, when the first report from the National Surgical Adjunct Breast and Bowel Project (Breast Cancer Prevention Trial BCPT; P-1) randomized clinical trial appeared in the literature supporting the hypothesis that breast can-cer can be prevented. This study showed that administration of tamoxifen reduced the risk for invasive and noninvasive breast cancer by almost 50% in all age groups. With the current availability of tamoxifen as a chemopreventive agent and with the increasing emphasis on early breast cancer detection and prevention, more women seek consultation to determine their risk for breast cancer. However, in the absence of any detectable breast lesion, clinically and mammographically, only a few women may volunteer to have their breasts sampled by surgical biopsy for risk assessment. Other non-surgical procedures include fine needle aspiration biopsy (FNAB), nipple aspirate fluid (NAF), and the recently introduced procedure, ductal lavage. These techniques may provide better alternatives. These minimally invasive procedures are capable of recruiting cellular material for cytomorphologic interpretation and biomarker studies.

Breast Fine Needle Aspiration Biopsy: Prevailing Recommendations and Contemporary Practices

In 1996, a National Cancer Institute conference was held in Bethesda,Maryland to define parameters for the practice of breast fine needle aspiration (BFNA). Representatives of the American Society of Cytopathology, Papanicolaou Society of Cytopathology, American College of Radiology, American College of Obstetricians & Gynecologists, Society of Surgical Oncology, American Academy of Family Physicians, College of American Pathologists, National Consortium of Breast Centers, International Academy of Cytology, American Society of Clinical Pathologists, American Cancer Society, American College of Surgeons, and American Society for Cytotechnology developed and reviewed recommendations. These guidelines were referred to as "The Uniform Approach to Breast Fine Needle Aspiration Biopsy." This article reviews these recommendations and the contemporary evolution of the practice of BFNA since their original publication.

Fine needle aspiration cytology versus percutaneous biopsy of nonpalpable breast lesions

Fine needle aspiration (FNA) and core biopsy (CB) are efficient alternatives to surgical biopsy: FNA provides a sampling of cells and is very cost effective. The main limits are insufficient sampling rate and the impossibility to diagnose invasion. CB allows architectural description and the diagnosis of specific benign and malignant lesions, but is more expensive and time-consuming.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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