Accuracy of fine needle aspiration cytology (FNAC) of axillary lymph nodes as a triage test in breast cancer staging

Introduction Axillary node fine needle aspiration cytology (FNAC) has the potential to triage women with operable breast cancer to initial nodal surgical procedure. Because of variability in the reported accuracy of this test its role and clinical utility in pre-operative staging remains controversial. Methods We retrospectively evaluated the accuracy of ultrasound-guided axillary FNAC in all consecutive clinically T1–2 N0–1 breast cancers that had undergone this test (491 biopsies). We included subjects with clinically or sonographically indeterminate or suspicious nodes. Pathological node status was used as the reference standard (based on axillary dissection or sentinel node biopsy). Results Sensitivity of node FNAC was 72.6% (67.3–77.9) and specificity was 95.7% (92.5–98.8) for all cases, sensitivity was lower at 64.6% (59.3–70.0) if inadequate cytology was included as a negative result. FNAC sensitivity was highest in women with clinically suspicious nodes [92.5% (88.2–96.7)] and lowest in women with sonographically abnormal and clinically negative nodes [50.0% (41.3–58.7)]. Specificity was high in both groups, 81.2% (54.5–96.0) and 97.2% (94.6–99.9), respectively. The false-negative rate was 15.3% (12.1–18.5), the false-positive rate was 1.4% (0.4–2.5), and the inadequacy rate was 10.8% (8.0–13.5). The likelihood of node FNAC being positive was significantly associated with tumour grade and stage, and the number of nodes involved with metastases. Discussion Our data show that axillary FNAC has moderate sensitivity (which varies according to selection criteria for the test) and consistently high specificity, is associated with low inadequacy and very few false positives. We estimate that its use would have improved triage to initial nodal procedure in about one quarter of our cases. If one accepts the premise that initial surgical staging of the axilla should be based on all information available through pre-operative diagnosis, then axillary FNAC should be adopted routinely into clinical practice.     

Accuracy of fine‐needle aspiration cytology of axillary lymph nodes in breast cancer patients

BACKGROUND

Fine‐needle aspiration (FNA) cytology of axillary lymph nodes is a simple, minimally invasive technique that can be used to improve preoperative determination of the status of the axillary lymph nodes in patients with breast cancer, thereby serving as a tool with which to triage patients for sentinel versus full lymph node dissection procedures. The aim of the current study was to determine the sensitivity and specificity of FNA cytology to detect metastatic breast carcinoma in axillary lymph nodes.

METHODS

A total of 115 FNAs of axillary lymph nodes of breast cancer patients with histologic follow‐up (subsequent sentinel or full lymph node dissection) were included in the current study. The specificity and sensitivity, as well as the positive and negative predictive values, were calculated.

RESULTS

The positive and negative predictive values of FNA cytology of axillary lymph nodes for metastatic breast carcinoma were 1.00 and 0.60, respectively. The overall sensitivity of axillary lymph node FNA in all the cases studied was 65% and the specificity was 100%. The sensitivity of FNA was lower in the sentinel lymph node group than in the full lymph node dissection group (16% vs 88%, respectively), which was believed to be attributable to the small size of the metastatic foci in the sentinel lymph node group (median, 0.25 cm). All false‐negative FNAs, with the exception of 1 case, were believed to be the result of sampling error. There was no ‘true’ false‐positive FNA case in the current study.

CONCLUSIONS

FNA of axillary lymph nodes is a sensitive and very specific method with which to detect metastasis in breast cancer patients. Because of its excellent positive predictive value, full axillary lymph node dissection can be planned safely instead of a sentinel lymph node dissection when a preoperative positive FNA result is rendered. Cancer (Cancer Cytopathol) 2008. © American Cancer Society.     

超声引导针吸活检在术前判断乳腺癌腋窝淋巴结状态中的应用

目的：研究对超声异常的腋窝淋巴结进行针吸活检的临床价值.方法：对47例cT1-2N0M0腋窝超声异常乳腺癌患者的腋窝淋巴结进行超声引导下针吸活检,结果与组织学病理结果进行对照.分析超声引导针吸活检术前判断乳腺癌腋窝淋巴结转移的敏感性、特异性、阳性预测值、阴性预测值和诊断准确率.结果：超声引导针吸活检判断腋窝淋巴结转移的敏感性、特异性、阳性预测值、阴性预测值和诊断准确率分别为82.8%、100.0%、100.0%、78.3%、89.4%.结论：超声引导针吸活检是术前评估腋窝淋巴结状态的有效检查方法,其结果对乳腺癌手术方式的选择具有重要参考价值.     

超声引导细针穿刺细胞学检查在胰腺癌诊断中的应用

目的:评价超声引导下细针穿刺细胞学检查在胰腺癌诊断中的价值以及穿刺相关并发症。方法:2002年5月～2005年12月,我院临床诊断胰腺癌病例232例,对其中行胰腺穿刺的46例患者进行了回顾性分析。结果:46例患者中,男性33例,女性13例,平均年龄62.1岁(40～79岁)。穿刺结果显示:34例呈恶性,2例呈异形细胞,10例呈良性。其中34例恶性病例最终均被证实为胰腺癌,无假阳性病例;10例良性中最终证实5例为良性,5例为恶性。2例异形细胞被证实为恶性。5例真阴性病例包括2例胰腺囊肿、2例胰腺结核和1例胰腺炎。以上结果提示超声引导下细针穿刺其敏感性、特异性、阳性预测值、阴性预测值以及准确性分别为82.9%、100.0%、100.0%、41.7%和84.8%。46例病例中,11例患者出现穿刺后腹部轻微钝痛,但均自愈,未有出血、感染或胰腺炎等穿刺相关并发症,长期随访未发现有腹腔播散或者穿刺道种植等并发症。结论:超声引导下细针穿刺诊断胰腺癌准确性高,并发症少,值得临床进一步推广。     

Ultrasound-guided fine needle aspiration cytology as an addendum to sentinel lymph node biopsy can perfect the staging strategy in melanoma patients

BackgroundUltrasound guided fine needle aspiration cytology (US-guided FNAC) can identify microscopic involvement of lymph nodes as in breast cancer and avoid surgical sentinel node (SN). Its utility in melanoma patients is controversial and subject of this study.MethodsBetween 2001 and 2010 over 1000 stage I/II consecutive melanoma patients prospectively underwent US-FNAC prior to SN biopsy. All patients underwent lymphoscintigraphy prior to US-FNAC. The Berlin US morphology criteria: Peripheral perfusion (PP), loss of central echoes (LCE) and balloon shaped (BS) were registered. FNAC was performed in case of presence of any of these factors. SN tumour burden was measured according to the Rotterdam criteria. All patients underwent SN or lymph node dissection (LND) in case of positive FNAC.FindingsMean/median Breslow thickness was 2.58/1.57 mm. Mean/median follow-up was 56/53 months (1–132). SN positivity rate was 21%. US-FNAC Sensitivity was 71% (US only) and 51% (US-FNAC). Sensitivity of US-FNAC was highest for T4 (76%) and ulcerated melanomas (63%). PP, LCE and BS had sensitivity of 69%, 24% and 24% respectively. Sensitivity of US-FNAC increased with increasing SN tumour burden. PP was an early sign of metastasis (58% in <0.1 mm metastases). Threshold size of a metastasis for FNAC was 0.3 mm. Five-year survival correlated to US-FNAC status (95% in negative and 59% in positive).InterpretationUltrasound guided FNAC (US-FNAC) according to the Berlin morphology criteria could correctly identify at least half of all tumour positive sentinel nodes, prior to the surgical SN procedure. Peripheral perfusion is an early sign of metastasis, which is very sensitive, but with lower positive predictive value (PPV). It is responsible for the sensitivity of the procedure. Balloon shape is a sign of advanced metastases, with lower sensitivity, but high PPV. US-FNAC sensitivity correlated with increasing T-stage, ulceration of the primary and increasing SN tumour burden. US-FNAC status accurately predicts survival.     

腋窝微小淋巴结在乳腺癌分期中的作用

目的探讨乳腺癌腋窝微小淋巴结对乳腺癌分期的影响。方法127例乳腺癌不同根治性手术清除的腋窝组织经专人按常规方法寻找淋巴结后，把腋窝脂肪组织切1cm厚浸泡于溶脂液（Carnoy＇s solution）6～12h，取出腋窝脂肪组织置于玻璃板上寻找微小淋巴结，检出的淋巴结行常规病理检查。结果依靠常规方法检出淋巴结2483枚（平均每例19．55&#177;7．95枚）；腋窝组织经溶脂液浸泡后检出1—6mm的淋巴结878枚（平均每例6．9&#177;5．31枚），其中3mm以下的淋巴结781枚。使平均腋窝淋巴结检出数量增加到26，47&#177;9．69枚。7例患者的pN改变，其中4例pN0升为pN1，2例pN1升为pN2，1例pN2升为pN3。结论该溶脂法能简捷地检出腋窝微小淋巴结，有助于乳腺癌的精确分期。     

A case of malignant melanoma, axillary lymph node metastasis proved by fine needle aspiration biopsy cytology

We report the case of a 57-year-old man with a malignant melanoma in the subunguinal region of his right thumb associated with the palpable axillary lymph nodes. Its metastasis was confirmed by fine needle aspiration biopsy cytology. Prognosis if a malignant melanoma is protean by its stage. Thus information regarding the axillary metastasis is mandatory for deciding the therapeutic plan. Fine needle aspiration biopsy cytology is a useful technique for diagnosing lymph node metastasis.     

小细胞型乳腺癌细针吸取细胞学诊断探讨

目的:探讨小细胞型乳腺癌细针吸取细胞学诊断要点及鉴别诊断.方法:分析26例小细胞型乳腺癌临床、细针穿刺和细胞学特点,同时与64例乳腺增生症、82例乳腺纤维腺瘤对照.结果: 26例小细胞型乳腺癌:≥40岁、穿刺针感脆样或偏软均占88.5%(23/26),穿刺容易吸出物质占80.8%(21/26),以散在或小细胞群为主、圆形细胞核占绝大多数、核间疏松排列均占76.9%(20/26),排列杂乱、无极性占84.6%(22/26),腺腔样、腺管样、爆竹样、栅栏样排列分别为61.5%(16/26)、34.6%(9/26)、19.2%(5/26)、30.8%(8/26),散在细胞中等量以上、圆形核占绝大多数均占84.6%(22/26),胞浆完整88.5%(23/26),未见肌上皮细胞92.3%(24/26),均明显高于乳腺增生症、乳腺纤维腺瘤的相对病例数,差异有统计学意义,均P＜0.01;细胞数量多的占69.2%(18/26),明显高于乳腺增生症4.7%(3/64),P＜0.01;黏液变的纤维间质成分及其与乳腺上皮细胞混杂均0例,明显低于乳腺纤维腺瘤的98.6%(80/82)、75.6%(62/82),均P＜0.01.结论:细胞量较多,以小细胞群或散在细胞为主,细胞排列松散、紊乱无极性,易见腺腔、腺管、爆竹、栅栏等特殊排列,胞浆完整、核圆形,散在细胞较易见,肌上皮细胞不见,≥40岁,穿刺针感脆样或偏软、容易吸出物质等是小细胞型乳腺癌细针吸取细胞学诊断要点,与乳腺增生症、乳腺纤维腺瘤可以鉴别.     

全自动DNA图像分析在乳腺细针穿刺细胞学诊断中的应用

目的探讨全自动DNA图像分析（DNA-ICM）系统在乳腺细针穿刺细胞学（FNAC）诊断中的应用价值。方法对95例乳腺肿块患者行细针穿刺,对所获细胞标本分别行常规细胞学诊断及DNA—ICM检测,比较两种诊断方法与组织病理学诊断结果的符合率。结果以组织病理诊断为标准,DNA—ICM与常规细胞学诊断符合率差异无统计学意义[88．4％（84／95）比94．7％（90／95）1（χ^2=2．457,P=0．117）;DNA—ICM检测排除了常规细胞学诊断的2例假阳性（可疑癌细胞）。DNA-ICM检测中,浸润性导管癌异常DNA含量的检出率高于浸润性小叶癌[90．3％（65／72）比50．0％（4／8）]（Fisher精确概率法,P=0．011）。结论DNA—ICM可以降低FNAC的假阳性率,但其对二倍体肿瘤诊断存在局限性。     

Ultrasonographically-guided fine-needle aspiration of axillary lymph nodes: role in breast cancer management

The knowledge of the status of axillary lymph nodes (LN) of patients with breast cancer is a fundamental prerequisite in the therapeutic decision. In the present work, we evaluated the impact of fine-needle aspiration cytology (FNAC) of ultrasonographically (US) selected axillary LN in the diagnosis of LN metastases and subsequently in the treatment of patients with breast cancer. Axillary US was performed in 298 patients with diagnosed breast cancer (267 invasive carcinomas and 31 ductal carcinoma in situ DCIS), and in 95 patients it was followed by FNAC of US suspicious LN. Smears were examined by routine cytological staining. Cases of uncertain diagnosis were stained in immunocytochemistry (ICC) with a combination of anticytokeratin and anti-HMFG2 antibodies. Eighty-five FNAC were informative (49 LN were positive for metastases, 36 were negative). In 49 of 267 patients with invasive breast carcinoma (18%), a preoperative diagnosis of metastatic LN in the axilla could be confirmed. These patients could proceed directly to axillary dissection. In addition, US-guided FNAC presurgically scored 49 out of 88 (55%) metastatic LN. Of all others, with nonsuspicious LN on US (203 cases including 31 DCIS), in which no FNAC examination was performed, 28 invasive carcinomas (16%) turned out to be LN positive on histological examination. Based on these data, US examination should be performed in all patients with breast cancer adding ICC-supported FNAC only on US-suspect LN. This presurgical protocol is reliable for screening patients with LN metastases that should proceed directly to axillary dissection or adjuvant chemotherapy, thus avoiding sentinel lymph node biopsy.     

Diagnostic performance of fluorodeoxyglucose-positron emission tomography/computed tomography combined with ultrasonography-guided fine needle aspiration cytology for identifying axillary lymph node status in patients with breast cancer

Aim

The aim of this study was to assess the diagnostic performance of fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) in combination with ultrasonography-guided fine needle aspiration cytology (US-guided FNAC) for the preoperative diagnosis of axillary lymph node (ALN) metastases in patients with breast cancer.

Materials and methods

A total of 318 patients with breast cancer were recruited retrospectively. Some of the cases that underwent neoadjuvant chemotherapy (NAC) were included. The sensitivity and specificity of FDG-PET/CT were calculated. We assessed the relationship between the combined results for US-guided FNAC with FDG-PET/CT and the pathological ALN status.

Results

A total of 271 patients underwent FDG-PET/CT. Of these patients, 41 underwent US-guided FNAC. The sensitivity and the specificity of FDG-PET/CT for the cases without NAC were 18.5%, 97.1%, respectively. The sensitivity in cases with NAC was 68.2%. As a whole, the sensitivity was 40.8%.ALN metastasis was detected using US-guided FNAC in a case with a negative FDG uptake in the ALN. The T stage was T2 in the case and the FDG uptake at the primary site was poor.

Conclusion

FDG-PET/CT has a good specificity for ALN metastasis, although its sensitivity is limited, especially in early-stage cases. In cases with a negative FDG uptake in the ALN, US-guided FNAC may play a role in the detection of lymph node metastasis when the primary tumor size is large and the FDG uptake in the primary tumor is low.     

The reliability of fine needle aspiration cytology in the diagnosis of breast cancer

Between September 1981 and December 1987, 1023 palpable breast tumors were submitted for cytological evaluation by fine needle aspiration before surgery (carcinoma: 793 cases, benign breast diseases: 230 cases). Clinical factor relating to the success of the aspirations were evaluated. Cases were regarded as positive when patients had a grade IV or more rating by Papanicolaou classification. The sensitivity was shown to be 73% (578/793); the specificity being 98% (226/230). A significantly lower rate of positive cancer identification occurred in smaller tumors (less than 2 cm, P less than 0.01) or scirrhous carcinomas (P less than 0.05). The comparison of positive rates between the aspiration cytology (66%) and the stamp cytology (95%) in 258 breast cancers (P less than 0.01) indicates the limited value of cytological diagnosis of breast cancers by fine needle aspiration.     

Accuracy of fine-needle aspiration cytology of axillary lymph nodes in breast cancer patients: a study of 115 cases with cytologic-histologic correlation

BACKGROUND: Fine-needle aspiration (FNA) cytology of axillary lymph nodes is a simple, minimally invasive technique that can be used to improve preoperative determination of the status of the axillary lymph nodes in patients with breast cancer, thereby serving as a tool with which to triage patients for sentinel versus full lymph node dissection procedures. The aim of the current study was to determine the sensitivity and specificity of FNA cytology to detect metastatic breast carcinoma in axillary lymph nodes. METHODS: A total of 115 FNAs of axillary lymph nodes of breast cancer patients with histologic follow-up (subsequent sentinel or full lymph node dissection) were included in the current study. The specificity and sensitivity, as well as the positive and negative predictive values, were calculated. RESULTS: The positive and negative predictive values of FNA cytology of axillary lymph nodes for metastatic breast carcinoma were 1.00 and 0.60, respectively. The overall sensitivity of axillary lymph node FNA in all the cases studied was 65% and the specificity was 100%. The sensitivity of FNA was lower in the sentinel lymph node group than in the full lymph node dissection group (16% vs 88%, respectively), which was believed to be attributable to the small size of the metastatic foci in the sentinel lymph node group (median, 0.25 cm). All false-negative FNAs, with the exception of 1 case, were believed to be the result of sampling error. There was no 'true' false-positive FNA case in the current study. CONCLUSIONS: FNA of axillary lymph nodes is a sensitive and very specific method with which to detect metastasis in breast cancer patients. Because of its excellent positive predictive value, full axillary lymph node dissection can be planned safely instead of a sentinel lymph node dissection when a preoperative positive FNA result is rendered. .     

Ultrasound and fine needle aspiration cytology of the axilla in the pre-operative identification of axillary nodal involvement in breast cancer

Aims

Pre-operative diagnosis of axillary nodal involvement in breast cancer allows one-stage axillary surgery. We evaluated the efficacy of axillary ultrasound (US) with US guided fine needle aspiration cytology (FNAC) in the diagnosis of axillary nodal involvement.

Methods

Over a 13-month period, we performed US of 369 axillae in patients with screen-detected (n = 278) and symptomatic (n = 91) invasive carcinoma of the breast, at the same time as US of the primary tumour. If abnormal lymph nodes were demonstrated, a single US guided FNAC of the most abnormal node was performed. US and FNAC results were compared with the final histology of the surgically excised lymph nodes.

Results

Among the 369 axillae studied, 102 had nodal macrometastases and 38 (37%) were identified by US guided FNAC. The rate was 33% in screen-detected and 44% in symptomatic patients. Sensitivity increased with increasing numbers of positive axillary nodes, and the more abnormal the appearances of the nodes on US.

Conclusion

US with FNAC of the most abnormal node allows pre-operative detection of a third of node positive axillae in screen-detected and over 40% of those with symptomatic breast cancer, allowing one-stage axillary surgery avoiding the sentinel node biopsy step in these patients.     

Preoperative ultrasound‐guided fine‐needle aspiration cytology for axillary staging in breast carcinoma

Axillary lymph node (ALN) status is considered to be the single most important prognostic indicator in patients with breast cancer. It can be assessed by various radiological, pathological and surgical techniques, the most accurate being histological examination of lymph nodes after axillary lymph node dissection (ALND). This prospective study was conducted to assess the feasibility and diagnostic accuracy of preoperative ultrasound (US) and ultrasound‐guided fine‐needle aspiration cytology (USG‐FNAC) of ALN in patients with breast cancer. Thirty patients with FNAC‐proven breast cancer, planned for definitive surgery with axillary clearance, were included in this study. Ultrasonographic evaluation of the axillae of these patients was conducted for alterations in size, shape, contour and cortical morphology of lymph nodes that could reflect presence of underlying metastases. Ultrasound‐guided fine‐needle aspiration cytology of the ALN was done in 24 of these patients. These findings were evaluated, with the ALN status determined by histological examination after ALND. Out of the 30 patients, eight had T₁, 16 had T₂, five had T₃, and one had T₄ lesions. Ultrasound evaluation of the ALN had a sensitivity of 86.3%, a specificity of 41.6%, a positive predictive value of 79%, a negative predictive value of 50% and a diagnostic accuracy of 73.3%. Sensitivity of USG‐FNAC was 78.95%, specificity was 100%, positive predictive value was 100%, negative predictive value was 55.56% and diagnostic accuracy was 83.33%. Our study concludes that preoperative USG‐FNAC of ALN is a simple, minimally invasive, easily available and reliable technique for the initial determination of ALN status in patients with breast cancer. Those who are USG‐FNAC positive can be directed towards ALND straight away, and only those who are USG‐FNAC negative should be considered for sentinel lymph node biopsy. This will save considerable operating time, especially where facilities for sentinel lymph node biopsy (costly dye, gamma camera, nuclear medicine facilities) are restricted or not available.