Fine-needle aspiration and core biopsy in the diagnosis of breast lesions: A comparison and review of the literature

Immunoglobulin G4-related sclerosing mastitis: an unexpected diagnosis for a breast mass

Immunoglobulin G4-related disease is an immune-mediated condition comprised of a number of various disorders sharing unique pathologic, serologic, and clinical features. Diagnosis of immunoglobulin G4-related sclerosing mastitis is challenging as the clinical and imaging findings mimic breast malignancies or other types of inflammatory mastitis. Herein, we describe a case of a female patient with a painless palpable mass in her right breast. An excisional core biopsy led to the rare diagnosis of immunoglobulin G4-related sclerosing mastitis, and the patient received steroid treatment for a month. To date, the patient has remained disease-free without any recurrence. As immunoglobulin G4-related sclerosing mastitis is a very rare disease, further studies are needed to reach conclusions about the pathogenesis, diagnosis, and treatment of this entity.

Exploring the Spectrum of Lymphadenopathy: Insights From a Three-Year Fine Needle Aspiration Cytology Study in a Tertiary Care Center

Introduction Lymphadenopathy, characterized by the enlargement of lymph nodes, is a common concern encountered by physicians in outpatient settings. It is deemed significant and warrants evaluation due to the diverse range of potential causes, ranging from treatable infections to incurable metastatic malignancies. Fine needle aspiration cytology (FNAC) emerges as a crucial tool in addressing these concerns, acknowledged for its rapid diagnostic capabilities, simplicity, accuracy, and minimal invasiveness. Objectives This retrospective study aims to characterize the spectrum of lymphadenopathy cases observed in a tertiary care center over a specified period, shedding light on the prevalence, etiology, and clinical outcomes associated with this condition. Methods Electronic medical records of patients presenting with lymphadenopathy to the tertiary care center between May 2021 and June 2023 were reviewed. Data on patient demographics, clinical presentation, imaging findings, and cytopathological and histopathological diagnoses were analyzed. Results A total of 300 cases of lymphadenopathy were identified during the study period. The study population exhibited a diverse range of age groups, with a slight predilection for the age range of 11-20 years. The most common sites of lymphadenopathy were in the cervical group, and the predominant clinical presentations included tender lymph nodes and fever. Etiologically, infectious causes, such as accounted for the majority of cases, followed by inflammatory and neoplastic etiologies. Notably, 2.6 % of cases presented with non-specific lymphadenopathy, warranting further investigation. Diagnostic modalities, including imaging studies and histopathological examinations, played a crucial role in establishing accurate diagnoses. The study also highlights the challenges in differentiating benign from malignant lymphadenopathy, emphasizing the need for a comprehensive diagnostic approach. Conclusion This study provides a comprehensive overview of the lymphadenopathy spectrum in a tertiary care center, emphasizing the importance of a multidisciplinary approach for accurate diagnosis and management. The findings contribute to our understanding of the epidemiology and etiological patterns of lymphadenopathy, guiding clinicians in optimizing patient care and outcomes in a tertiary healthcare setting.

Multimodality Imaging of Benign and Malignant Diseases of the Nipple-Areolar Complex

The nipple-areolar complex (NAC), a unique anatomic structure of the breast, encompasses the terminal intramammary ducts and skin appendages. Several benign and malignant diseases can arise within the NAC. As several conditions have overlapping symptoms and imaging findings, understanding the distinctive nipple anatomy, as well as the clinical and imaging features of each NAC disease process, is essential. A multimodality imaging approach is optimal in the presence or absence of clinical symptoms. The authors review the ductal anatomy and anomalies, including congenital abnormalities and nipple retraction. They then discuss the causes of nipple discharge and highlight best practices for the imaging workup of pathologic nipple discharge, a common condition that can pose a diagnostic challenge and may be the presenting symptom of breast cancer. The imaging modalities used to evaluate and differentiate benign conditions (eg, dermatologic conditions, epidermal inclusion cyst, mammary ductal ectasia, periductal mastitis, and nonpuerperal abscess), benign tumors (eg, papilloma, nipple adenoma, and syringomatous tumor of the nipple), and malignant conditions (eg, breast cancer and Paget disease of the breast) are reviewed. Breast MRI is the current preferred imaging modality used to evaluate for NAC involvement by breast cancer and select suitable candidates for nipple-sparing mastectomy. Different biopsy techniques (US -guided biopsy and stereotactic biopsy) for sampling NAC masses and calcifications are described. This multimodality imaging approach ensures an accurate diagnosis, enabling optimal clinical management and patient outcomes. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Image-Guided Fine-Needle Aspiration Cytology for BRCA Mutation Assessment of PSMA-Positive Lymph Node Metastases in a Patient With Metastatic Castration-Resistant Prostate Cancer

ABSTRACT

A 64-year-old man with metastatic castration-resistant prostate cancer presented for prostate-specific membrane antigen (PSMA) PET/CT in preparation for 177 Lu-PSMA radioligand therapy. For precedent BRCA mutation assessment, fine-needle aspiration cytology of 2 PSMA-positive lymph node metastases was conducted. The acquired material was suitable for next-generation sequencing-based gene panel diagnostics and did not show a BRCA1 / 2 mutation, thus PSMA radioligand therapy was initiated. Fine-needle aspiration cytology of lymph node metastases may be a viable option in evaluating further therapeutic alternatives.

Core Needle Biopsy Guidance Based on Tissue Morphology Assessment with AI-OCT Imaging

This paper presents a combined optical imaging/artificial intelligence (OI/AI) technique for the real-time analysis of tissue morphology at the tip of the biopsy needle, prior to collecting a biopsy specimen. This is an important clinical problem as up to 40% of collected biopsy cores provide low diagnostic value due to high adipose or necrotic content. Micron-scale-resolution optical coherence tomography (OCT) images can be collected with a minimally invasive needle probe and automatically analyzed using a computer neural network (CNN)-based AI software. The results can be conveyed to the clinician in real time and used to select the biopsy location more adequately. This technology was evaluated on a rabbit model of cancer. OCT images were collected with a hand-held custom-made OCT probe. Annotated OCT images were used as ground truth for AI algorithm training. The overall performance of the AI model was very close to that of the humans performing the same classification tasks. Specifically, tissue segmentation was excellent (~99% accuracy) and provided segmentation that closely mimicked the ground truth provided by the human annotations, while over 84% correlation accuracy was obtained for tumor and non-tumor classification.

A Proposed Cytodiagnosistic Approach for Breast Lesions

In clinical practice, the diagnosis of breast lesions is achieved by the triple approach of the specialized surgeon, radiologist and pathologist. The recommended approach to breast lesions should always include a detailed history, along with a thorough clinical examination, mammography and/or ultrasound, as well as preoperative cytodiagnosis. In this context, fine needle aspiration cytology and core needle biopsy are the methods of choice for histological diagnosis. Herein, we aim to explain why these procedures seem to be superior compared to open biopsy and we propose a cytodiagnostic algorithm for breast lesions.

The effectiveness of ultrasound-guided core needle biopsy in detecting lymph node metastases in the axilla in patients with breast cancer: systematic review and meta-analysis

OBJECTIVE

This study aimed to perform a meta-analysis to investigate the diagnostic safety and accuracy of Ultrasound-Guided Core Needle Biopsy (US-CNB) Axillary Lymph Nodes (ALNs) region in patients with Breast Cancer (BC).

METHODS

The authors searched the electronic databases PubMed, Scopus, Embase, and Web of Science for clinical trials about US-CNB for the detection of ALNs in breast cancer patients. The authors extracted and pooled raw data from the included studies and performed statistical analyses using Meta-DiSc 1.4 and Review Manager 5.3 software. A random effects model was used to calculate the data. At the same time, data from the Ultrasound-guided Fine-Needle Aspiration (US-FNA) were introduced for comparison with the US-CNB. In addition, the subgroup was performed to explore the causes of heterogeneity. (PROSPERO ID: CRD42022369491).

RESULTS

In total, 18 articles with 2521 patients were assessed as meeting the study criteria. The overall sensitivity was 0.90 (95% CI [Confidence Interval], 0.87‒0.91; p = 0.00), the overall specificity was 0.99 (95% CI 0.98‒1.00; p = 0.62), the overall area under the curve (AUC) was 0.98. Next, in the comparison of US-CNB and US-FNA, US-CNB is better than US-FNA in the diagnosis of ALNs metastases. The sensitivity was 0.88 (95% CI 0.84‒0.91; p = 0.12) vs. 0.73 (95% CI 0.69‒0.76; p = 0.91), the specificity was 1.00 (95% CI 0.99‒1.00; p = 1.00) vs. 0.99 (95% CI 0.67‒0.74; p = 0.92), and the AUC was 0.99 vs. 0.98. Subgroup analysis showed that heterogeneity may be related to preoperative Neoadjuvant Chemotherapy (NAC) treatment, region, size of tumor diameter, and the number of punctures.

CONCLUSION

US-CNB has a satisfactory diagnostic performance with good specificity and sensitivity in the preoperative diagnosis of ALNs in BC patients.

The Advantage of Using an Optical See-Through Head-Mounted Display in Ultrasonography-Guided Needle Biopsy Procedures: A Prospective Randomized Study

An optical see-through head-mounted display (OST-HMD) can potentially improve the safety and accuracy of ultrasonography (US)-guided fine-needle aspiration. We aimed to evaluate the usefulness of an OST-HMD in US-guided needle-puncture procedures. We conducted a prospective randomized controlled study in which we compared the accuracy and safety of the US-guided needle puncture procedure and the stress on the practitioner when using OST-HMD versus standard US display (SUD). Inexperienced medical students were enrolled and randomly divided into two groups. A breast phantom was used to evaluate the required time and accuracy of the US-guided needle puncture. Practitioner stress was quantified using a visual analog scale (VAS). When the procedure was performed for the first time, the time required to reach the target lesion at a shallow depth was significantly shorter in the OST-HMD group (39.8 ± 39.9 s) than in the SUD group (71.0 ± 81.0 s) (p = 0.01). Using the OST-HMD significantly reduced the unintentional puncture of a non-target lesion (p = 0.01). Furthermore, the stress felt by the practitioners when capturing the image of the target lesion (p < 0.001), inserting and advancing the needle more deeply (p < 0.001), and puncturing the target lesion (p < 0.001) was significantly reduced in the OST-HMD group compared with that in the SUD group. Use of OST-HMD may improve the accuracy and safety of US-guided needle puncture procedures and may reduce practitioner stress during the procedure.

Diagnostic yield and accuracy of paediatric image-guided fine needle aspiration biopsy of deep organ tumours

Background

Paediatric tumour cytological diagnosis by image-guided fine needle aspiration biopsy (FNAB) with rapid on-site evaluation (ROSE) has not gained wide acceptance despite increasing publications advocating the procedure.

Objective

The primary aim was an audit of the diagnostic yield and accuracy of paediatric image-guided FNAB with ROSE at a single institution. Evaluation of safety was a secondary aim.

Method

Details of consecutive cases of paediatric image-guided FNAB with ROSE for suspected non-benign deep-seated lesions performed from 01 January 2014 to 30 April 2020 were retrieved from the institutional radiology and laboratory databases. Diagnostic yield and accuracy were evaluated using clinico-pathological-radiological correlation and/or subsequent histological specimen diagnosis correlation. Complications and the frequency of key radiological features potentially affecting yield and accuracy were described.

Results

Of 65 cases retrieved, cytology showed malignancy in 52, benign features in five and one indeterminate diagnosis; seven samples were insufficient for cytological assessment. Of the 65 cases, 58 had subsequent formal histological diagnosis. The overall diagnostic yield was 98.5%, with 94.5% sensitivity, 100.0% specificity, 100.0% positive predictive value, 75.0% negative predictive value and 95.3% diagnostic accuracy. All cases (n = 26) demonstrating restricted diffusion on MRI yielded adequate samples and cyto-histopathological correlation.

Conclusion

Paediatric image-guided FNAB with ROSE has a relatively high diagnostic yield, sensitivity, specificity, positive predictive value and accuracy in the diagnosis of deep-seated tumours. The relatively low negative predictive value may reflect insufficient samples obtained from cystic and/or benign lesions. Sampling from areas of restricted MRI diffusion may enhance diagnostic yield.

Updated Neoadjuvant Treatment Landscape for Early Triple Negative Breast Cancer: Immunotherapy, Potential Predictive Biomarkers, and Novel Agents

Simple Summary

In recent years, several agents have been tested in randomized clinical trials in addition to anthracycline and taxane-based neoadjuvant chemotherapy (NACT) in early-stage triple-negative breast cancer (TNBC) to improve pathological complete response rate and, ultimately, survival outcome. Platinum agents, immune checkpoint inhibitors (ICIs), and PARP-inhibitors are the most extensively studied, while established predictors of their efficacy are lacking. Based on the biological features of TNBC, the purpose of this review is to provide an overview of the role of platinum agents, immunotherapy, and novel target therapies in the neoadjuvant setting. Moreover, based on safety issues and financial costs, we provide an overview of potential biomarkers associated with increased likelihood of benefit from the addition of platinum, ICIs, and novel target therapies to NACT.

Abstract

Triple-negative breast cancer (TNBC) is characterized by the absence of hormone receptor and HER2 expression, and therefore a lack of therapeutic targets. Anthracyclines and taxane-based neoadjuvant chemotherapy have historically been the cornerstone of treatment of early TNBC. However, genomic and transcriptomic analyses have suggested that TNBCs include various subtypes, characterized by peculiar genomic drivers and potential therapeutic targets. Therefore, several efforts have been made to expand the therapeutic landscape of early TNBC, leading to the introduction of platinum and immunomodulatory agents into the neoadjuvant setting. This review provides a comprehensive overview of the currently available evidence regarding platinum agents and immune-checkpoint-inhibitors for the neoadjuvant treatment of TNBC, as well as the novel target therapies that are currently being evaluated in this setting. Taking into account the economic issues and the side effects of the expanding therapeutic options, we focus on the potential efficacy biomarkers of the emerging therapies, in order to select the best therapeutic strategy for each specific patient.

Label-free multimodal nonlinear optical imaging of needle biopsy cores for intraoperative cancer diagnosis

SIGNIFICANCE

Needle biopsy (NB) procedures are important for the initial diagnosis of many types of cancer. However, the possibility of NB specimens being unable to provide diagnostic information, (i.e., non-diagnostic sampling) and the time-consuming histological evaluation process can cause delays in diagnoses that affect patient care.

AIM

We aim to demonstrate the advantages of this label-free multimodal nonlinear optical imaging (NLOI) technique as a non-destructive point-of-procedure evaluation method for NB tissue cores, for the visualization and characterization of the tissue microenvironment.

APPROACH

A portable, label-free, multimodal NLOI system combined second-harmonic generation (SHG) and third-harmonic generation and two- and three-photon autofluorescence (2PF, 3PF) microscopy. It was used for intraoperative imaging of fresh NB tissue cores acquired during canine cancer surgeries, which involved liver, lung, and mammary tumors as well as soft-tissue sarcoma; in total, eight canine patients were recruited. An added tissue culture chamber enabled the use of this NLOI system for longitudinal imaging of fresh NB tissue cores taken from an induced rat mammary tumor and healthy mouse livers.

RESULTS

The intraoperative NLOI system was used to assess fresh canine NB specimens during veterinary cancer surgeries. Histology-like morphological features were visualized by the combination of four NLOI modalities at the point-of-procedure. The NLOI results provided quantitative information on the tissue microenvironment such as the collagen fiber orientation using Fourier-domain SHG analysis and metabolic profiling by optical redox ratio (ORR) defined by 2PF/(2PF + 3PF). The analyses showed that the canine mammary tumor had more randomly oriented collagen fibers compared to the tumor margin, and hepatocarcinoma had a wider distribution of ORR with a lower mean value compared to the liver fibrosis and the normal-appearing liver. Moreover, the loss of metabolic information during tissue degradation of fresh murine NB specimens was shown by overall intensity decreases in all channels and an increase of mean ORR from 0.94 (standard deviation 0.099) to 0.97 (standard deviation 0.077) during 1-h longitudinal imaging of a rat mammary tumor NB specimen. The tissue response to staurosporine (STS), an apoptotic inducer, from fresh murine liver NB specimens was also observed. The mean ORR decreased from 0.86 to 0.74 in the first 40 min and then increased to 0.8 during the rest of the hour of imaging, compared to the imaging results without the addition of STS, which showed a continuous increase of ORR from 0.72 to 0.75.

CONCLUSIONS

A label-free, multimodal NLOI platform reveals microstructural and metabolic information of the fresh NB cores during intraoperative cancer imaging. This system has been demonstrated on animal models to show its potential to provide a more comprehensive histological assessment and a better understanding of the unperturbed tumor microenvironment. Considering tissue degradation, or loss of viability upon fixation, this intraoperative NLOI system has the advantage of immediate assessment of freshly excised tissue specimens at the point of procedure.

MicroRNA 21 and microRNA 10b: early diagnostic biomarkers of breast cancer in Egyptian females

BACKGROUND

Breast cancer (BC) is one of the most prevalent cancers in developing and developed countries among women worldwide. Mammography is one of the superior methods for BC detection, but it carries up to 20% false-negative results, especially in early cases. Histological examination of tissue biopsies and fine-needle aspiration cytology are invasive techniques. Hence, minimally invasive markers are needed for the improved detection of BC. microRNAs, small, noncoding, single-stranded RNAs functioning as tumor suppressor genes or oncogenes, are attractive biomarkers for early detection. This study aimed to examine the serum levels of miR21 and miR10b in patients with BC especially in the early stages compared to healthy controls to evaluate their potential use as BC biomarkers.

METHODS

This study included 90 females who were divided into two groups. Group I included 70 patients with BC and was subdivided into group Ia with 40 nonmetastatic BC patients and group Ib with 30 metastatic BC patients. Group II included 20 apparently healthy females as a control group. Serum miR21 and miR10b as biomarkers and miR16 as a housekeeping gene were evaluated using real-time polymerase chain reaction.

RESULTS

The median levels of miR10b and miR21 were statistically significantly upregulated in the sera of patients with BC compared to healthy controls (P = 0.001). Receiver operating characteristic curve analyses demonstrated that serum levels of miR10b and miR21 were useful biomarkers for distinguishing between patients with BC and the control group, with an area under the curve (AUC) of 0.991 with 97.1% sensitivity and 100% specificity at a cutoff of 3.1 for miR10b and an AUC of 0.965 with 95.7% sensitivity and 85% specificity at a cutoff of 1.7 for miR21. Regarding the early stages of BC, the median levels of the fold change of serum miR21 and miR10b were statistically significantly higher in patients with BC (stages I and IIa) than in the control group (P < 0.001).

CONCLUSIONS

Both miR21 and miR10b have valuable diagnostic roles in detecting the early stages of BC.

Tissue Pathogens and Cancers: A Review of Commonly Seen Manifestations in Histo- and Cytopathology

Tissue pathogens are commonly encountered in histopathology and cytology practice, where they can present as either benign mimickers of malignancy or true malignancies. The aim of this review is to provide a timely synthesis of our understanding of these tissue pathogens, with an emphasis on pertinent diagnostic conundrums associated with the benign mimickers of malignancy that can be seen with viral infections and those which manifest as granulomas. The oncogenic pathogens, including viruses, bacteria, and parasites, are then discussed with relationship to their associated malignancies. Although not exhaustive, the epidemiology, clinical manifestations, pathogenesis, and histological findings are included, along with a short review of emerging therapies.

Diagnosis on Excision Biopsy of Breast Tissues Labeled As Fibroepithelial Tumors on Trucut Samples in a Developing Country

Introduction: Fibroadenomas (FAs) and phyllodes tumors (PTs) are less prevalent but allied to have malignant transformation in many instances. It is a challenge to diagnose the phyllodes by conventional trucut biopsy technique.

Objective: To evaluate the histological characteristics of tumors labeled as fibroepithelial lesions of breast tissues on trucut biopsy and compare with a diagnosis on excision biopsy.

Methods and materials: It was a descriptive cross-sectional study that was carried out in Shaukat Khanum Memorial Hospital and Research Centre within six years from January 2015 to January 2021. In trucut samples, stromal cellularity, stromal cell nuclear atypia, mitotic count, stromal overgrowth, the enhancement of stromal cellularity adjacent to epithelium were scrutinized. In each category, the activity was seen as absent, mild, moderate, or severe. Mitotic activity was graded as 0-1, 0-5, 5-10, >10.

Results: A total of 125 patients were registered for the study. The mean age of patients in our study was 33.86 ± 9.95 years. The mean size was 41.02 ± 27.38 mm with a mean lump duration of 7.52 ± 5.34 months. In the FA group, the trucut sampling report showed the stromal cellularity as mild in 62 (69.7%) and stromal cell nuclear atypia as absent in 68 (76.4%) cases. But in the phyllodes tumor group, the stromal cellularity was severe in 10 (27.8%) patients and stromal cell nuclear atypia was severe in five (13.9%). The ultimate outcome showed that 89 (71.2%) patients had FA and 36 (28.8%) had PT at excision.

Conclusion: Assessment of tumor size, stromal cellularity, mitoses, and enhancement of stromal cellularity adjacent to epithelium are useful markers for diagnosing the PT in trucut needle biopsy.

Fine-Needle Aspiration Biopsy Cytopathology of Breast Lesions Using the International Academy of Cytology Yokohama System and Rapid On-Site Evaluation: A Single-Institute Experience

INTRODUCTION

Breast cancer is rapidly emerging as the leading cause of cancer in Indian women. Robust cytopathology and histopathology services are required to tackle this growing burden. The use of rapid on-site evaluation (ROSE) and the International Academy of Cytology (IAC) Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy (FNAB) Cytopathology, which offers structured protocols, are expected to improve breast cytopathology reporting.

METHODS

We retrieved the cytopathology slides, categorized them by the IAC Yokohama System and histopathology data of all the patients who had been investigated for breast lesions from September 2016 to December 2018, and compared the cytopathology and histopathology. Risk of malignancy (ROM) and performance metrics, like sensitivity, specificity, predictive values, accuracy, and area under the curve were computed.

RESULTS

A total of 1,147 FNABs were evaluated, of which 442 (38.5%) underwent ROSE and 624 (54.4%) histopathology. Reported using IAC categories, our cohort recorded 4.9% inadequate, 65.3% benign, 7.8% atypical, 3.3% suspicious for malignancy, and 18.7% malignant lesions. The overall sensitivity and specificity for identifying in situ and malignant lesions were 99.1% and 99.3%, respectively, and were substantially improved by ROSE. ROSE improved the concordance between cytopathology and histopathology from 76.9% to 90.2%, by reducing inadequate (p < 0.001) cases. The ROM increased along a gradient from inadequate to malignant categories, with the gradient being sharpened by ROSE. The false negativity rate was 0.7% and false positivity rate 0%.

CONCLUSION

Incorporating ROSE and the IAC Yokohama System for breast cytopathology reporting improves accurate diagnosis of breast lesions, prevents missed diagnoses, and provides reliable estimates of ROM. These protocols also aid in standardizing a reproducible system for monitoring and auditing of breast pathology services, identify areas that need strengthening, and improve training at pathology centers.

Intraoperative Label-Free Multimodal Nonlinear Optical Imaging for Point-of-Procedure Cancer Diagnostics

Intraoperative imaging in surgical oncology can provide information about the tumor microenvironment as well as information about the tumor margin. Visualizing microstructural features and molecular and functional dynamics may provide important diagnostic and prognostic information, especially when obtained in real-time at the point-of-procedure. A majority of current intraoperative optical techniques are based on the use of the labels, such as fluorescent dyes. However, these exogenous agents disrupt the natural microenvironment, perturb biological processes, and alter the endogenous optical signatures that cells and the microenvironment can provide. Portable nonlinear imaging systems have enabled intraoperative imaging for real-time detection and diagnosis of tissue. We review the development of a label-free multimodal nonlinear optical imaging technique that was adapted into a portable imaging system for intraoperative optical assessment of resected human breast tissue. New developments have applied this technology to assessing needle-biopsy specimens. Needle-biopsy procedures most always precede surgical resection and serve as the first sampling of suspicious masses for diagnosis. We demonstrate the diagnostic feasibility of imaging core needle-biopsy specimens during veterinary cancer surgeries. This intraoperative label-free multimodal nonlinear optical imaging technique can potentially provide a powerful tool to assist in cancer diagnosis at the point-of-procedure.

Fine-Needle Aspiration Cytology versus Core-Needle Biopsy for Breast Lesions: A Dilemma of Superiority between the Two

INTRODUCTION

Core-needle biopsy (CNB) is a minimally invasive procedure used in preoperative diagnosis of breast lumps. It has been seen that in few years, the CNB seems to be replacing the fine-needle aspiration cytology (FNAC), although no study had yet conclusively proved a superiority of one over the other.

AIMS AND OBJECTIVES

The aim of this study was to study the cytohistological spectrum of palpable breast lesions and to evaluate the diagnostic accuracy of FNAC versus CNB for breast lesions.

MATERIALS AND METHODS

The study was a cross-sectional study conducted in the Department of Pathology and Surgery, over a period of 1 year in 152 patients. All the patients were subjected to FNAC and CNB. Cytosmears were stained with May-Grunwald Giemsa and hematoxylin and eosin was done on CNB and excision biopsy (EB) specimens. Sensitivity and specificity were calculated in percentage with 95% confidence interval with reference to CNB/surgical specimens. Kappa statistics were used to compare the level of agreement between FNAC versus CNB and CNB versus surgical specimens.

RESULTS

A total of 152 patients were taken for FNAC and CNB. EB was performed in only 104 patients. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FNAC verses CNB in correlation with subsequent histopathology were found to be (93.40 vs. 94.06%), (97.50 vs. 100.00%), (99.00 vs. 100.00%), (84.78 vs. 33.33%), and (94.52 vs. 94.23%), respectively.

CONCLUSION

CNB has overcome the pitfall of FNAC but CNB cannot replace FNAC but both procedures are complementary to each other.

Application of noise-reduction techniques to machine learning algorithms for breast cancer tumor identification

The application of machine learning (ML) techniques to digitized images of biopsied cells for breast cancer diagnosis is an active area of research. We hypothesized that reducing noise in the data would lead to an increase in classification accuracies. To test this hypothesis, we first compared several classification techniques in their ability to discriminate between malignant and benign breast cancer tumors using the Wisconsin Breast Cancer Data Set and subsequently evaluated the effect of noise reduction techniques on model accuracies. We applied two noise-reduction techniques based on Principal Component Analysis - dimensionality reduction and outlier removal - to a comprehensive list of ML algorithms with different learning paradigms including Decision Trees (fine, medium, coarse), dimensionality reduction techniques (Linear Discriminant Analysis, Quadratic Discriminant Analysis, Partial Least Squares-Discriminant Analysis), logistic Regression, Bayesian techniques (Gaussian Naive, Kernel Naive), Support Vector Machines (Linear, Quadratic, Cubic, Gaussian), instance-based techniques (fine, medium, coarse, cosine, cubic, and weighted K-Nearest Neighbors), and Artificial Neural Networks. Results showed that noise removal through dimensionality reduction is most effective when using a cross-validated number of principal components, and accuracies surpassing 99% across all ML models are obtained when both noise-reduction techniques are applied sequentially. Even though such a high accuracy has been demonstrated in few instances for specific algorithms, the methodology proposed herein is the first published report demonstrating the applicability of a technique to a wide range of ML models to achieve high accuracies. We show that dimensionality reduction and outlier analysis can be used as effective approaches to improve discrimination accuracies. Also, dimensionality reduction through a cross-validated number of principal components can provide an effective framework for reducing noise in the data prior to applying a ML algorithm.

A Prospective Evaluation of Tru-Cut Biopsy and Fine-needle Aspiration Cytology in Male Breast Cancer Detection

BACKGROUND

Male breast-cancer (MBC) is often diagnosed late. Our purpose was to evaluate fine-needle aspiration cytology (FNAC) versus Tru-Cut biopsy (TCNB) in MBC diagnosis.

PATIENTS AND METHODS

Men with suspicious breast lesions were prospectively enrolled; 54 met the inclusion criteria and underwent FNAC and TCNB. FNAC, TCNB and gold-standard results were compared.

RESULTS

Unsatisfactory results were 11.1% after FNAC and none after TCNB (p=0.027). After gold-standard evaluation, the diagnosis of FNAC and TCNB was confirmed, respectively, in 63.0% and 98.1% and changed in 37.0% and 1.9% (p<0.001). The malignancy rate after FNAC, TCNB and surgery were, respectively, 25.9%, 33.3% and 35.1% (FNAC vs. TCNB p=0.5276, FNAC vs. surgery p=0.404; TCNB vs. surgery p=1). Among invasive carcinomas, 93.8% were identified by FNAC vs. 87.5% by TCNB (p=1); all ductal carcinoma in situ (DCIS) were detected after TCNB and none after FNAC (p=0.1).

CONCLUSION

FNAC leads to a significantly higher number of inadequate samplings and seems to be subject to increased DCIS misdiagnoses. TCNB correlated better to the final histological report.

A retrospective analysis of 512 cases of breast fine needle aspiration cytology utilizing the recently proposed IAC Yokohama system for reporting breast cytopathology

BACKGROUND

Recently the International Academy of Cytology (IAC) introduced a new reporting system for breast fine-needle aspiration cytology that classifies cytologic diagnoses into five-categories: (I) insufficient material, (II) benign, (III) atypical, (IV) suspicious of malignancy, and (V) malignant. The current study was undertaken to categorize the breast lesions utilizing the newly proposed IAC Yokohama classification system and evaluate the risk of malignancy (ROM) for respective categories and the diagnostic yield of this technique.

METHODS

All FNAs of breast lesions over 2.5 years were categorized retrospectively using the newly proposed IAC Yokohama reporting system. The ROM was calculated along with sensitivity, specificity, positive and negative predictive value, diagnostic accuracy, false positive, and false-negative rate using the histological diagnosis as the gold standard.

RESULTS

The 512 cases were distributed as follows: Category I (insufficient material) 7.4%, Category II (benign) 74%, Category III (atypical) 5.7%, Category IV(suspicious) 1.4%, and Category V (malignant) 11.5%. Histopathological correlation was available in 285 (55.7%) cases. The respective ROM calculated was 33.3%, 0.5%, 13.3%, 83.3%, and 100% for Category I-V. The Sensitivity, Specificity, Positive and Negative Predictive Value, and Diagnostic accuracy were 95%, 99.5%, 98.27%, 98.6, and 98.5% respectively.

CONCLUSIONS

Despite previous attempts to establish a standardized diagnostic terminology, there has been a lack of a single internationally approved standardized reporting system allowing substantial diagnostic clarity and incorporating distinct diagnostic categories, each linked with a specific ROM and recommended management. This System also provides enhanced communication between pathologists and attending clinicians for the benefit of the patient.

Transvaginal Ultrasound-Guided Core Biopsy-Experiences in a Comprehensive Cancer Centre

Simple Summary

Adequate histological diagnosis defines the treatment in gynaecologic oncology. Although transvaginal ultrasound (TVUS) has widespread use in the diagnosis of pelvic tumours, TVUS-guided core biopsy is not a common procedure. In this study we summarize our experience in TVUS-guided biopsies performed in a comprehensive cancer centre, discussing the results of 303 patients who underwent this procedure. In addition, we compare the histological results of the biopsies with subsequent surgical histological results in 94 cases. Our study demonstrates that TVUS-guided core biopsy is a safe and effective histological sampling procedure providing adequate tissue for pathological evaluation in 99% of cases. Compared to surgically obtained histology, this procedure can reliably guide therapy, as its performance is satisfactory. In our opinion, TVUS-guided core biopsy is an effective diagnostic method providing possible benefits to patients referred for suspicion of gynaecological malignancy.

Abstract

In this paper, we report our experience of transvaginal ultrasound (TVUS)-guided core biopsies involving 303 patients referred to the gynaecological ultrasound unit of our national comprehensive cancer centre. Adequate histologic specimens were obtained in 299 patients (98.7%). The most common sites of biopsy sampling were the adnexa (29.7%), the vaginal stump or wall (13.5%), the uterus (11.6%) and the peritoneum (10.2%). Malignancy was confirmed in two-thirds of patients (201/303) and a primary malignancy was diagnosed in 111 of the 201 histologically verified malignant cases (55.2%). Interestingly, 23.9% (48/201) of malignant tumours were proven to have a non-gynaecological origin. Among them, gastrointestinal tumours occurred the most frequently (31/48 patients). Three abscesses were discovered following the biopsy procedure, resulting in a complication rate of 1%. In 94 (31%) patients, subsequent surgery allowed the comparison of the ultrasound-guided and surgically obtained histologic results. We found inaccuracy in 12 cases (12.8%), which is discussed in this paper in detail. Sensitivity, specificity, PPV and NPV to diagnose malignancy was 94.8%, 94.1%, 98.7% and 80.0%, respectively. This is the largest study reported to date about the efficacy and safety of TVUS-guided core biopsy in evaluating pelvic lesions giving rise to a suspicion of gynaecological cancer.

Application of preoperative computed tomographic lymphography for precise sentinel lymph node biopsy in breast cancer patients

Background

In light of the extensive application of sentinel lymph node biopsy (SLNB) in clinically node-negative breast cancer patients and the recently investigated failure of SLNB after lumpectomy, it has become important to explore methods for preoperative mapping of sentinel lymph nodes (SLNs) and their lymphatics to direct precise SLNB and improve the identification rate of SLNs.

Methods

Twenty-seven patients with suspected breast cancer based on the results of the clinical examination and imaging were enrolled in the study. Computed tomographic lymphography (CTLG) followed by CT three-dimensional reconstruction was performed to determine the localization of SLNs and lymphatics on the body surface preoperatively. Intraoperatively combined staining with methylene blue and indocyanine green was used to evaluate the accuracy and feasibility of CTLG.

Results

SLNs and lymphatics from the breast were identified using CTLG in all patients, and preoperative SLNs and lymphatics localization on the body surface showed a significant role in the selection of operative incision and injection points. The accuracy rate of SLN and lymphatic detection by CTLG was 92.6% compared with intraoperatively combined staining. Moreover, preoperative CTLG performed well in SLN number detection, and the accuracy rate was 95.2%.

Conclusion

We evaluate the procedure and application of preoperative CTLG in the superficial localization of SLNs and lymphatics, which may lead to a decreased incidence of cutting off the lymphatics of SLNs and consequently more rapid and accurate SLN detection. This method promotes personalized SLN mapping, providing detailed information about the number and anatomical location of SLNs and lymphatics for adequate surgical planning for breast cancer patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01190-7.

A decade of change: Trends in the practice of cytopathology at a tertiary care cancer centre

OBJECTIVES

The practice of cytopathology has evolved over the past decade with a growing need for doing more with less tissue. Changes in clinical practice guidelines and evolving needs in tissue acquisition for diagnosis and treatment have affected various areas of cytopathology in different ways. In this study, we evaluated the changing trends in cytopathological practice at our institution over the past decade.

METHODS

We performed a retrospective review of our institutional database for cytopathology cases from calendar years 2009 (n = 28038) and 2019 (n = 31386) to evaluate the changing trends in practice.

RESULTS

The overall number of exfoliative cases decreased 10% over the past decade, primarily due to a 64% decrease in gynaecological Pap testing. However, the volume of serous body cavity and cerebrospinal fluids increased 125% and 44%, respectively. The overall volume of fine needle aspiration (FNA) cases increased 38% from 2009 to 2019. The number of FNA cases increased across most body sites, driven primarily by a 180% increase in endobronchial ultrasound-guided transbronchial needle aspiration cases. In contrast, breast FNA volume decreased 43%. Ancillary studies increased substantially over the past decade, including immunostains (476%) and molecular testing (250%).

CONCLUSIONS

The trends in our cytopathological practice showed an increased volume of cases, especially in non-gynaecological specimens. As expected, the number of FNA cases used for immunostains and molecular testing increased substantially, indicating an upward trend in ancillary studies in cytopathological practice.

Breast Cancer During Pregnancy: A Marked Propensity to Triple-Negative Phenotype

Breast and cervical cancers comprise 50% of all cancers during pregnancy. In particular, gestational breast cancer is considered one of the most aggressive types of cancers, which is a rare but fatal disease. However, the incidence of this type of cancer is increasing over the years and its prevalence is expected to rise further as more women delay childbearing. Breast cancer occurring after pregnancy is generally triple negative with specific characterizations of a poorer prognosis and outcome. On the other hand, it has been pointed out that this cancer is associated with a specific group of genes which can be used as precise targets to manage this deadly disease. Indeed, combination therapies consisting of gene-based agents with other cancer therapeutics is presently under consideration. We herein review recent progress in understanding the development of breast cancer during pregnancy and their unique subtype of triple negative which is the hallmark of this type of breast cancer.

Classification of Male Breast Lesions According to the IAC Yokohama System for Reporting Breast Cytopathology

OBJECTIVE

This study aims to determine the diagnostic utility of the International Academy of Cytology (IAC) Yokohama System for reporting breast cytopathology in lesions of the male breast.

STUDY DESIGN

Fine-needle aspiration biopsy (FNAB) reports between 2015 and 2019 were retrospectively recategorized according to the 5-tiered IAC Yokohama Reporting System. Our database yielded a total of 1,532 FNAB reports from breast lesions, obtained from 1,350 male patients. The risk of malignancy (ROM) and diagnostic performance of FNAB were determined using follow-up histopathological diagnosis and/or clinical follow-up, where available, for each category.

RESULTS

The category distribution were as follows: inadequate, 40%; benign, 57%; atypical, 0.6%; suspicious for malignancy, 0.7%; and malignant, 1.6%. The ROM in each category was nondiagnostic, 11%; benign, 3%; atypical, 28%; suspicious for malignancy, 56%; and malignant, 100%. The sensitivity, specificity, positive predictive value, and negative predictive value were recorded as 63, 100, 100, and 84.6% respectively, when only malignant cases were considered as positive tests.

CONCLUSION

This study validates the IAC Yokohama System for reporting male breast cytopathology. In accordance with the aim of the Yokohama System to establish best practice guidelines for reporting breast cytopathology, this comprehensive scheme facilitates comparisons between local and international institutions. The ROM acts as an internal audit for quality assurance within one's own laboratory and provides guidance for clinical management. It highlights inefficiencies such as high inadequacy rates for category 1 and also features strengths with impressive specificity for categories 4 and 5.

Fine-Needle Aspiration Cytology (FNAC) is a reliable diagnostic tool for small breast lesions (≤ 1.0 cm): a 20-year retrospective study

Background

Breast cancer is a major public health problem worldwide. It is recommended that small breast lesions or those suspicious for malignancy be evaluated via histopathological examination (“core biopsy” or surgical specimens), and lesions that are probably benign and palpable should be examined via fine-needle aspiration cytology (FNAC). This study aimed to assess the accuracy of FNAC for the diagnosis of small breast lesions.

Methods

We reviewed all anatomopathological reports of FNACs collected between January 1, 2000 and December 31, 2019 (n = 24,721) in a private community pathology service. Lesions up to 1.0 cm (≤1.0 cm) (n = 8334) were included for evaluation and classified according to the recommendation of the International Academy of Cytology Yokohama System for Reporting Breast Fine Needle Aspiration Biopsy Cytopathology in the following categories: (1) insufficient/inadequate; (2) benign; (3) atypical, probably benign; (4) suspicious of malignancy; and (5) malignant. Subsequently, the results of the FNACs were compared to those of the respective histopathological examinations (n = 785).

Results

FNAC had a specificity of 99.6%; sensitivity, 97.4%; positive predictive value, 99.6%; negative predictive value, 97.6%; and accuracy, 98.5%.

Conclusions

FNAC is a reliable method for diagnosing small breast lesions (≤1.0 cm).

Accuracy of the International Academy of Cytology Yokohama system of breast cytology reporting for fine needle aspiration biopsy of the breast in a dedicated breast care setting

BACKGROUND

The International Academy of Cytology (IAC) Yokohama system is a recently proposed system for reporting breast cytology by fine needle aspiration biopsies (FNAB). Multiple studies are needed to confirm the risk of malignancy (ROM) of the various reporting categories of this system. The present article studies the accuracy of the IAC Yokohama system in our center.

METHODS

Over a period of 1 year (September 2018-August 2019), all cases of breast masses assessed by FNAB and histological correlation were studied retrospectively. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) and overall accuracy of the IAC Yokohama system for diagnosing malignancy were assessed. The rates of malignancy (ROM) of each diagnostic category were also estimated.

RESULTS

Three hundred and twenty-one FNABs had cyto-histological correlation. The percent sensitivity (with 95% Confidence Intervals) when the atypical, suspicious of malignancy and the malignant categories were regarded as positive for malignancy were 98.2% [95.5%, 99.5%], 96.0% [92.5%, 98.2%], and 86.7% [81.5%, 90.8%] respectively. The percent specificity (with 95% Confidence intervals) for the same categories in the same order were 59.5% [47.4%, 70.7%], 91.9% [83.2%, 97.0%], and 100% [95.1%, 100%] respectively. The area under curve (AUC) for diagnosing malignancy was 0.981[0.963, 0.993]. The ROM for the benign, atypical, suspicious of malignancy and malignant category were 8.3% [2.3%, 20.0%], 17.2% [5.8%, 35.8%], 77.8% [57.7%, 91.4%], and 100% [98.1%, 100%] respectively.

CONCLUSION

The IAC Yokohama system is suitable for accurately reporting breast lesions on FNAB.

A pragmatic approach to tackle the rising burden of breast cancer through prevention & early detection in countries 'in transition'

Among the emerging economies Brazil, Russia, India, China and South Africa (together known as the BRICS countries) share collectively approximately 40 per cent of the global population and contribute to 25 per cent of the world gross domestic products. All these countries are facing the formidable challenge of rising incidence of breast cancer and significant number of premature deaths from the disease. A multidimensional approach involving prevention, early detection and improved treatment is required to counteract the growing burden of breast cancer. A growing trend in the prevalence of major preventable risk factors of breast cancer such as obesity, western dietary habits, lack of physical activity, consumption of alcohol and smoking is contributing significantly to the rising burden of the disease in BRICS nations. Specific interventions are needed at the individual and population levels to mitigate these risk factors, preferably within the broader framework of non-communicable disease control programme. Population-based quality assured mammography-based screening of the 50-69 yr old women can reduce breast cancer mortality at least by 20 per cent. However, none of the BRICS countries have been able to implement population-based organized screening programme. Large scale opportunistic screening with mammography targeting predominantly the younger women is causing harms to the women and wasting precious healthcare resources. There are recent national recommendations to screen women with mammography in Brazil and Russia and with clinical breast examination in China (along with ultrasound) and India. Given the challenges of implementing systematic screening of the population, the BRICS countries should prioritize the early diagnosis approach and invest in educating the women about the breast cancer symptoms, training the frontline health providers to clinically detect breast cancers and appropriately refer for diagnostic confirmation, and creating improved access to good quality diagnostic and treatment facilities for breast cancer. The early diagnosis approach has been proved to achieve downstaging and improve survival at a fraction of the resources needed for population screening. The countries also need to focus on improving the services and capacity for multidisciplinary treatment of breast cancer, histopathology and immunohistochemistry, safe administration of chemotherapy and palliative care.

DNA methylation patterns of RAR-β2 and RASSF1A gene promoters in FNAB samples from Greek population with benign or malignant breast lesions

BACKGROUND

Promoter hypermethylation is common in Breast Cancer (BC) with studies mainly in histological specimens showing frequent methylation of tumor suppressor genes (TSGs) compared with normal tissues. The aim of this study was to estimate the frequency of promoter methylation of RAR-β2 and RASSF1A genes in breast FNAB material aiming to evaluate the methylation status of these two genes as biomarker for detecting BC in Greek population.

METHODS

FNAB material from 104 patients was collected for cytological evaluation and epigenetic analysis. DNA was extracted and subjected to bisulfite conversion. A methylation-specific PCR was carried out and the final products were separated with electrophoresis in 2% agarose gels.

RESULTS

From 104 samples, RASSF1A hypermethylation was observed in 78 (75%) and RAR-β2 hypermethylation in 64 (61.6%). 84% and 78% of the cases diagnosed with breast malignancy (n = 50) were methylated for RASSF1A and RAR-β2, respectively. Methylated RASSF1A and RAR-β2 were also detected in 88.3% and 76.5% in samples diagnosed as suspicious for malignancy (n = 17) and in 57.2% of samples diagnosed with atypia (n = 14). The Odds Ratio for breast malignancy was 4.545 in patients with RASSF1A hypermethylation and 9.167 in patients with RAR-β2 hypermethylation underlying their promoter's methylation positive correlation with breast malignancy.

CONCLUSION

To optimize the sensitivity and specificity of this epigenetic setting, more TSGs related to BC should be gradually imported in our evaluated methylation panel and be validated in a larger study sample with the aim that the obtained epigenetic profiles will provide clinicians with valuable tools for management of BC patients in Greece.

Ultrasound-Guided Core Biopsy of Breast Lesions in a Resource Limited Setting: Initial Experience of a Multidisciplinary Team

Objective

There is increasing tendency to multidisciplinary care of patients with of breast lesions. This study sought to evaluate the initial experience of the diagnostic arm of a new breast program in a resource limited setting.

Materials and Methods

In 2015, we commenced the pilot phase of an IRB-approved breast care protocol. As part of the protocol's diagnostic arm, an ultrasound-guided breast core biopsy training was implemented. Eligible patients were clinically evaluated and underwent CNB using 16G needle under US guidance. The procedure was rated by the participants and histopathological results compared with surgical specimens.

Results

Eighty six participants (18.22%) with 113 palpable breast lesions completed the study. The diagnostic accuracy, sensitivity, and specificity were 94.44%, 92.86%, and 95.83% respectively. Unweighted kappa-coefficient (k) agreement between histopathology of core biopsy and surgically excised specimens, were 0.798 (95% CI of 0.69 - 0.90) and 0.801 (95% CI of 0.71-0.92) for benign and malignant breast lumps respectively. The procedure was well accepted and all the patients were willing to accept a repeat CNB and would recommend it.

Conclusion

Despite the prevailing challenges, co-ordinated team diagnosis is feasible and may result in the modest improvement in the diagnostic accuracy of breast lesions and patient satisfaction.

The association between methods of biopsy and survival following breast cancer: A hospital registry based cohort study

Percutaneous biopsy in breast cancer has been associated with an increased risk of malignant cell seeding. However, the importance of these observations remains obscure due to lack of corroborating evidence from clinical studies. We determined whether method of biopsy is associated with breast cancer survival. This hospital registry-based cohort study included 3416 non-metastatic breast cancer patients diagnosed from 1993 to 2011 in a tertiary setting. Factors associated with biopsy methods were assessed. Multivariable Cox regression analysis was used to determine the independent prognostic impact of method of biopsy. Overall, 990 patients were diagnosed by core needle biopsy (CNB), 1364 by fine needle aspiration cytology (FNAC), and 1062 by excision biopsy. Excision biopsy was significantly associated with more favorable tumor characteristics. Radiotherapy modified the prognostic impact of biopsy method (Pinteraction < .001). Following multivariable analysis, excision biopsy was consistently associated with lower risk of mortality compared to FNAC in women receiving adjuvant radiotherapy (adjusted hazard ratio: 0.81, 95%CI: 0.66-0.99), but not in those who did not receive adjuvant radiotherapy (adjusted hazard ratio: 0.87, 95%CI: 0.65-1.17). While the risk of mortality was not different between patients undergoing FNAC and CNB when radiotherapy is administered, in the absence of radiotherapy, CNB was associated with higher risk of mortality than FNAC (adjusted hazard ratio: 1.57, 95%CI: 1.16-2.12). Given that our results contradict with findings of previous clinical studies assessing the prognostic impact of method of biopsy in women with breast cancer, further studies are warranted.

Needle Biopsy Adequacy in the Era of Precision Medicine and Value-Based Health Care

CONTEXT.—

Needle biopsy of diseased tissue is an essential diagnostic tool that is becoming even more important as precision medicine develops. However, the capability of this modality to efficiently provide samples adequate for diagnostic and prognostic analysis remains quite limited relative to current diagnostic needs. For physicians and patients, inadequate biopsy frequently leads to diagnostic delay, procedure duplication, or insufficient information about tumor biology leading to delay in treatment; for health systems, this results in substantial incremental costs and inefficient use of scarce specialized diagnostic resources.

OBJECTIVE.—

To review current needle biopsy technology, devices, and practice with a perspective to identify current limitations and opportunities for improvement in the context of advancing precision medicine.

DATA SOURCES.—

PubMed searches of fine-needle aspiration and core needle biopsy devices and similar technologies were made generally, by tissue site, and by adequacy as well as by health economics of these technologies.

CONCLUSIONS.—

Needle biopsy adequacy can be improved by recognizing the importance of this diagnostic tool by promoting common criteria for needle biopsy adequacy; by optimizing needle biopsy procedural technique, technologies, clinical practice, professional education, and quality assurance; and by bundling biopsy procedure costs with downstream diagnostic modalities to provide better accountability and incentives to improve the diagnostic process.

Fine-Needle Aspiration Biopsy Management of the Axilla in Primary Breast Carcinoma

CONTEXT

Fine-needle aspiration biopsy (FNAB) is frequently used to stage the axilla preoperatively in patients with primary breast carcinoma. In the light of the ACOSOG-Z0011 and AMAROS trials that specified sentinel lymph node biopsy as an inclusion criterion, the role of FNAB in axillary staging is changing.

OBJECTIVE

This article will review the diagnostic accuracy of FNAB in staging of the axilla in patients with primary breast carcinoma. The efficacy of axillary FNAB compared with core-needle biopsy will be evaluated. The evolving approach to staging of the axilla, in the light of ACOSOG-Z0011 and AMAROS trials, will be discussed.

DATA SOURCES

Data were sourced from published peer-reviewed articles in PubMed (US National Library of Medicine) and published guidelines including the European Guidelines for Quality Assurance in Breast Cancer and those from the European Society of Medical Oncology (ESMO), Union for International Cancer (UICC), American Society of Clinical Oncology (ASCO), and the American Society of Breast Surgeons.

CONCLUSIONS

FNAB of the axilla is almost 100% specific with a sensitivity between 40 and 90%. A positive FNAB reduces the need for a second axillary procedure by up to 20% with reduced morbidity and cost. The recent ACOSOG-Z0011 and AMAROS trials have reduced the use of FNAB axilla in American protocols, but it remains the standard of care in Europe.

Breast Fine Needle Aspiration Biopsy Cytology Using the Newly Proposed IAC Yokohama System for Reporting Breast Cytopathology: The Experience of a Single Institution

OBJECTIVE

Recently the International Academy of Cytology (IAC) proposed a new reporting system for breast fine needle aspiration biopsy (FNAB) cytology. We aimed to categorize our samples according to this classification and to assess the risk of malignancy (ROM) for each category as well as the diagnostic yield of breast FNAB.

STUDY DESIGN

Breast FNAB specimens obtained between January 2007 and December 2017 were reclassified according to the newly proposed IAC Yokohama reporting system. The ROM for each category was determined. Diagnostic yield was evaluated based on a three-category approach, benign versus malignant.

RESULTS

The samples were distributed as follows: insufficient material 5.77%, benign 73.38%, atypical 13.74%, suspicious for malignancy 1.57%, and malignant 5.54%. Of the 3,625 cases collected, 776 (21.4%) had corresponding histology. The respective ROM for each category was 4.8% for category 1 (insufficient material), 1.4% for category 2 (benign), 13% for category 3 (atypical), 97.1% for category 4 (suspicious for malignancy), and 100% for category 5 (malignant). When only malignant cases were considered positive tests, the sensitivity, specificity, and diagnostic accuracy were 97.56, 100, and 99.11%, respectively.

CONCLUSIONS

Our study is the first to categorize breast FNAB cytology samples according to the proposed IAC reporting system and to evaluate patient outcomes based on this categorization.

IAC standardized reporting of breast fine-needle aspiration cytology, Yokohama 2016: A critical appraisal over a 2 year period

BACKGROUND

Breast cytology is a significant component of the "Triple approach" for pre-operative diagnosis of breast lumps, the other two being clinical assessment and radiological imaging. The role of Fine needle aspiration cytology (FNAC) as a first line investigation in diagnosing breast lesions is well documented, however histopathology is the gold standard. Cyto-histopathological correlation is of great relevance and also increases precision.AIMS \& OBJECTIVES:The present study was conducted with the aim to categorize breast lesions according to the latest standardized reporting system proposed by International academy of cytologists (IAC) in 2016. Evaluation of diagnostic accuracy, sensitivity and specificity of FNAC in diagnosing breast lesions and cyto-histopathological correlation was planned.

MATERIALS AND METHODS

All FNAs of breast lesions over a period of 2 years were included in the study. The cases were grouped into five standardized categories proposed by the International academy of cytology: Category I (Insufficient material), Category II (Benign), Category III (Atypical, probably benign), Category IV (Suspicious, probably in situ or invasive) & Category V (Malignant) respectively. Specificity, sensitivity, diagnostic accuracy, negative and positive predictive value of FNAC were calculated and cyto-histopathological correlation assessed wherever possible.

RESULTS

Out of 468 breast lesions reported on FNAC, the category wise distribution was - Category I, II, III, IV & V accounting for 23(4.9%), 342(73.07%), 7(1.5%), 11(2.35%) and 85(18.16%) respectively. Histopathology was performed in 331/468 cases with cyto histological concordance of 98.4% and a type agreement rate of 90.9%. The sensitivity, specificity, positive and negative predictive value and diagnostic accuracy was 98.90%, 99.16%, 97.82%, 99.58% and 99.09% respectively.

CONCLUSION

FNAC is a simple, reliable, cost effective, first line diagnostic procedure for all breast lumps. In collaboration with physical examination and imaging studies (triple approach), FNAC is a highly sensitive diagnostic tool. Adopting a universally acceptable standardized reporting system for breast cytology can enhance the diagnostic accuracy of FNAC.

FNAC Versus CNB: Who Wins the Match in Breast Lesions?

The triple test lies at the heart of preoperative diagnosis of breast lesions. Raised awareness and self-assessment have significantly increased the rate of detection of breast pathologies. The managing clinicians usually decide the imaging and pathological modalities to the best interest of the patients. Core needle biopsy (CNB), cell-block studies, and fine needle aspiration cytology (FNAC) coupled with rapid on-site evaluation (ROSE) have significantly increased the accuracy of preoperative diagnosis. Immunocytochemistry, immunohistochemistry on cell blocks, and other ancillary studies give confidence to the clinicians to decide the best treatment strategies.

Current approaches in the clinical management of pregnancy-associated breast cancer-pros and cons

Malignancies are one of the leading causes of mortality in women during their reproductive life. Treatment of gynecological malignant tumors during pregnancy is possible but not simple, since it creates a conflict between care of the mother and the fetus. BC is the most prevalent malignancy diagnosed in pregnancy, ranking up to 21% of all pregnancy-related malignancies. Due to its stets increasing prevalence, aggressive cancer subtype, and severe ethical and psychological aspects linked to the disease, experts raise an alarm for an acute necessity to improve the overall management of the PABC-the issue which has strongly motivated our current paper. Comprehensive research data and clinical experience accumulated in recent years have advanced our understanding of the disease complexity. PABC treatment must be individualized with an emphasis on optimal care of the mother, while observing standard treatment protocols with regard to safety of the fetus. Treatment protocols should be elaborated based on the individualized patient profile, bearing in mind the acute danger to the mother, maximizing the therapy efficacy and minimizing harmful effects to the fetus. Complex consulting on treatment options, their impacts on pregnancy and potential teratogenic effects requires tight "doctor-patient" collaboration. Complications that may arise due to the treatment of breast cancer in pregnancy require a multiprofessional expertise including oncologists, neonatologists, perinatologists, obstetricians, teratologists, and toxicologists, and an extensive psychological support throughout the pregnancy and after giving birth. Thereby, specifically psychological aspects of PABC diagnosis and follow-up are frequently neglected, being not yet adequately explored in the entire disease management approach. Herewith, we update the status quo regarding the currently available diagnostic modalities, complex treatment algorithms, and novel clinical approaches which altogether argue for an urgent necessity of a paradigm shift moving away from reactive to predictive, preventive, and personalized medical approach in the overall management of PABC meeting the needs of young populations, persons at high risk, affected patients, and families as the society at large.

Impact of sentinel lymph node biopsy in newly diagnosed invasive breast cancer patients with suspicious node: a comparative accuracy survey of fine-needle aspiration biopsy versus core-needle biopsy

Comparing diagnostic accuracy study between ultrasonography (US) guided fine-needle aspiration biopsy (FNAB) and core-needle biopsy (CNB) of the Sentinel lymph nodes (SLNs) in newly diagnosed invasive breast cancer patients. We selected 289 newly diagnosed invasive breast cancer patients from June 2015 to July 2017. Ultrasound (US) guided fine-needle aspiration cytology (FNA) and core-needle biopsy (CNB) was performed to identify patients with suspicious sentinel lymph node (SLN). Patients with a cortical thickness > 2 mm or atypical morphological characteristics were recommended FNA and CNB. Axillary lymph node dissection (ALND) was applied to patients with biopsy-proven metastasis, and sentinel lymph node biopsy (SLNB) was applied to FNA or CNB negative patients. ALND was also performed when SNB is positive. Out of 289 patients, only 131 patients met final study criteria. Lymph node status was evaluated by FNA, CNB, SLND, and ALND. Among 131 patients, 45 were deemed positive for metastasis and 86 were determined to be negative with CNB, whereas 38 were deemed positive for metastasis and 93 were determined to be negative by using FNAB. CNB was used to correctly identify seven axillae as positive for metastasis that were deemed negative by using FNAB. There were no positive FNAB results in axillae that were negative for metastasis with CNB. All patients underwent SLNB and those with biopsy-proved axillary metastases were assigned directly to ALND as the primary staging procedure. The final histopathologic assessment indicated that 50 (38.2%) of the 131 axillae studied had axillary LN metastases. Axillary US-guided CNB was used to correctly identify 45 (90.0%) of the 50 LN-positive axillae, whereas axillary US-guided FNAB was used to correctly identify 38 (76.0%, P < 0. 001). There were no false-positive results. CNB netted 5 false-negative results, and FNAB resulted in 12. There was significantly different accuracy between different diagnostic tools. In our study, we demonstrated that CNB is a more reliable approach than FNA for the preoperative diagnosis of SLN metastasis.

Breast Metaplastic Squamous Cell Carcinoma Diagnosed with Fine Needle and Core Biopsy: A Case Study

BACKGROUND Breast metaplastic squamous cell carcinoma (SCC) is a rare primary breast carcinoma, and overexpression of HER2 in this carcinoma is extremely uncommon. CASE REPORT We presented a case of a 48-year-old Asian female with breast metaplastic SCC. Fine needle aspiration biopsy (FNAB) and core needle biopsy (CNB) of the lesion were taken prior to surgical resection. FNAB smears demonstrated highly atypical squamous cells and a diagnosis positive for malignancy was rendered. CNB and a surgical resection specimen revealed invasive squamous carcinoma with keratin pearl formation and intercellular bridges. Further study demonstrated this was an unusual metaplastic SCC case with basal-HER2 (+) phenotype. HER2 has been linked to poor prognosis and response to therapy. CONCLUSIONS The pathological diagnosis of the breast metaplastic SCC was made initially by FNAB and CNB. Identification of basal-HER2 (+) phenotype was critical for selection of hormonal therapies and chemotherapy.

Carcinoma in situ of the breast in New South Wales, Australia: Current status and trends over the last 40 year

BACKGROUND

The incidence of non-invasive breast cancer has increased substantially over time. We aim to describe temporal trends in the incidence of carcinoma in situ of the breast in New South Wales (NSW), Australia.

METHODS

Descriptive study of trends in the incidence of ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS) in women who received a diagnosis from 1972 to 2012, recorded in the NSW Cancer Registry.

RESULTS

Carcinoma in situ as a proportion of all breast cancer was 0.4% during the prescreening period 1972 to 1987 and is currently 14.1% (2006 to 2012). Among 10,810 women diagnosed with DCIS, incidence across all ages rose from 0.15 per 100,000 during 1972 to 1983 to 16.81 per 100,000 over 2006 to 2012, representing a 100-fold increase (IRR 113.10; 95% CI 81.94 to 156.08). Among women in the target age group for screening (50-69 years) incidence rose from 0.27 per 100,000 to 51.96 over the same period (IRR 195.50; 95% CI 117.26 to 325.89). DCIS incidence peaks in women aged 60-69 years. DCIS incidence has not stabilized despite screening being well established for over 20 years, and participation rates in the target age range remaining stable.

CONCLUSIONS

Our findings raise questions about the value of the increasing detection of DCIS and aggressive treatment of these lesions, especially among older women, and support trials of de-escalated treatment.

Pre-operative axillary staging: should core biopsy be preferred to fine needle aspiration cytology?

Objective

To determine the diagnostic accuracy of ultrasound guided fine needle aspiration (FNA) cytology and core needle biopsy (CNB) of axillary lymph nodes pre-operatively in newly diagnosed operable primary breast cancer.

Methods

An observational study for all patients who underwent pre-operative FNA cytology or CNB during September 2013–August 2014 was conducted at our institution (County Hospital, Stafford, UK). The accuracy of pre-operative axillary staging was compared to the post-operative histology. For this sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) were calculated.

Results

A total of 81 consecutive patients were evaluated by axillary ultrasound. Patients identified with potentially abnormal axillary lymph nodes underwent definitive surgery. Seven patients had positive cytology/histology who did not undergo definitive surgery and were excluded (N = 74) from the study. CNB had a sensitivity of 100% versus 72% (p = 0.006) for FNA cytology. Both had 100% specificity and PPV. The NPV of CNB was 100% versus 72% for FNA cytology. Among 35% of patients that underwent FNA cytology required repeat procedure versus 2.6% of patients who underwent CNB. 0/38 patients that had CNB required a second operation while 7/43 patients with negative FNA cytology had positive lymph nodes identified at sentinel lymph node biopsy (SLNB) requiring surgical re-intervention with axillary node clearance.

Conclusion

CNB was superior to FNA cytology when interrogating the axilla. We recommend CNB to be adopted routinely in pre-operative axillary staging to reduce surgical re-intervention.