Fine needle aspiration cytology of the breast. Experience at an outpatient breast clinic

The Role of Fine Needle Aspiration Cytology in Triple Assessment of Patients with Malignant Breast Lumps

Background:

Breast cancer is the leading female malignancy in the world and now the most common cancer in Nigeria. The evaluation of patients with breast cancer requires stepwise diagnostic approach to achieve a combined diagnostic information required to make an enhanced decision on how best to approach management. The aim of this study is to evaluate the role of fine needle aspiration cytology (FNAC) in the triple assessment of patients with malignant breast lumps in our center.

Patients and Methods:

This is a descriptive prospective study of patients with palpable breast lumps over an eighteen-month period. The patients were sequentially subjected to FNAC and open biopsy. Those whose lumps were malignant were further evaluated.

Results:

There were 88 (44.9%) and 108 (55.1%) biopsy confirmed breast cancers and benign lumps, respectively. From cytology reports, there were 12 (6.1%) unsatisfactory (C1), 96 (49%) benign (C2), 8 (4.1%) atypical (C3), 10 (5.1%) suspicious of malignancy and 70 (35.7%) unequivocally malignant (C5) smears. FNAC performed better than clinical examination in the validity tests for breast malignancy. The diagnostic results for breast malignancies were 97.2% (sensitivity), 98.9% (specificity), 1.4% (false positive rate []), 2.1% (false negative rate), 98.6% (positive predictive value), 97.9% (negative predictive value), and overall diagnostic accuracy of 98.2%.

Conclusion:

Considering the high performance of diagnostic cytology noted above, FNAC has proved itself to be useful and significantly accurate in making diagnosis of breast cancers in our center.

Fine needle aspiration cytology of atypical (C3) and suspicious (C4) categories in the breast and its histopathologic correlation

BACKGROUND

In 1996, National Cancer Institute (NCI) proposed five categories for the diagnosis of breast cytology in order to bring a degree of uniformity to the diagnostic reporting. Of these, categories 3 and 4 were sparsely studied.

AIMS

The present study was undertaken for the evaluation of the fine needle aspiration cytology (FNAC) categories of C3 and C4 in the breast lump and its histopathological correlation.

MATERIALS AND METHODS

In the retrospective study, a total number of 728 FNACs were categorized according to the NCI; of these, 28 cases of category C3 and 65 cases of category C4 were compared with histopathological diagnoses.

RESULTS

On histopathological examination of category C3, 18 (64.3%) cases showed benign lesions and 10 (35.7%) cases showed malignancy and among the C4 category, benign lesions found in nine (13.8%) and malignancy found in 56 (86.2%) cases. There was a significant statistical difference between the number of benign and malignant diagnoses for cytological categories of C3 (64.3%) and C4 (86.2%) (P < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of C4 category in the diagnoses of malignancy were 84.8%, 66.7%, 86.2%, and 64.3%, respectively.

CONCLUSION

FNAC of the breasts is a simple, cost-effective, accurate, quick, and relatively less painful procedure, and it continues to play an integral part in the management of breast lesions. Our study concluded that there was a statistically significant difference between the number of benign and malignant diagnoses for categories of C3 and C4.

Role of triple test score in the evaluation of palpable breast lump

INTRODUCTION

Fine-needle aspiration cytology (FNAC) method is safe, reliable and time saving outdoor procedure with little discomfort to the patient for detecting Carcinoma breast. The efficacy can further be enhanced when physical breast examination, mammography and FNAC (the triple test [TT]) are jointly taken into consideration.

AIMS AND OBJECTIVES

The aim was to evaluate the role of TT score (TTS) in palpable breast masses.

MATERIALS AND METHODS

This prospective study was carried out from May 2010 to April 2012. In the subjects referred to the Department of Pathology for FNAC of the breast mass, the TTS was calculated, and histopathological findings were noted.

RESULTS

In the study period TTS score was calculated in 200 cases out of 225 FNAC's of breast. Of 124 benign cases on cytology, only three showed discordant TTS. Out of 62 malignant cases, 61 showed concordant TTS and one case of mastitis on histopathology showed TTS of five. Out of all the benign lesions, two cases of fibrocystic disease and a single case of phylloides tumor gave a TTS ≥6. These cases were diagnosed as infiltrating ductal carcinoma and angiosarcoma respectively on histopathology. Histopathological correlation was possible in only 70 patients. Of these 70, 28 were from the benign category and 42 were from the malignant category. TTS of ≥6 has a sensitivity of 97.44%, specificity of 100%. FNAC has a sensitivity of 88.37%, specificity of 96.42%.

CONCLUSIONS

TT reliably guides evaluation of palpable breast masses. Histological correlation indicated TTS to be better diagnostic tool than FNAC alone.

Cytological study of palpable breast lumps presenting in an Indian rural setup

INTRODUCTION

Benign as well as malignant breast lesions are quite common in Indian population. It is the second most common cancer site after cancer cervix. Fine-needle aspiration cytology (FNAC) is safe, reliable, and time saving outdoor procedure with little discomfort to the patient. FNAC is useful in diagnosis and further planning of treatment without need for biopsy. The current study was carried out with aims of studying the frequency of various breast lesions on FNAC in a rural area in India and its histopathological correlation.

MATERIALS AND METHODS

This was 2 years prospective study carried out from May 2010 to April 2012. Physical examination of breast mass by palpation was done. Smears were stained with May-Grunwald Giemsa and Papanicolaou stain.

RESULTS

Of the 225 cases, 131 were in the benign category and 65 belonged to the malignant category, while the cytology study of 13 cases was unsatisfactory. Seventy-six cases were available for histological correlation. Of 29 cytological benign cases, 26 were confirmed as benign, but 3 turned out to be malignant. Out of 36 cytological malignant cases, 35 were confirmed as malignant. FNAC was 88.37% sensitive and 96.42% specific in diagnosing malignant lesions.

CONCLUSION

Fine-needle aspiration cytology is a rapid and effective method for the primary categorization of palpable breast lumps into benign, malignant, atypical, suspicious, and unsatisfactory categories. Benign breast lesions are common than malignant lesions. Histological correlation indicated FNAC to be a good diagnostic tool.

Histopathological correlation of atypical (c3) and suspicious (c4) categories in fine needle aspiration cytology of the breast

Introduction. According to the National Cancer Institute (NCI) guidelines in 1996, breast lesions are categorized as C1 to C5 on fine needle aspiration (FNA) cytology. Very few studies are available in the English literature analyzing histopathology outcome of C3 (atypical, probably benign) and C4 (suspicious, probably malignant) lesions. Our study aims to correlate FNA cytology of breast lump diagnosed as C3 and C4 lesion with histopathological examination. Methods. During a period of 2 years, 59 cases of C3 and 26 cases of C4 were retrieved from total 1093 cases of breast FNA. All the cases were reviewed by two cytopathologists independently. The final 24 cases of C3 and 16 cases of C4 categories were correlated with histopathological diagnosis. Result. Among C3 category, 37.5% revealed malignant findings, whereas of C4 category, 87.5% were malignant on histopathology. This difference was statistically significant (P = 0.0017). Sensitivity, specificity, positive predictive values, and negative predictive value of C4 category in diagnosing breast malignancy were 60.8%, 88.2%, 87.5%, and 62.5%, respectively. Conclusion. Although FNAC is simple, safe, cost-effective and accurate method for diagnosis of breast masses, one must be aware of its limitations particularly in C3 and C4 categories. Also, since both these categories carry different probabilities of malignancy and thus different management, we therefore, support maintaining C3 and C4 categories.

Quality Appraisal of Diagnostic Accuracy Studies in Fine-Needle Aspiration Cytology: A Survey of Risk of Bias and Comparability

Context.—The quality of diagnostic accuracy studies is determined by 2 key factors: risk of bias and comparability. Bias can distort accuracy estimates and poor reporting impairs comparability. While diagnostic accuracy studies for fine-needle aspiration cytology (FNAC) are frequently published, the methodologic issues associated with this body of literature have never been reviewed.

Objective.—To assess the quality of design and reporting of diagnostic test accuracy studies in FNAC.

Data Sources.—Diagnostic accuracy studies were identified by a Medline (US National Library of Medicine) search. Sixty-four FNAC diagnostic test accuracy studies were randomly selected for structured review with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) survey. Studies were divided between 2 time periods: 2000-2001 and 2009-2011.

Conclusions.—Diagnostic test accuracy studies of FNAC suffer from numerous deficiencies in study design, which negatively affect the reliability of accuracy estimates.

Fine-needle aspiration of gray zone lesions of the breast: fibroadenoma versus ductal carcinoma

While breast lesions have characteristic cytological features, some lesions, particularly adenocarcinoma and fibroadenoma, may present with overlapping features causing erroneous diagnoses. The current study aimed to define significant cytomorphologic features predictive of fibroadenoma and adenocarcinoma, respectively. Further, we intended to evaluate the predictive characteristics for differentiation between gray zone lesions and to identify root causes contributing to misdiagnoses. First, direct smears prepared from 14 histology-confirmed fibroadenomas and 14 adenocarcinomas were reviewed and characteristics of commonly encountered morphologic features were assessed. We then retrospectively and blindly reviewed nine cytohistologic discrepant cases using the significant characteristic as a guideline, in order to assess whether these discrepant cases could be correctly categorized. Morphologic characteristics predictive of fibroadenoma included moderate cellularity, large, folded cellular sheets/aggregates, staghorn projections, smooth and round borders, monolayers, honeycomb arrangement, smaller nuclear size, and background bipolar cells. Predictive characteristics of adenocarcinoma included high cellularity, loose cohesive sheets/aggregates, pointed projections, irregular borders, larger nuclear size, irregular nuclear membrane, prominent nucleoli, and single atypical epithelial cells. Retrospective, blind review correctly re-classified seven out of nine cytohistologic discrepant cases, including five false negative cases and two false positive cases. Root causes contributing to the misdiagnoses were large branching sheets of carcinoma mimicking folded sheets of fibroadenoma; fibroblasts mimicking myoepithelial cells; apocrine cells mimicking carcinoma cells; and not recognizing the loose myxoid matrix presenting as soap bubbles in fibroadenoma. In conclusion, this study identified significant characteristics that can assist in achieving accurate diagnosis in a subpopulation of breast aspirates that present with overlapping features.

Fine needle aspiration cytology in young women with breast cancer: diagnostic difficulties

BACKGROUND

Breast carcinoma is the most common malignancy in women worldwide. Though fine needle aspiration cytology (FNAC) plays an important role in preoperative diagnosis, there may be diagnostic delays in affected young women due to a lower index of suspicion.

METHODS

The files of the Departments of Pathology, Singapore General Hospital, Singapore, and Prince of Wales Hospital, Hong Kong, were searched for cases of breast carcinoma in women aged 35 years or less. Those with prior FNA procedures comprised our study group. The FNA smears were reviewed and classified into five categories: inadequate, benign, equivocal, suspicious, malignant. The findings were correlated with subsequent histology.

RESULTS

Thirty-four women aged 35 years and below underwent 35 FNACs, with one woman having bilateral FNA procedures. Upon review, one (2.9%) was classified as inadequate, one (2.9%) benign, five (14.3%) equivocal, five (14.3%) suspicious, 21 (60%) malignant and slides were not available for review for two (5.6%) cases. For six benign and equivocal cytological diagnoses, subsequent histology disclosed pure ductal carcinoma in situ (DCIS, 1 case), mucocoele-like lesions with DCIS (2 cases), invasive and in situ ductal carcinoma with neuroendocrine features (1 case) and two cases of invasive ductal carcinoma.

CONCLUSION

Diagnostic difficulties in cytological interpretation of aspirates from breast carcinoma in young women may lead to unwanted delays, which occurred in six (17.6%) of 34 women in our series. Low grade cancers posing a pitfall in cytological diagnosis have to be considered.

Cell blocks of breast FNAs frequently allow diagnosis of invasion or histological classification of proliferative changes

Two major limitations of breast fine needle aspiration (FNA) compared with core needle biopsies (CNB) are the inability to determine whether a cancer is invasive and to classify proliferative lesions. We studied 40 consecutive "rapid cell blocks" from breast FNAs with surgical pathology follow-up to test whether cell blocks can overcome these limitations. Of 25 carcinomas, invasion could be identified in the cell block sections in 11 (44%). One cystosarcoma phyllodes was suspected based on the cell block sections. Cell blocks from 12 of 14 benign breast FNAs showed sufficient cells to assign a histologic diagnosis of no hyperplasia (1 case, confirmed on follow-up) and usual hyperplasia (11 cases; confirmed in eight of 11 on follow-up). Specific histologic diagnoses included intraductal papilloma (2 cases), and in situ lobular neoplasia (2 cases). Cell blocks complement smears and monolayers and appear to overcome major limitations of breast FNA.

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.

Diagnosis and subclassification of breast carcinoma by fine-needle aspiration biopsy: results of the interlaboratory comparison program in non-gynecologic cytopathology

CONTEXT

The College of American Pathologists Interlaboratory Comparison Program in Non-Gynecologic Cytopathology is a popular educational program for nongynecologic cytology that had 1018 participating laboratories by the end of 2000. Data generated from this program allow for tracking performance on slides in a diverse group of laboratories.

OBJECTIVE

We reviewed the performance of participating laboratories on fine-needle aspiration biopsies of the breast with particular interest in the ability of participants to accurately subclassify breast carcinoma.

DESIGN

We reviewed the responses of participating laboratories for glass slides of breast fine-needle aspiration biopsies for the year 2000. We analyzed benchmarking data provided for each specific diagnosis.

RESULTS

The overall false-negative rate for laboratories was 6.2%, and the overall false-positive rate was 1.1%. Most of the breast carcinomas were correctly identified as malignant on the general diagnosis, but participants had more difficulty subclassifying types of breast carcinoma. The rate of correct exact diagnosis was 65% for ductal adenocarcinoma, 20% for lobular adenocarcinoma, 12% for medullary carcinoma, and 27% for mucinous carcinoma.

CONCLUSIONS

This study shows that fine-needle aspiration biopsy of the breast is a reliable method for the diagnosis of breast carcinoma, but difficulties still exist in our ability to determine tumor subtype.

Diagnosis of non-palpable breast cancer: a review

The literature on several methods of diagnosing non-palpable breast carcinoma has been reviewed. Skin projection and dye are methods not frequently used. Several aspects of FNA biopsy/cytology, ultrasound-directed methods, frozen section and MRI localization procedures are highlighted and comparisons are made. Much attention is being payed to needle localization breast biopsy and stereotactic core needle breast biopsy. The management of patients with mammographic abnormalities is shifting from needle localization to breast biopsy stereotactic core needle biopsy. Items of comparison between the two mentioned methods are accuracy, indications, complications and costs. The role of the ABBI system in the management of breast cancer has not yet been defined. A cooperative effort between the mammographer, surgeon and pathologist is critical to a successful image-guided breast biopsy programme.

Ultrasound-guided core needle biopsy as an initial diagnostic test for palpable breast masses

PURPOSE

To determine the role of ultrasound (US)-guided core needle biopsy as an initial diagnostic test for palpable breast masses.

MATERIALS AND METHODS

Ninety-eight consecutive patients, each with a palpable breast mass, were referred for US-guided core biopsy by a multidisciplinary team of physicians who specialize in the care of breast diseases. All palpable breast masses were clearly visible on high-resolution US. Ninety-nine core needle biopsies were performed under local anesthesia with use of freehand technique, mostly in an outpatient setting. Core needle path through each mass was documented in two orthogonal sections. A mean of 3.4 tissue core samples (range, 1-7) were obtained in each patient.

RESULTS

Core needle biopsy resulted in the diagnosis of 66 malignancies, two cases of atypical ductal hyperplasia (ADH), and 30 benign diseases of the breast. Surgery with curative intent was performed in 63 breast malignancies and excisional biopsies were performed for 10 benign diseases (two cases of ADH and eight benign lesions). Twenty-five breast masses were managed nonoperatively: chemotherapy was performed in three locally advanced breast cancers and 3-year follow-up was conducted for 22 benign lesions. Malignancies were correctly diagnosed in all cases. No malignancy was discovered at surgery or during clinical follow-up of ADH and no benign breast lesions were diagnosed by core needle biopsy. US-guided core needle biopsy is 100% sensitive and specific for palpable breast malignancies, with no false-positive results. A puncture site ecchymosis was the only morbidity or complication noted.

CONCLUSION

US-guided core needle biopsy is a safe and accurate first diagnostic test for palpable breast masses that require tissue proof.

Fine-Needle Aspiration Biopsy of Nonpalpable Breast Lesions in a Multicenter Clinical Trial: Results from the Radiologic Diagnostic Oncology Group V

PURPOSE

To determine the diagnostic accuracy of ultrasonographically (US) and stereotactically guided fine-needle aspiration biopsy (FNAB) in the diagnosis of nonpalpable breast lesions.

MATERIALS AND METHODS

At 18 institutions, 442 women who underwent 22-25-gauge imaging-guided FNAB were enrolled. Definitive surgical, core-needle biopsy, and/or follow-up information was available for 423 (95.7%) of these women. The reference standard was established from additional clinical and imaging information for an additional six (1.4%) women who did not undergo further histopathologic evaluation. The FNAB protocol was standardized at all institutions, and all specimens were reread by one of two expert cytopathologists.

RESULTS

When insufficient samples were included in the analysis and classified as positive, the sensitivity and specificity of FNAB were 85%-88% and 55.6%-90.5%, respectively; accuracy ranged from 62.2% to 89.2%. The diagnostic accuracy of FNAB was significantly better for detection of masses than for detection of calcifications (67.3% vs. 53.8%, P =.006) and with US guidance than with stereotactic guidance (77.2% vs. 58.9%; P =.002).

CONCLUSION

FNAB of nonpalpable breast lesions has limited value given the high insufficient sample rate and greater diagnostic accuracy of other interventions, including core-needle biopsy and needle-localized open surgical biopsy.