Needle aspiration of the breast with immediate reporting of material

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.

Use of Ultrasound Localization to Improve Results of Fine Needle Aspiration Cytology of Breast Masses

A prospective randomized controlled trial of 116 patients with breast masses was conducted to compare the accuracy of ‘blind’ aspiration cytology performed in the clinic with aspiration cytology using ultrasound localization. The unsatisfactory aspiration cytology rate was significantly reduced by ultrasound localization (P=0.028). This was mainly due to an improvement in the unsatisfactory rate for tumours less than 3 cm in diameter (P=0.036). The results were influenced by the number of needle manoeuvres performed, < 10 needle manoeuvres being associated with a 54% unsatisfactory aspiration rate compared with 25% when > 10 manoeuvres were performed (P= <0.02). One experienced aspirator in the clinic had results comparable to those achieved with ultrasound localization.

It is concluded that experience and technique are the most important factors in obtaining a satisfactory aspirate from breast masses. Routine ultrasound localization prior to aspiration confers some benefit. Consideration should be given to the use of the ultrasound-assisted technique following a previous unsatisfactory aspiration, particularly if the tumour is less than 3 cm in diameter.

Is there a role for on-site evaluation of thyroid fine needle aspiration to reduce the nondiagnostic rate?

The use of immediate on-site evaluation of fine-needle aspiration biopsy (FNAB) specimens can determine the adequacy of specimens and provides a specific preliminary diagnosis. In this prospective study, we evaluated the impact of on-site assessment of thyroid FNAB performed under ultrasound guidance. Totally, 204 (170 female, 34 male) patients (102 on site, 102 control group) were included. The patients were randomized on site and regular cytologic examination groups. Quick May-Grünwald Giemsa stain was used for on-site examination and FNA was continued until adequate aspirate for optimal cytological examination. Two (2.0 %) of the 102 patients evaluated with on-site examination had a nondiagnostic result. However, 16 (15.7 %) of the 102 patients examined by regular cytologic examination method, had nondiagnostic result. The difference between these two groups was statistically significant (p < 0.0001). The major cause of a nondiagnostic thyroid FNAB specimen is the failure to aspirate a sufficient number of cells necessary for diagnosis cystic lesions. Immediate on-site evaluation can significantly decrease the nondiagnostic rate of thyroid FNAB specimens.

Diagnosis and Treatment of Intracystic Breast Carcinomas

Cystic breast masses are very common in female patients attending breast clinics. Most of them are benign and managed by simple aspiration. We reviewed histology records for the last 12 years to find patients with cystic breast carcinomas and to evaluate special clinical signs that may help to identify patients with this rare entity. Eighteen patients with cystic breast carcinomas were found among 1510 new breast cancer patients (1.19%) who were seen at our Breast Unit during this period. Ten had intracystic papillary carcinoma (0.66% of all breast cancers), seven had cystic degeneration of ductal carcinoma, and one had a mucinous carcinoma. The diagnosis of intracystic papillary carcinoma was based on cyst fluid cytology and breast imaging in most patients and on open breast biopsy in two cases only. The prognosis of our cystic breast carcinoma patients was excellent regardless of the specific histologic type of the tumor. We conclude that cysts in postmenopausal women should be viewed with suspicion. Bloodstained aspirated cyst fluid should be sent for cytology and breast imaging should be carried out in all these cases. Residual mass after cyst aspiration is also an indication for open biopsy.

Individual specimen triage of effusion samples: an improvement in the standard of practice, or a waste of resources?

The standard of practice in cytopathology does not include an individual specimen triage (IST) for sample optimization, but rather prescribes a uniform procedure, e.g., for smears, cell blocks, and cytospins. IST requires additional resources. We sought to evaluate whether IST would result in enhanced diagnostic accuracy and specimen turnaround time in effusions. In order to evaluate the efficacy of IST, 50 effusion samples (31 pleural, 16 peritoneal, and 3 pericardial), each with a minimum volume of 50 ml, were utilized. Each sample was prepared via IST to include at least two initial prepared Diff-Quik-stained cytospins on which the IST was based, as well as a standard cytopreparation protocol for nontriaged samples (NTS) which was limited to 3 smears (2 Papanicolaou-stained, and 1 Diff-Quik-stained) and a hematoxylin-eosin (H&E)-stained cell block section. All triaged and NTS were reviewed retrospectively to determine if IST offered any advantages over the standard cytopreparation protocol for effusion samples. Each was evaluated for diagnostic concordance, turnaround time for final diagnosis, and optimal preparation. In 46 cases, diagnoses in IST and NTS were 100% concordant. Four cases showed minor discrepancies between the original and the NTS diagnoses. In general, the discordant cases were due to sparse cellularity in a specimen composed largely of blood. There was no difference in turnaround time for final diagnosis. Based on a review of all samples, the combination of cell block preparation and cytospins (stained with Diff-Quik and Papanicolaou stains) were considered optimal for microscopic evaluation. IST offers no practical advantage over the NTS standard specimen preparation in relation to the accuracy of final diagnosis or turnaround time. The lysing of grossly bloody fluids with subsequent preparation of cytospins yielded superior preparations for microscopic evaluation over NTS. The standard preparation of effusion samples should include the preparation of a cell block, and cytospins stained with Diff-Quik and Papanicolaou stains, for optimal microscopic evaluation.

Improved FNA cytology results with a near patient diagnosis service for non-breast lesions

AIM

To review fine needle aspiration (FNA) cytology from sites other than the breast a year before and a year after the introduction of a near patient FNA diagnosis (NPFD) service in which the FNA were performed by a pathologist and reported within a few minutes.

METHODS

The setting was a large hospital in rural New Zealand. The year before the introduction of the NPFD service was examined retrospectively, and the year after prospectively. The pattern of use and the quality of the results before and after starting the NPFD service were compared.

RESULTS

Time taken to report the specimens decreased from a few days to a few minutes. There were statistically significant changes in the following: an increase from 237 to 304 in the number of non-breast FNA performed, and in particular an increase from 65 to 113 in the number for general surgery; an increase in the use of immunolabelled flow cytometry from 0 to 19 and cell blocks from 3 to 41; an increase in specificity from 53% to 80%; a decrease in the overall inadequacy rate from 29% to 9%; and a decrease in the inadequacy rate for cancers from 9% to 2%. The cost of the non-breast FNA service increased by about 9200 Pounds a year.

CONCLUSIONS

Starting an NPFD service for sites other than the breast greatly reduced the reporting time and produced statistically significant increases in the use of FNA cytology and in the quality of the results.

Immediate cytodiagnosis and imaging in the clinical management of discrete benign breast lesions

Benign breast disease accounts for the majority of referrals to a specialist breast clinic. Delayed investigation prolongs patient anxiety and increases outpatient waiting lists. Few centres offer the triple test of clinical examination, fine needle aspiration cytology (FNAC) and breast imaging by mammography and/or ultrasonography at initial presentation. We have analysed the practicality of such a service during the 12 months following its introduction in our district general hospital. We studied the cohort of 178 patients who presented with a discrete breast lump which was subsequently shown to be benign. A triple test was performed in 72% of all patients. In 100 patients (56%) this was performed at initial assessment. Of these, 87 had clinically benign disease confirmed by FNAC and breast imaging and they were informed of the results within 3 h. A triple assessment during the initial consultation allows the majority of patients with discrete benign breast disease to be given immediate reassurance.

Impact of fine-needle aspiration cytology, ultrasonography and mammography on open biopsy rate in patients with benign breast disease

The management of breast disease has been influenced by breast imaging and fine-needle aspiration cytology (FNAC) for preoperative diagnosis. To investigate the impact of introducing an in-clinic FNAC service on patient management, the pathology records of patients presenting before and after introduction of the service were studied. Four management changes emerged. The number of patients investigated by histology and/or cytology increased (from 266 to 503), as did specimen numbers (392 to 728). The use of pathological services changed, with more cytology specimens (39 to 554), fewer needle-core biopsies (62 to three) and fewer excision biopsies (245 to 118). The number of patients admitted for surgery fell, especially those with a benign histological diagnosis (174 to 49). These figures demonstrate a change in the management of benign breast disease, from surgery with histopathological diagnosis to cytological diagnosis with surgery only if indicated clinically or from imaging.

Quality assurance in breast cancer screening cytology: a review of the literature and a report on the U.K. national cytology scheme

The National Breast Screening Programme in the United Kingdom has had an external quality assessment (EQA) scheme for breast screening histopathology since 1990. Recently, it was decided, by the Cytology sub-group of the National Co-ordinating Committee for Breast Screening Pathology, to institute two forms of cytology quality assurance. An EQA scheme is planned with circulation of slides to pathologists, but this involves extra time and effort from the participants at a time when general pathology workloads are high. Because of this, a computer routine has been written to analyse the data already present within the National Breast Screening Computer Systems, to enable the calculation of sensitivity and specificity of fine needle aspiration, correlating the cytology results with subsequent histology or follow-up mammography for lesions where no biopsy is performed. This routine uses standardised terminology and calculations and, therefore, inter-unit comparisons can be made. Where problems are identified within a unit, the Quality Assurance team can investigate the cause and institute appropriate measures to correct the problem. This article details the procedures involved in this audit and reviews the literature, recalculating the parameters in a standard manner for a number of publications. The results of the cytology quality assurance routine from seven screening units in one health region in the U.K. are presented and the measures taken to improve the level of service are discussed.

Multiple brushings with immediate Riu's stain via flexible fibreoptic bronchoscopy without fluoroscopic guidance in the diagnosis of peripheral pulmonary tumours

BACKGROUND

Accurate diagnosis of peripheral pulmonary lesions usually relies on fluoroscopic guided procedures. As fluoroscopy is not routinely available in many respiratory units, an approach not using fluoroscopy but with a high diagnostic yield is highly desirable.

METHODS

Immediate cytological examination of multiple brushings using Riu's stain, a modified Wright's stain, was performed in 38 patients with peripheral pulmonary lesions not visible at bronchoscopy. The results were compared with the final diagnoses determined by histological examination or subsequent Papanicolaou staining of cytological specimens and clinical course.

RESULTS

Of the 38 patients 29 were subsequently confirmed to have a malignant tumour. Our method provided a diagnosis of malignancy in 86% of these lesions. The accuracy (91%) and sensitivity (88%) were higher for lesions > 3 cm in diameter than for those of diameter < or = 3 cm (87% and 83%). There were no false positive results. The 29 lesions correctly diagnosed as malignant by Riu's stain required significantly fewer brushings (mean (SD) 3 (2)) than the nine benign lesions (5 (4)).

CONCLUSIONS

This technique provides a high diagnostic yield, avoids the need for fluoroscopy, and is probably safer than percutaneous biopsy.

One-stop diagnosis for symptomatic breast disease

A consultant-led one-stop diagnostic service has been available at a busy symptomatic breast clinic each week at St Bartholomew's Hospital for 18 months. Women can be investigated appropriately using mammography, ultrasonography and cytology with immediate reporting. The aim is to achieve a diagnosis and management plan for each patient at the initial outpatient visit. A prospective audit of four consecutive clinics was undertaken to assess the impact of this service on clinical practice. Fifty patients out of 134 new and 386 follow-up clinic attenders had one-stop investigations. As a result of immediate reporting, 48 (96%) patients had a management decision made at the first outpatient visit, 9 (18%) were offered surgery, and 18 (36%) were discharged with a benign diagnosis and no dominant mass. Four symptomatic cancers were detected and evaluated on a one-stop basis, constituting 8% of the workload of this clinic. The mean wait from designated appointment until surgical consultation was 37.7 min (range -68-171 min) and that for investigation until subsequent clinical review was 56.9 min (range -4-191 min). Thirty-six (72%) one-stop patients had a total wait of less than 2 h and 95% were seen in under 3 h. It is felt that the one-stop clinic allows optimum patient management, minimises anxiety associated with symptomatic breast disease, and maximises utilisation of hospital outpatient resources.

The value of aspiration cytologic examination of the breast. A statistical review of the medical literature

The decision to perform surgery in patients with a breast mass usually is made on the basis of combined diagnostic information, with fine-needle aspiration cytologic examination (FNAC) playing a central role. To determine and compare the quality of FNAC of the breast, a search was performed of the English literature for articles with quantitative information about their results. Twenty-nine such articles, containing 31,340 aspirations, were identified and summarized. Required data were extracted from these articles. These numbers were analyzed with the use of a two-by-four contingency table to relate the FNAC result (definitely malignant, suspect, benign, or unsatisfactory cytologic material) with the final diagnosis (malignant or benign breast disease). Test characteristics such as sensitivity, specificity, and the likelihood ratios for the four different FNAC results were derived for each study and compared. There was a striking difference between studies with regard to the probability of a particular FNAC upshot (e.g., in patients with breast cancer, the chance of obtaining definitely malignant cytologic material ranged from 0.35 to 0.92), the sensitivity (range, 0.65 to 0.98), the specificity (range, 0.34 to 1.0), and likelihood ratios. In the opinion of the authors, it is virtually impossible to infer general test characteristics of FNAC of the breast from the medical literature because of differences in methods and different biases. At best, the maximum attainable performance of this test can be described. For the development of a policy for breast mass management, the local test characteristics of this highly operator-dependent test should be established.

Immediate interpretation of FNA smears from the head and neck region

FNA smears from 540 patients, investigated for visible and/or palpable lesions in the head and neck, examined immediately during consultation have been compared with the final cytologic diagnoses and, when possible, with histologic results. Preliminary and final cytologic diagnoses differed in 25 cases (4.6%). Major discrepancies as to whether a lesion was benign or malignant occurred in 15 cases (2.8%). Histologic follow-up was available for 188 lesions (35%). There were 5 false-positive (2.6%) and 9 false-negative (4.7%) diagnoses, giving a sensitivity of 90.6% and a specificity of 94.6%. The main diagnostic problem was benign, reactive lymphadenitis versus malignant lymphoma, which was responsible for 11 of 14 erroneous cytologic diagnoses (3 false-positive and 8 false-negative smears).

Effects of fine needle aspiration on subsequent mammograms

The effects of fine needle aspiration on subsequent mammography were studied in a group of women who were referred with palpable breast lumps. Fifty-two women aged between 36 and 73 (median 53) years underwent mammography before and within 5 days of needle aspiration. Preaspiration and postaspiration mammograms were examined 'blind' by one radiologist. In ten cases, a difference was seen between the preaspiration and postaspiration films. In seven (aged 36-50 years) this was due to aspirated cysts. In three the differences were unexpected and were more significant, although the radiological diagnosis was not altered. If this proportion is extrapolated for a large number of patients then significant numbers of artifacts from fine needle aspiration might be seen on mammograms. It is possible that some might be interpreted falsely as malignant and some small cancers might be obscured. Women accepted mammography more readily before aspiration than after.

How many tests are required in the diagnosis of palpable breast abnormalities?

Palpable breast nodules in 143 patients attending our primary diagnosis breast clinics were assessed by clinical examination, needle cytology, mammography, ultrasonography and magnetic resonance imaging (MRI). The diagnostic accuracy of all test combinations was compared with the final diagnosis of malignant or benign disease. Two-test combinations increased the sensitivity of diagnosis over that of the individual tests to between 93% and 100% except for MRI/mammography and MRI/cytology. The combinations of three or more tests increased the sensitivity further, but at the expense of an increased false-positive rate. MRI does not appear to have an important role in the primary diagnosis of breast cancer. Mammography is necessary because of the possibility of occult or multifocal disease. Clinical examination was associated with a high false-positive rate. The combination of cytology and ultrasound was best at correctly diagnosing malignancy, but in this series only 42% of patients underwent ultrasound examination. The role of breast ultrasound together with needle aspiration cytology for the diagnosis of malignancy in palpable breast nodules deserves further evaluation.

Sample size in fine needle aspiration biopsy

The weights of biopsy specimens from bovine liver taken for fine needle aspiration cytology (FNAC) by three groups of physicians, were compared. The groups differed from each other in their extent or degree of experience in FNAC. When the physicians used their normal technique, the mean sample weight increased significantly with experience, from 4.6 mg in the least experienced group to 17.2 mg in the group with the longest experience. Thirty-six per cent of the samples taken by the group with the least experience were in the weight class 0-2 mg, whereas no such samples were encountered for the other groups. When all the physicians were advised to use the same, standard technique there were no statistically significant differences in mean sample weight between the groups or in the proportion of samples in class 0-2 mg. Sample weights correlated significantly (P less than 0.001) with cell counts. This study shows that differences in the technique of FNAC are responsible for differences in sample weights and cell counts, including the number of the acellular samples obtained. This could explain in some part the wide variation in the reported accuracy rates of FNAC.

Rapid reporting on fine needle aspiration of breast lumps in outpatients

A retrospective analysis of the performance and value of fine needle aspiration of symptomatic breast masses in a special outpatient "breast clinic" within a district general hospital was carried out. All but a few aspirations were performed by a group of histopathologists, with, immediate cytological reporting. Fine needle aspiration was more sensitive for detecting malignancy than clinical assessment alone, the sensitivity increasing with the experience of the aspirator. The results compared favourably with those in reported series from specialist centres in the United Kingdom. The value of fine needle aspiration extends to the overall management of patients with breast masses but the results must be assessed in conjunction with the clinical context in view of the possibility of false negative or, more rarely, false positive cytological diagnoses.

Extended role for needle biopsy in the management of carcinoma of the breast

Treatment choice in primary breast cancer is wide and still controversial; it seems likely that the optimum treatment for individual patients could be dictated by biological indicators of tumour behaviour. If biopsy could provide prognostic information as well as detailed tissue diagnosis then definitive treatment, with or without adjuvant systemic therapy, could be planned from the outset. We studied 140 patients with a clinical diagnosis of primary breast cancer to determine how much information could be obtained from Tru-Cut needle biopsies performed at the first clinic visit. Ten patients were found to have benign disease. Of 130 carcinomas, 123 (95 per cent sensitivity) were diagnosed correctly from the needle biopsies, with seven false negative and no false positive results (100 per cent specificity). Precise histopathology was predicted in 121 (93 per cent). Grade was correctly assessed in 77 of 112 (69 per cent), but needle biopsy was not accurate for assessment of lymphatic invasion nor elastosis. Steroid hormone receptors were assayed in 59 needle biopsies, and the incidence of oestrogen receptor positivity (34, 58 per cent) was similar to the resected tumours (35, 59 per cent), but the incidence of progesterone receptor positivity (26, 44 per cent) was lower (33, 56 per cent, P less than 0.04). Immunostaining with monoclonal antibody human milk fat globule membrane was accurate in the needle biopsies. DNA analysis by flow cytometry was performed in 37 tumours and the concordance between needle biopsies and resected samples was high. Tru-Cut needle biopsy obviates open biopsy and gives reliable detailed information.

Cytodiagnosis and other methods of biopsy in the modern management of breast cancer

Since 1970 fine-needle aspiration cytology for breast tumours has grown in popularity and is now routinely used in the initial diagnosis of palpable breast masses in the United States and other parts of the world. Fast staining methods of the aspirate enables reporting within 10 minutes of the aspirate being performed. Training and experience is important in obtaining satisfactory smears for diagnosis, and pitfalls are false-negative and false-positive findings, which may have dire consequences for the patient if cytological diagnosis is the final arbiter. Conditions such as benign mammary dysplasia and sclerosing adenosis are the most common sources of highly cellular smears and often show marked atypia, which makes distinction from carcinoma difficult. Also, atypical papillary formations present a diagnostic problem, and biopsy is indicated to exclude a papillary carcinoma. Fine-needle aspirations very seldom cause traumatic complications, and these are usually of a minor degree. Seeding along the needle track has occurred, but in most cases with a larger-caliber (18 s.e.g.) needle. Aspiration itself has been shown to have no effect on the survival rates in breast carcinoma. Contemporary reports show that around 90% of cases of breast cancer can be detected with confidence by means of this procedure. The reduction in scar formation facilitates future evaluation of the patient as scar tissue often interferes with the interpretation of mammograms. Cost effectiveness is evident in terms of decreased use of anaesthetics and operating time and a reduction in the use of frozen section histology by about 80%.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of fine needle aspiration cytology with immediate reporting in the diagnosis of breast disease

Fine needle aspiration biopsy for cytological examination (FNAC) is becoming increasingly accepted as a means of tissue diagnosis in breast disease. This study examines the feasibility and accuracy of FNAC in 'immediate reporting' by a consultant cytopathologist in a busy breast clinic. Over a 2-year period, 884 cytology reports were analysed. An initial clinical report and subsequent final cytological diagnosis was made. Fine needle aspiration provided adequate material for cytological evaluation in 635 of the 884 biopsies (71.6 per cent) and this proportion was greater when discrete lumps were considered (463 of 562 biopsies = 82.4 per cent). In diffuse and cystic disease, however, the adequacy of specimens was reduced: 50 per cent and 65 per cent respectively. On immediate reporting the diagnostic sensitivity for all patients was 88 per cent (discrete lumps only, 92.5 per cent) and the specificity was 99.8 per cent (discrete lumps only, 100 per cent). FNAC retains its diagnostic accuracy when immediate reporting is employed and this study demonstrates that this technique can be used in making a diagnosis in patients with breast disease.

Aspiration cytology in the management of breast lesions

In a group of patients with breast lumps, diagnosis made by pre-operative aspiration cytology was compared with that obtained by histological section of excised specimens. Results showed that aspiration cytology correctly diagnosed 89% of malignant lesions and 92.6% of benign lesions based upon histological diagnosis. Cytological diagnosis of benign disease had a false negative rate of 6% while cytological diagnosis of malignant disease had a 2.7% false positive rate. Only 3.5% of cytologies returned an inadequate diagnosis. This study shows that aspiration cytology should be useful in allowing a better psychological preparation of patients before surgery as well as better utilization of operation theatre facilities.

Ultrasound mammography in the management of breast cancer

In this centre, ultrasound mammography has been shown to be more accurate in elucidating the nature of palpable breast lesions than X-ray mammography. A prospective study was devised to determine whether this accuracy could be translated into improved management of patients with breast carcinoma. A total of 223 patients with palpable breast masses were assessed by clinical examination, imaging (X-ray and ultrasound mammography) and aspiration cytology. Each was scored on a five-point scale and treatment was planned according to the total score. According to the protocol, an adequate total score would permit definitive surgery avoiding frozen section. By using sonography rather than radiology, the number of correct diagnoses could be improved by 25 per cent. This was because the greater sensitivity of ultrasound (92.8 per cent) compared to X-ray mammography (82.5 per cent) was reflected in a higher total score, which was sufficient to allow definitive surgical treatment without prior histological confirmation of diagnosis.

Fine needle aspiration cytology, with immediate reporting, in the outpatient diagnosis of breast disease

One hundred and fifty one new patients attending a breast clinic over a 6 month period underwent fine needle aspiration cytology (FNAC), with immediate reporting of the smears in the clinic. Thirty nine smears (25.8%) were classified as unequivocally malignant, 10 (6.6%) as being suspicious of malignancy, 61 (40.3%) as benign and 41 (27.1%) were acellular. There were no false positive diagnoses and only one false negative cytological diagnosis of breast cancer [corrected]. Immediate reporting of results enabled the diagnosis to be discussed with the patient at the first attendance and allowed improved surgical management of both benign as well as malignant breast disease.

Reduction of the surgical excision rate in benign breast disease using fine needle aspiration cytology with immediate reporting

Patients attending a breast clinic in two different periods were studied. In the first period fine needle aspiration cytology (FNAC) was not available and in the second it was used on all discrete solid breast lumps and reported immediately in the clinic. With the use of FNAC the overall surgical excision rate for discrete solid lumps was reduced from 83 per cent to 41 per cent and the excision rate in patients with benign disease was reduced from 74 per cent to 23 per cent (P less than 0.001). All patients with breast cancer in the second period had malignant cytology and no patient with benign or acellular cytology has been shown, after a minimum follow-up period of 18 months, to have breast cancer. Using FNAC with immediate reporting, the number of operations performed in patients with benign breast disease can be safely reduced.

Fine needle aspiration cytology of breast masses: an evaluation of its accuracy and reasons for diagnostic failure

A study of 1458 patients who had undergone breast aspiration cytology was conducted to determine the diagnostic accuracy of the technique. The effect of tumour histology and size on the unsatisfactory aspirate and false negative rate was examined. Seven hundred and thirty one patients (50%) had histological diagnoses. The sensitivity of aspiration cytology for malignancy was 64% for the first aspiration, but was 91% in patients who had had 3 aspirates. The specificity was 56%, this low figure was almost entirely due to inadequate or unsatisfactory cytological preparations. The positive and negative predictive values of aspiration cytology were 99.4% and 85% respectively demonstrating high diagnostic accuracy given a satisfactory aspirate. Invasive lobular carcinoma yielded a significantly higher unsatisfactory rate than invasive ductal carcinoma (P less than 0.001) and fibroadenoma yielded a significantly lower unsatisfactory rate than fibroadenosis (P less than 0.001). Mass size influenced the unsatisfactory rate for invasive ductal carcinoma (P less than 0.05) and fibroadenoma, but not for invasive lobular carcinoma or fibroadenosis. Only 2 of the 32 false negatives were due to misinterpretation, the remainder resulted from the aspiration needle missing the mass. We conclude that aspiration cytology is an accurate preoperative diagnostic procedure for the evaluation of breast masses. Unsatisfactory or negative aspirates should be regarded as 'non-results' if there is clinical or radiological suspicion of malignancy.

Fine-needle aspiration of the breast

One of the numerous controversial issues related to the clinical management of breast cancer is the role of fine-needle aspiration (FNA). Despite its enthusiastic use in the diagnosis of thyroid nodules, its application to breast abnormalities has been accepted reluctantly. Breast FNA necessitates technical and interpretative skill and continual practice and is not 100% accurate. It also entails an additional, although moderate, expense. To assess the accuracy and determine the possible role of FNA at our institution, we performed both FNA and excisional biopsy in 100 unselected women with palpable breast nodules and correlated the cytologic and histologic findings. Our results were similar to those in previously published studies. FNA had a false-negative rate of 6%, no false-positive results, and an accuracy of 94%. After reviewing the potential assets and liabilities of this technique, we believe that breast FNA may add a measure of confidence in the diagnosis of benign breast lesions, provides a safeguard for preventing misdiagnosis of malignant lesions, and might expedite and reduce the cost of managing both primary and recurrent breast cancer.

Improved understanding of mammary cancer

Interest in cancer of the breast has begun to yield a concentrated sequence of specific information as to its basic nature, dietary influences, and its hormonal and genetic determinants. Clearly, the advent of improved early diagnosis has allowed the presentation to the clinician of a more favorable aspect of the tumor than has previously been seen, and has altered the overall clinical character of the disease. These advances open the possibilities of greatly expanded and enhanced treatment options, both for the informed physician and the inquiring patient. The rewards of early diagnosis include the possibilities of functional reconstruction, which may alter the potential patient attitude to such an extent that even earlier diagnosis will be achieved in years ahead. The complex issues of multimodality therapy and the honest and valid stratification of patients are the key issues in the further study of this challenging illness.

Out-patient diagnosis of breast cancer

A method of diagnosis of the solid discrete breast lump using frozen section examination of a Tru-cut needle biopsy is described. In 194 patients, the Tru-cut biopsy report is compared to the histological report of the excised lesion. Overall accuracy is 90 per cent, sensitivity 89 per cent, specificity 96 per cent, predictive value of a positive report 99 per cent, and predictive value of a negative report 56 per cent. The advantage of the technique is that many patients with breast cancer can be informed of the diagnosis at their first attendance.

Accuracy of aspiration cytology in the diagnosis of breast disease

The accuracy of fine needle aspiration cytology has been assessed in 480 consecutive breast lesions where definitive histology was later available. The results in terms of specificity and sensitivity have also been compared to mammography and clinical examination. With adequate smears aspiration cytology was 100 per cent specific with no false positive diagnosis. This compares with 15 false positive mammograms and 12 false positive diagnoses on clinical examination. Cytology was unsatisfactory in 36 per cent of benign lesions owing to poor cellularity of the sample but when considered with mammography and examination led to a reduction in biopsies for benign disease. A definitive cytological diagnosis of malignant tumours resulted in a reduction in frozen sections with a substantial saving of resources and improvement in patient counselling. No mastectomy was performed for benign disease.

Diagnosis of breast lesions by aspiration biopsy cytology

From November 1981 to the end of August 1984, 456 patients with breast lesions underwent aspiration biopsy cytology (A.B.C.). This study includes 109 for whom the diagnosis was histologically confirmed at surgical biopsy. Seventy-five lesions were histologically proven to be malignant and 34 were benign. The accuracy of diagnoses with A.B.C. was; true positive 86.7 per cent (65/75) of the time, true negative 82.6 per cent (28/34) of the time, false negative 5.3 per cent (4/75) of the time and false positive 5.7 per cent (2/34) of the time. Unsatisfactory or inadequate aspirated tissue made A.B.C. diagnosis difficult in 5.5 per cent (6/109) of the cases. Three out of 7 with malignant tumors, who were wrongly diagnosed as benign by A.B.C., had tumors with a diameter of 1.0 cm or less. Two benign cases which were falsely diagnosed as malignant also had small tumors about 1.0 cm in diameter. Although A.B.C. is more reliable than other conventional supplementary diagnostic techniques (mammography, ultrasonography, etc.), it is important to carefully follow clinically questionable cases which appear negative, using A.B.C..

Fine needle aspiration cytology

Fine needle aspiration cytology is an inexpensive, atraumatic technique for the diagnosis of disease sites. This paper describes the technique and illustrates how it may be applied to the management of tumours throughout the body. The limitations of the method, the dangers of false positive reports, and the inevitability of false negative diagnoses are emphasised. In a clinical context the method has much to offer by saving patients from inappropriate operations and investigations and allowing surgeons to plan quickly and more rationally. It is an economically valuable technique and deserves greater recognition.

Fine needle aspiration cytology, in relationships to clinical examination and mammography in the diagnosis of a solid breast mass

The accuracy of clinical examination, mammography and fine needle aspiration cytology in identifying malignancy has been assessed in 1655 breast masses from two time periods. Clinical examination and mammography remained consistent at identifying malignancy but 9 per cent of all breast carcinomas were considered benign by both techniques (sensitivity 91 per cent). Fine needle aspiration cytology, when performed by multiple aspirators in the first study period, had a sensitivity of only 66 per cent for malignancy. During the second period of study, when all aspirates were performed by a single aspirator, sensitivity rose to 99 per cent. The two patients with false negative cytology in this latter period had both clinical and mammographic evidence of malignancy. No patient with malignant cytology was subsequently shown to have benign disease. It is concluded that a combination of clinical examination and mammography, with fine needle aspiration cytology performed by committed individuals with aptitude for the technique and interpreted by experienced pathologists, can identify all patients with breast cancer before surgery.

Assessment of a scoring scheme for the preoperative diagnosis of breast lumps

The value and accuracy of a scoring system applied to clinical examination, aspiration cytology and mammography has been assessed in the diagnosis of 224 consecutive 'new' patients attending a breast clinic with a breast lump. In 72 of 99 patients with breast cancer (80%) the scores were high enough to allow definitive surgery without formal histology; all were subsequently confirmed as breast carcinomas. Cytology proved the most accurate investigation with no false positives and a correct diagnosis in 146 of 148 adequate specimens (98.6%). This system reduced the frozen section rate by 74% and allowed for a more appropriate counselling of patients prior to mastectomy.

Outpatient breast biopsies on a gynecologic service

One hundred forty-six breast biopsies in 143 patients were done on outpatient basis, without general anesthesia, on a gynecologic service between 1975 and 1980. This procedure has advantages over in-hospital biopsy in terms of cost, time, reduced immediate risk, and patient acceptance. Greater long-term risk, if carcinoma is found, has not been substantiated. Gynecologists need this procedure as an adjunct to the management of benign breast conditions and should be trained to do it.

Aspiration cytology in the preoperative management of breast cancer

The value and accuracy of aspiration cytology was assessed in the management of 444 patients presenting with a solid breast lump. The first 233 patients were assessed cytologically and frozen-section histology was performed when indicated. In this group a correct positive cytological diagnosis was made in 80% of cases. There were no false positive results. The next 211 patients were assessed cytologically and, when a firm diagnosis of malignancy was made, definitive treatment was carried out without frozen-section histology. In this group cytology was 90.6% reliable in diagnosing malignancy. No mastectomies were performed for benign disease. The use of frozen-section histology has been reduced by about 80%.

The presentation and progress of macroscopic breast cysts

A total of 322 cases of macroscopic breast cysts presenting at a district general hospital has been studied with a minimum follow-up period of 5 years. In almost half the patients (44.18 per cent) a further cyst occurred following aspiration, and in two-thirds of these, more than one subsequent cyst developed. There was a 50-year age span from the youngest to the oldest patient at presentation: however, the majority of cysts (61.80 per cent) occurred in the perimenopausal age group (40-50 years). The subsequent incidence of carcinoma was more than twice that which would be expected in the population at large, but no case of carcinoma that was not suspected clinically was revealed by cytology.

Intraoperative fine needle aspiration biopsy of thoracic lesions

Forty-one intraoperative fine needle aspiration biopsies were performed on 35 patients during exploratory thoracotomy (33 patients) or mediastinoscopy (2 patients). Each biopsy was done with a 22 gauge needle. Smears were prepared at the operating table, air-dried, sent directly to the laboratory, stained, and interpreted immediately by the pathologist. Preparation and reporting time averaged ten minutes. Surgical decisions were made on the basis of the pathologist's reports. Intraoperative fine needle aspiration biopsy was 100% accurate in differentiating inflammatory from neoplastic lesions. Ninety-five percent diagnostic accuracy for malignancy (39 out of 41 specimens) was obtained. It permitted quick biopsy of lesions deep within the lung parenchyma without the need to cut across uninvolved tissue, thus permitting appropriate resection in each patient. There were no deaths related to the procedure.