Diagnosis of breast lesions: fine-needle aspiration cytology or core needle biopsy? A review

Diagnosis of breast lesions is routinely performed by the triple assessment of a specialised surgeon, radiologist and pathologist. In this setting, fine-needle aspiration cytology (FNAC) and core needle biopsy (CNB) are the current methods of choice for pathological diagnosis, both with their specific advantages and limitations. Evidence-based literature discussing which of both modalities is preferable in breast lesion diagnosis is sparse and there is no consensus among different specialised breast cancer centres. This study reviews FNAC and CNB for diagnosing breast lesions, comparing methodological issues, diagnostic performance indices, possibilities for additional prognostic and predictive tests and cost effectiveness. Overall, CNB achieved better sensitivity and specificity especially in those lesions that were not definitively benign or malignant, non-palpable and/or calcified lesions. Although FNAC is easier to perform, interpretation requires vast experience and even then, it is more often inconclusive requiring additional CNB. The authors conclude that overall CNB is to be preferred as a diagnostic method.     

Can mucinous lesions of the breast be reliably diagnosed by core needle biopsy?

Lesions of the breast containing extravasated mucin span a continuum from benign mucoceles to invasive mucinous (colloid) carcinoma. It is well known that distinguishing benign from malignant mucinous lesions is difficult infine-needle aspiration material. Whether these lesions also are difficult to distinguish in core needle biopsy material is not known. To address this, I reviewed the results of 4,297 breast core needle biopsies. Mucinous lesions were identified in 22 cases (0.51%), and excisional biopsy material was available for 15 of these. At excision, 0 of 8 benign mucinous lesions showed carcinoma, while 7 of 7 mucinous lesions associated with carcinoma at the time of core needle biopsy showed carcinoma at excision. The vast majority of mucinous lesions of the breast can be diagnosed accurately by core needle biopsy. Whether all such lesions require excision is not known at this time.     

Can hamartoma of the breast be distinguished from fibroadenoma using fine‐needle aspiration cytology?

In an attempt to determine if it is possible to distinguish hamartoma of the breast from fibroadenoma using fine-needle aspiration cytology, we reviewed the cytological slides of 13 histopathologically confirmed cases of hamartoma of the breast and compared them with the cytological features of 13 histologically confirmed fibroadenomas. In each case, we studied the epithelial and stromal features. Cytologic characteristics were retrospectively evaluated in a semiquantitative manner. In conclusion, the finding of intact lobular units and a relative paucity of stroma may suggest the diagnosis of hamartoma.     

Conversion to core biopsy in preoperative diagnosis of breast lesions: is it justified by results?

AIMS: In recent years there has been increased use of core biopsy for the preoperative diagnosis of screen detected and symptomatic breast lesions. The aim of this study was to compare the quality assessment parameters for preoperative diagnosis by fine needle aspiration cytology (FNAC) before conversion to core biopsy with those for core biopsy after conversion in screening and symptomatic practice. Accuracy of typing and grading of tumours on core biopsy was assessed. METHODS: Correlation of FNAC (C1-5) and core biopsy (B1-5) results (total of 1768 cases) with subsequent available resection histology was performed for 473 FNAC samples in 1997/98, 349 core biopsies in 1998/99 performed in symptomatic practice, for 561 FNAC samples in 1997/98, and 385 core biopsies in 1998/99 performed in screening. Quality assessment parameters were calculated using the methodology detailed in the National Health Service Breast Screening Programme guidelines for cytology practice. RESULTS: Increased absolute and complete specificity, lower inadequate rates, and lower suspicious rates were found for core biopsy compared with FNAC in both symptomatic and screening practice. Typing of tumours was attempted in 86.7% of core biopsies in symptomatic practice and was accurate in 93.6% (132 of 141 where type was stated). Grading of tumours was attempted in 63.5% of invasive carcinomas, with the provisional grade on core biopsy being confirmed on later histology in 75% of grade 1 cases, in 70% of grade 2 cases, and in 86% of grade 3 cases. No case provisionally graded as 1 was subsequently found to be grade 3 and no provisionally grade 3 case was found to be grade 1. CONCLUSION: Conversion to core biopsy for the preoperative diagnosis of breast lesions increases specificity and reduces inadequate and suspicious rates. Grading and typing of tumours and assessment of oestrogen receptor status by immunocytochemistry is also possible in core biopsy, thereby increasing diagnostic information available when considering treatment options.     

Thyroid fine‐needle aspiration cytology: Is there a place to virtual cytology?

Telecytology has been used for education, training, and consultation. Cytological studies from gynecological, nongynecological and fine‐needle aspiration cytology (FNAC) specimens (including studies of thyroid FNAC) analyzed the diagnostic accuracy and reproducibility of telecytology‐based predominantly on static digital images. The aim of this study was to evaluate the diagnostic reproducibility of virtual cytology by measuring intraobserver and interobserver agreements among two cytopathologists, using the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) nomenclature. 502 glass slides from 222 cases of thyroid FNAC were retrieved and scanned by a high‐resolution scanner generating whole slides images (virtual cytology). Conventional and virtual cytology were analyzed by a skilled cytopathologist and the intraobserver agreement rate was 77.5% with the corresponding κ value of 0.54, suggesting a moderate agreement between both methods. A second cytopathologist analyzed the same slides only by virtual cytology and the interobserver agreement rate was 80.2% with the corresponding κ value of 0.57, suggesting a moderate agreement between both cytopathologists. The virtual cytology resulted in a higher proportion of aspirates classified as nondiagnostic (20.3 and 14.9% for the first and second cytopathologist, respectively) as compared to conventional cytology (8.1%). Regarding specific diagnostic categories as defined by the BSRTC nomenclature, the follicular lesion of undetermined significance category presented the lowest concordance rates, corresponding to 5.9% intraobserver agreement and no (0.0%) interobserver agreement. We suggest that virtual cytology can be an alternative to conventional cytology in assessment of thyroid FNAC specimens, but nondiagnostic aspirates obtained by virtual cytology should be reassessed by conventional cytology. Diagn. Cytopathol. 2013;41:793–798. © 2013 Wiley Periodicals, Inc.     

Can core biopsy reliably diagnose mucinous lesions of the breast?

Mucinous lesions in the breast are uncommon. They constitute a wide spectrum of lesions ranging from extravasated mucin associated with fibrocystic change to mucinous carcinoma. There are limited data on the reliability of core biopsy in the diagnosis of mucinous lesions of the breast. We reviewed the core biopsy and surgical biopsy diagnoses in 32 mucinous lesions of the breast. We conclude that core biopsy is highly reliable for accurate diagnosis of mucinous lesions of the breast.     

Is it possible to start the treatment based on immediate cytologic evaluation of core needle biopsy of the spinal lesions?

Core needle biopsy is widely used to diagnose spinal lesions. Final histopathological report of the specimen usually can be given after several days. These several days delay may prevent early treatment in some patients. Our aim was to investigate if treatment of spinal lesions could be started according to the immediate cytologic evaluation of the core needle biopsy. The cytological materials of the 213 core needle spinal biopsy were prepared immediately after biopsy procedure. Of these biopsies, only 101 core needle biopsy had a final diagnosis which formed the backbone of the current study. Cytological materials of these cases were compared with both histopathologic results of the core biopsy and with final diagnosis obtained by open surgery or clinical follow up. According to final diagnoses 40 patients had infections, 59 patients had neoplasms and 2 patients had no pathology. When the diagnosis that determines the treatment is considered, the overall success rates (positive predictive value:PPV) of cytology and histology were 0.65 and 0.76 respectively. Moreover when the specific diagnosis were analyzed separetely in the subgroups of tuberculous infection, lymphoma and plasmacytoma; PPV of both cytological and histological assessments was 1.00. In spinal metastasis, PPV was 0.97 for cytology and 1.00 for histology. Rapid cytologic interpretation of core needle biopsy material is a useful and reliable tool to determine the spinal lesions which require urgent treatment. When the cytological specimen reveals the diagnosis of spinal metastasis, lymphoma, plasmacytoma or tuberculosis, the treatment may be started without waiting the result of the histological examination.     

Diagnostic limitations in testicular cytopathology: To what extent is fine‐needle aspiration reliable for the diagnosis of epidermoid cyst of the testis?

This article describes the cytologic and histologic findings of a epidermoid cyst of the testis diagnosed by means of fine-needle aspiration (FNA) cytology. The gross and cytologic features are creamy aspirate, squamous cells, squamae, and fragments of granulomatous tissue. The cytologic features are fairly typical and similar to those observed in cutaneous epidermoid cysts; however, in this setting, the differential diagnosis should be carried out mainly with teratoma and dermoid cysts. The patient's age and precise location of the mass are paramount in the differential diagnosis. We believe that FNA is a reliable tool for the diagnosis of testicular epidermoid cysts, but the differential diagnosis with dermoid cysts should be based on histology.     

Should fine‐needle aspiration cytology be the first choice diagnostic modality for assessment of all nonpalpable breast lesions? The experience of a breast cancer screening center in Alexandria,Egypt

Fine‐needle aspiration cytology (FNAC) of breast masses has been replaced by ultrasound‐guided core‐needle biopsy (USG‐CNB) in many countries. However, in Egypt, breast FNAC continues to play the major role in diagnosing breast masses. In this prospective study, we evaluated the efficacy of USG‐FNACs performed at a breast cancer screening center by comparing the FNAC results with the corresponding definitive histological examination outcome. We also investigated the role that CNB can play as a complementary diagnostic tool for FNAC in selected cases. A total of 229 consecutive nonpalpable breast masses were included in this study. Each FNAC was placed into one of four categories: 3.5% nondiagnostic, 13.5% benign, 12.3% atypical/suspicious (indeterminate), and 70.7% malignant. The overall diagnostic accuracy was 98.9%, with a specificity and sensitivity of 99.3 and 96.7%, respectively. The overall positive predictive values and negative predictive values were 99.3 and 96.7%, respectively. Only 37 masses (16%) were converted to CNB, with the indeterminate cytology being the most common cause (54%) for this conversion. Two cases demonstrating the superior benefit of FNAC over CNB are illustrated. Although we started the study by reserving CNB as a first choice to assess microcalcifications without architectural distortion, we ended the study by deciding to perform combined FNAC and CNB for this type of lesions. In conclusion, aiming to maximize the preoperative diagnosis of cancer, it would be cost efficient and time saving to use FNAC as a first‐line investigation to benefit from the wealth of cytological information yielded, followed by CNB in selected cases. Diagn. Cytopathol. 2010;38:880–889. © 2010 Wiley‐Liss, Inc.     

Intraprocedural evaluation of fine‐needle aspiration smears: How good are we?

A significant percentage of fine‐needle aspirations (FNAs) is obtained using radiographic image guidance. Such image‐guided aspirates are associated with increased costs, and it is highly desirable that adequate material for diagnosis is obtained at the time of the initial procedure. Hence, intraoperative evaluation of smear material is frequently performed to evaluate adequacy and to triage the aspirate to specialized tests such as flow cytometry and cytogenetics for appropriate work‐up. Although FNA under radiologic guidance has been shown to be useful, little data exist as to the accuracy of such intraprocedural evaluation. The quality‐assurance records between May 2009 and May 2010 were electronically searched for all FNA cases with intraprocedural evaluation. The reports were obtained and reviewed to compare the intraprocedural diagnosis and the final cytopathologic diagnosis. Percentage of deferred cases and percentage of disagreement were calculated. From May 2009 to May 2010, a total of 775 FNAs were performed with intraprocedural review. These cases were reviewed by seven board‐certified cytopathologists. In 738 cases, the preliminary interpretation agreed with the final diagnosis. In 2.2% (17 of 775) of cases, the interpretation was deferred until‐cell block, and/or cytospin preparations were obtained. In 2.6% (20 of 775) of cases, a disagreement in diagnosis existed between the initial interpretation and the final sign‐out diagnosis. Intraprocedural interpretation of FNA material appears to be highly reliable with disagreements occurring in only 2.6% of cases. This degree of disagreement is slightly higher than that reported in some frozen section studies. Diagn. Cytopathol. 2012. © 2011 Wiley Periodicals, Inc.     

Will the spectrum of lesions prompting a "B3" breast core biopsy increase the benign biopsy rate?

Aim: To audit the benign surgical biopsies in women screened, assessed, and referred by the Leeds/Wakefield Breast Screening Unit for the year 1999-2000 with a view to determining any association with a preoperative B3 core biopsy categorisation. METHODS: The results of all preoperative diagnostic procedures in all patients who underwent surgical excision for a lesion proving benign in the year 1999-2000 were reviewed. Cases were categorised according to whether the preoperative fine needle aspirate cytology (FNAC) or core biopsy had been equivocal or of uncertain malignant potential (C3/B3), inadequate or unrepresentative (C1/B1), or benign (C2/B2). In those cases with a C3/B3 FNAC or core biopsy result, reasons for the uncertainty were determined by examination of the report and, where necessary, slides. In cases with C1/B1 or C2/B2 investigations and in those without a preoperative procedure, the reasons for surgical referral were determined from the screening records. Case records of all patients with a B3 core biopsy categorisation who subsequently proved to have malignancy were also reviewed. RESULTS: Thirty six women had benign surgical biopsies in the 1999-2000 screening year. In 13 of the 36 patients, referral for diagnostic biopsy rested on radiological and/or pathological suspicion of radial scar. The core biopsy category was B3 in all but one, which was in the B1 category. In a further 10 patients, referral was based primarily on a pathological B3 categorisation. The reasons for this were as follows: papillary lesion (two), fibroepithelial lesion (two), atypical intraductal epithelial proliferation (two), stromal mucin (two), atypical lobular hyperplasia (one), and an unusual vascular lesion (one). Two cases with a C3 on FNAC also derived from papillary lesions. In the remaining nine patients, the radiological features were sufficiently suspicious to prompt referral in the presence of either inadequate/unrepresentative (C1/B1) or benign (B2) preoperative pathological findings. Two women had no preoperative needle biopsy. CONCLUSIONS: In 22 of 36 benign biopsies, the initial core biopsy categorisation was B3. According to the current system of core biopsy categorisation, a diversity of lesions must be designated as of "uncertain malignant potential" (B3) because the technique provides insufficient tissue for full histological assessment. The use of this category may increase the number of benign biopsies if all such cases are referred for surgery. An increase in the benign biopsy rate may be averted if larger amounts of tissue can be obtained using newer vacuum assisted techniques such as the Mammotome.     

Is fine-needle aspiration biopsy a practical alternative to open biopsy for the primary diagnosis of sarcoma? Experience with 140 patients

We reviewed the clinicopathologic features of 145 consecutive fine-needle aspiration biopsy (FNAB) specimens from 140 patients without a previous diagnosis of sarcoma. Among 138 adequate specimens, 42 bone sarcomas and 80 soft tissue sarcomas were recognized as sarcomas; histologic subtyping was easier in bone than in soft tissue sarcomas and in pediatric than in adult cases. There was no correlation in accuracy of subtyping in low- vs high-grade sarcomas. FNAB was most accurate for subtyping of skeletal osteosarcoma, pediatric small round cell bone/soft tissue sarcomas, synovial sarcoma, skeletal chondrosarcoma, and adult myxoid soft tissue sarcomas. Although almost always recognized as sarcoma, subtyping of adult pleomorphic soft tissue sarcomas generally was not possible but did not influence therapy; all were considered high-grade sarcomas for treatment purposes. There were 4 misinterpretations of subtype in soft tissue sarcomas; none resulted in a change in therapy. Cytogenetic analysis on aspirated material confirmed t(11;22) in 2 Ewing and t(X;18) in 3 synovial sarcomas. No procedure-related complications occurred. Among bone and soft tissue sarcomas, FNAB was sufficient for initiation of definitive therapy in 87% and 83% of patients, respectively. Most FNAB specimens from bone and soft tissue sarcomas are recognized easily as sarcoma, but subtyping seems more accurate in bone sarcomas. Although histologic subtyping of adult soft tissue sarcomas is often impossible, no influence on initial therapy is usually observed. In contrast, subtyping of pediatric sarcomas by FNAB seems highly accurate and is necessary for appropriate therapy.     

Occult papillary microcarcinoma of the thyroid--a potential pitfall of fine needle aspiration cytology?

The use of fine needle aspiration cytology detected papillary carcinoma in two patients with multinodular goitre measuring 0.7 cm and 0.9 cm in diameter, respectively. Like most of the cases from previous large series, the tumours progressed slowly as shown by absence of enlarged glands on surgical exploration and no clinical signs of metastasis after two and five years of follow up. This study shows that aspiration cytology can detect a virtually harmless occult papillary carcinoma that will oblige patients to have surgery. This very occasional "pitfall" of fine needle aspiration should not preclude this well known beneficial method from being used in the management of thyroid disease.