Fine-needle aspiration for breast mass diagnosis

Role of fine-needle aspiration biopsy in breast lesions: analysis of a series of 4,110 cases

From January of 1990 to December of 1992, 6,954 consecutive cytologic breast fine-needle aspiration biopsies (FNAB) were performed at the Laboratory of Pathology of Sant'Anna Hospital in Turin. Of these cases 62% were solid nodes, 35% were cystic nodes, and 2.7% were nonpalpable breast lesions (stereotaxic or ultrasound guided FNAB). We verified 4,110 cases: 913 cases underwent surgery and 3,197 were evaluated clinically, and/or cytologically, and/or with mammography at least 1 yr after the first diagnosis, or checked with the database of the Tumor Registry of Turin. In our series the FNAB sensitivity was 94.6%, specificity was 99.9%, accuracy was 98.8%, inadequate samples were 6.4%, false-negative rate was 1.4%, and false-positive rate was 0.3%. Our results indicate that the use of cell block improves sensitivity (from 85.2 to 94.6%) and strongly reduces false-negative results (from 3.9 to 1.4%). We conclude that FNAB is a discriminant procedure to the surgical biopsy in cases with clinical, ultrasound, or mammographic low or intermediate suspect, contributing to allow a high malignant/benign surgical biopsy rate and to reduce the need for frozen section diagnosis and medical costs.

Complications of mastectomy and their relationship to biopsy technique

BACKGROUND

Wound complication rates after mastectomy are associated with several factors, but little information is available correlating biopsy technique with the development of postmastectomy wound complications. Fine-needle aspiration (FNA) biopsy is an accurate method to establish a diagnosis, but it is unknown whether this approach has an impact on complications after mastectomy.

METHODS

Charts of 283 patients undergoing 289 mastectomies were reviewed to investigate any association between biopsy technique and postmastectomy complications.

RESULTS

The diagnosis of breast cancer was made by FNA biopsy in 50%, open biopsy in 49.7%, and core needle biopsy in 0.3%. The overall wound infection rate was 5.3% (14 of 266), but only 1.6% when FNA biopsy was used compared with 6.9% with open biopsy (p = 0.06). Among 43 patients undergoing breast reconstruction concomitantly with mastectomy, the infection rate was 7.1% (0% after FNA, 12% after open biopsy). Neither the development of a postoperative seroma (9.8%) nor skin flap necrosis (5.6%) was influenced by the biopsy technique used.

CONCLUSIONS

These data suggest that wound infections after mastectomy may be reduced when the diagnosis of breast cancer is established by FNA biopsy.

Breast disease

Breast diseases are a common aspect of primary care practice. Common benign and malignant breast diseases are reviewed. The evaluation of common breast problems is presented and current recommendations for diagnostic and screening mammography are discussed.

Unsatisfactory aspirates from fine-needle aspiration biopsies: a review

While there is much evidence that fine-needle aspiration biopsy (FNAB) is sensitive and specific, there is little information comparing the proportions of unsatisfactory aspirates obtained by clinicians or pathologists. We reviewed 2,199 FNAB reports of superficial lesions. Cases were grouped by organ/site and according to who performed the biopsy. The proportions of unsatisfactory aspirates were computed for clinicians and pathologists. Both groups performed approximately equal numbers of procedures. Overall, 9% of aspirates obtained were unsatisfactory (n = 191). Pathologists had lower proportions of unsatisfactory aspirates in all sites. Of aspirates obtained by clinicians, 14% were unsatisfactory, compared to 3% of those obtained by pathologists (P < .00001). The proportion of unsatisfactory aspirates appears to decrease as physician experience increases, and pathologists may have more experience with FNAB than do clinicians. Other advantages pathologists may have include technique and working with tissue regularly. Both clinicians and pathologists can expect to decrease their proportions of unsatisfactory aspirates by performing FNABs frequently.

Paragonimiasis in a cystic breast mass: case report and implications for examination of aspirated cyst fluids

We report a case of paragonimiasis diagnosed by fine-needle aspiration of a breast mass in a middle-aged Korean female with a history of breast silicone injections. Although parasitoses have been discovered by aspiration of cyst fluid in otherwise sterile sites (i.e., liver and lung), the cystic presentation in the breast of a middle-aged female complicated the diagnosis in this case. Some authors have argued against the routine cytologic examination of nonbloody cyst fluids in premenopausal women, but this protocol may lead to a false negative diagnosis in the rare instance of a parasitic cyst. While microscopic examination of breast cyst fluid is probably not warranted in every patient, it may be useful in patients at risk for unusual cystic lesions, especially if clinical and mammographic signs of fibrocystic change are absent.

Breast biopsy in women 30 years old or less

Forty women 30 years of age or less underwent breast biopsy at Roswell Park Cancer Institute between January 1980 and January 1989. Thirty-eight of the 40 women had a palpable breast mass. Thirty-one of these young women had self-detected breast masses, and the median duration before presentation was 6 months. Physical characteristics were described in 30 of the masses. Twenty-three were described as "fibroadenomas" or smooth, firm, and mobile. Seven masses were described as irregular. The median size of the breast mass was 1.5 cm (range: 0.5 to 9.0 cm). Mammography was performed in 20 patients, but results were reported as abnormal in only 6. Twenty of the masses were described histologically as fibroadenoma. Twelve were described histologically as "fibrocystic disease" or "stromal fibrosis." One case (2.5%) was invasive adenocarcinoma. Probability of serious underlying breast pathology in young women is low but not nil. Noninvasive and minimally invasive techniques are proposed by some authors as cost-efficient methods that may substitute for open biopsy in these patients. Unfortunately, false-negative results persist and are particularly unacceptable in these young women. During the same time period as our study, 54 women aged 30 years or less were referred to Roswell Park Cancer Institute with a previously diagnosed invasive breast cancer. The incidence of breast cancer in this biopsy series was 2.5%. The potential costs of misdiagnosed early breast cancer in young women negate any rationalization for less invasive biopsy techniques. Following aspiration to rule out a benign cyst, and a possible period of brief observation for spontaneous resolution (2 or 3 months), excisional biopsy is recommended for young women with a breast mass.

Evaluation of a palpable breast mass

A palpable mass in a woman's breast represents a potentially serious lesion and requires evaluation by history taking, physical examination, and mammography. The initial objective is to distinguish simple cysts from solid lesions, which can be accomplished with needle aspiration (Fig. 2). A solid lesion requires a firm diagnosis, and this usually calls for removing the lesion for histologic examination. A positive result on cytologic examination after aspiration is sufficiently accurate to justify one-stage diagnosis and treatment, with confirmation by examination of a frozen section obtained during the procedure. A negative or suspicious finding on cytologic evaluation is inconclusive, and outpatient biopsy is indicated. Perfection in diagnosis will require the removal of every solid mass. This can be expected to result in the biopsy of many benign lesions, but removal of many of them is desirable on other grounds. Although in some instances the probability of cancer may be exceedingly small, it is never zero. If biopsy is not recommended, the probability of cancer should be estimated so that the patient can decide whether the level of risk is acceptable to her.

Stratified diagnostic approach to fine needle aspiration of the breast

The clinical value of fine needle aspiration (FNA) of the breast is enhanced by incorporating into the cytologic diagnosis explicit comments on the level of diagnostic certainty. This stratification of diagnostic certainty is based predominantly on the cytologic features but occasionally also takes into consideration the clinical situation. Strong clinical and mammographic suspicion of mammary carcinoma associated with FNA, diagnostic of typical, intermediate to high-grade mammary carcinoma, warrants proceeding to definitive therapy without further diagnostic studies. False-positive results are virtually eliminated by placing cases with any uncertainty into a "probable" category, which does not support definitive therapy. In addition, oversimplified "benign versus malignant" approaches to FNA diagnoses ignore the heterogeneity of breast masses, with in situ and low-grade carcinomas warranting special clinical management and usually being placed in the "probable" category. Thus, malignant diagnoses are stratified into "definite" and "probable," with only the former supporting definitive therapy. Within our recent series of 1,005 FNAs of the breast, we were able to confirm the diagnosis in all 62 patients with a "definite" carcinoma diagnosis, and only 3 of 25 "probable" cancer diagnoses were benign at tissue biopsy. Thus, false-positive results were successfully avoided in the "definite" category. Furthermore, a much greater incidence of unusual and good prognosis tumor types were identified by the "probable" category. If the clinical setting is relatively suspicious only, a definitive diagnosis of cancer by FNA is rare and not necessary because the clinical question to be addressed is only whether to biopsy. This approach to FNA diagnosis, unlike the oversimplified "benign versus malignant" scheme, provides an approach that is more likely to result in optimal therapy for breast neoplasms, with low-grade or in situ carcinomas requiring special clinical management since these types of cancers are found predominantly in the "probably malignant" category. It also provides additional security against false-positive diagnoses by incorporating clinical level of certainty statements into FNA diagnostic categories, which more closely reflect the diversity and inherent complexity in the appropriate diagnosis and therapy of mammary carcinomas.

Multisurface method of pattern separation for medical diagnosis applied to breast cytology

Multisurface pattern separation is a mathematical method for distinguishing between elements of two pattern sets. Each element of the pattern sets is comprised of various scalar observations. In this paper, we use the diagnosis of breast cytology to demonstrate the applicability of this method to medical diagnosis and decision making. Each of 11 cytological characteristics of breast fine-needle aspirates reported to differ between benign and malignant samples was graded 1 to 10 at the time of sample collection. Nine characteristics were found to differ significantly between benign and malignant samples. Mathematically, these values for each sample were represented by a point in a nine-dimensional space of real variables. Benign points were separated from malignant ones by planes determined by linear programming. Correct separation was accomplished in 369 of 370 samples (201 benign and 169 malignant). In the one misclassified malignant case, the fine-needle aspirate cytology was so definitely benign and the cytology of the excised cancer so definitely malignant that we believe the tumor was missed on aspiration. Our mathematical method is applicable to other medical diagnostic and decision-making problems.