Rapid reporting on fine needle aspiration of breast lumps in outpatients

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

BSCC Code of Practice--fine needle aspiration cytology

The British Society for Clinical Cytology Code of Practice on fine needle aspiration cytology complements that on exfoliative cytopathology, which was published in the last issue (Cytopathology 2009;20:211-23). Both have been prepared with wide consultation within and outside the BSCC and have been endorsed by the Royal College of Pathologists. A separate code of practice for gynaecological cytopathology is in preparation. Fine needle aspiration (FNA) cytology is an accepted first line investigation for mass lesions, which may be targeted by palpation or a variety of imaging methods. Although FNA cytology has been shown to be a cost-effective, reliable technique its accurate interpretation depends on obtaining adequately cellular samples prepared to a high standard. Its accuracy and cost-effectiveness can be seriously compromised by inadequate samples. Although cytopathologists, radiologists, nurses or clinicians may take FNAs, they must be adequately trained, experienced and subject to regular audit. The best results are obtained when a pathologist or an experienced and trained biomedical scientist (cytotechnologist) provides immediate on-site assessment of sample adequacy whether or not the FNA requires image-guidance. This COP provides evidence-based recommendations for setting up FNA services, managing the patients, taking the samples, preparing the slides, collecting material for ancillary tests, providing rapid on-site assessment, classifying the diagnosis and providing a final report. Costs, cost-effectiveness and rare complications are taken into account as well as the time and resources required for quality control, audit and correlation of cytology with histology and outcome. Laboratories are expected to have an effective quality management system conforming to the requirements of a recognised accreditation scheme such as Clinical Pathology Accreditation (UK) Ltd.

Interpretation of fine needle aspiration cytology of the breast: a comparison of cytological, frozen section, and final histological diagnoses

This study examines the performance of the preliminary, on-site interpretation by the pathologist of fine needle aspiration (FNA) cytology smears compared to the final cytology report, the frozen section diagnosis and the final histopathological report. We found that both the preliminary and the final cytology reports gave satisfactory results over the minimum standards for quality assurance required by both the Norwegian breast screening programme and the NHS BSP in the UK with the exception of the 'suspicious' rate. We noted that the preliminary report had fewer false negatives (2.1%) than the final report (4.3%). We show that an unequivocal cytological diagnosis of malignancy is a reliable diagnosis, and in cases where mammography/ultrasonography and clinical examination are in agreement with FNA, frozen section examination is unnecessary. However, cases with a suspicious or equivocal FNA should be considered for frozen section analysis.

Quality assurance in breast cancer screening cytology: a review of the literature and a report on the U.K. national cytology scheme

The National Breast Screening Programme in the United Kingdom has had an external quality assessment (EQA) scheme for breast screening histopathology since 1990. Recently, it was decided, by the Cytology sub-group of the National Co-ordinating Committee for Breast Screening Pathology, to institute two forms of cytology quality assurance. An EQA scheme is planned with circulation of slides to pathologists, but this involves extra time and effort from the participants at a time when general pathology workloads are high. Because of this, a computer routine has been written to analyse the data already present within the National Breast Screening Computer Systems, to enable the calculation of sensitivity and specificity of fine needle aspiration, correlating the cytology results with subsequent histology or follow-up mammography for lesions where no biopsy is performed. This routine uses standardised terminology and calculations and, therefore, inter-unit comparisons can be made. Where problems are identified within a unit, the Quality Assurance team can investigate the cause and institute appropriate measures to correct the problem. This article details the procedures involved in this audit and reviews the literature, recalculating the parameters in a standard manner for a number of publications. The results of the cytology quality assurance routine from seven screening units in one health region in the U.K. are presented and the measures taken to improve the level of service are discussed.

Evidence that the sensitivity is increased and the inadequacy rate decreased when pathologists take aspirates for cytodiagnosis

The results of the diagnostic accuracy of breast fine needle aspiration specimens taken by the pathologist in a joint surgical clinic are compared with those taken by a surgeon. In the joint clinic the complete sensitivity rose by 15% and the number of missed malignancies fell by half.

The Lensman microscope: tool or toy?

The experience of using the Lensman microscope for 1 year indicates that this inexpensive, pocket-sized instrument, which can be used at the bedside or in the outpatient department, can assess the quality of needle aspirates although it is not suitable for making definitive cytological diagnoses.

Fine needle aspiration of palpable breast lumps: a 1-year audit using the Cytospin method

A fine-needle aspiration (FNA) service for the diagnosis of palpable breast lumps was started at the Royal Preston Hospital, Preston, UK, in November 1989. Over the subsequent year, 407 FNAs were taken from 393 women. A simple technique was used which involved the surgeon flushing the aspirate into 10 ml of Cytospin collection fluid; cytocentrifuge preparations were then safely and conveniently prepared in the laboratory. Slides were stained with Papanicolaou and H&E. The method detected 112 out of a total of 121 cancers (92.6%); of the nine that were undetected, five aspirates were inadequate and four were falsely reported as negative. There were no false positives. The overall inadequate rate was 11.0%. Excluding inadequate samples, the absolute sensitivity was 89.7% and complete sensitivity 96.6% with 94.4% specificity. This 1-year audit has shown the Cytospin method of FNA in palpable breast disease to have a favourable sensitivity and specificity, and therefore to be an alternative to conventional FNA using direct smears.

A one year audit of fine needle aspiration cytology for the pre-operative diagnosis of breast disease

In 1988, 985 patients presenting with breast disease, most with a palpable abnormality, were investigated by the triple approach (clinical examination, imaging and fine needle aspiration cytology [FNAC]). Using FNAC, 28% of patients were diagnosed as having carcinoma, 45% benign disease, 4% had suspicious cytology and 3% equivocal cytology. The remaining 20% had inadequate aspirates. Two false positive diagnoses of carcinoma were made (a false positive rate of 0.7%); one was a case of high grade non-Hodgkin's lymphoma and the other a papillary lesion with epithelial atypia. The false negative rate was 6.4%. Of these 49 patients, six had carcinoma-in-situ and 19 had low grade tumours. The absolute and complete sensitivities for the diagnosis of carcinoma in this series were 84.7% and 91.9% respectively and the absolute and complete specificities 99.7% and 98.3%, respectively. These figures compare favourably with those from other centres and confirm the efficacy of FNAC as part of the triple approach to the diagnosis of breast disease. The use of FNAC has resulted in a reduction in the number of Trucut and frozen section biopsies performed. Eighty three per cent of the patients with benign disease diagnosed by the triple approach have avoided excision biopsy, none of whom have subsequently been found to have carcinoma. Eighty patients with advanced breast carcinoma were spared operative intervention.

Fine needle aspiration cytology of the breast: factors affecting sensitivity

At Northampton General Hospital a pathologist takes, stains and immediately reports aspirates at a fine needle aspiration clinic which is run in conjunction with a busy surgical breast clinic. The effect of various factors on the sensitivity of the technique have been quantified. Small tumour size, certain types of tumour and lesions difficult to palpate are causes of reduced sensitivity. Acellular samples had little effect on sensitivity. In this clinic trainee aspirators achieved good results early in their experience. After one year each had improved to the level of an experienced aspirator.

Audit of diagnostic accuracy of FNA cytology specimens taken by the histopathologist in a symptomatic breast clinic

One thousand and two patients with palpable breast lumps have had fine needle aspiration at a surgical symptomatic breast clinic where the pathologist takes, stains and immediately reports the aspiration cytology smears. High levels of complete sensitivity (95.7%) and specificity (100%) have been maintained with a combined complete sensitivity for aspiration cytodiagnosis, mammography and clinical assessment of 99.7%. Significant reductions of unnecessary biopsies and out-patient revisits have allowed major resource savings to be made. In view of the high degree of accuracy obtained by this approach to the investigation of palpable breast lesions, combined clinics with their benefits for the patient, both physical and psychological, should be encouraged.