Is FNA Still a Useful Tool in the Diagnosis of Breast Masses? A 5-Year Review with Cytohistopathologic Correlation

For patients who present to clinicians with palpable breast lesions, the triple test: (physical examination, mammography and fine-needle aspiration cytology) can be employed to provide accurate diagnosis. In this study, the sensitivity, specificity and predictive values of triple test components were studied separately and in combination. During the study period (from January 1998 to December 1999), 140 patients with palpable breast masses were subjected to all components of the triple test followed by confirmatory open biopsy. Physical examination showed 82.6% sensitivity, 97.3% specificity and 86.4% positive predictive value. Mammography showed 87.5% sensitivity, 97.3% specificity and 87.5% positive predictive value and fine-needle aspiration cytology (FNAC) showed 91.7% sensitivity, 100% specificity and 100% positive predictive value in concordant cases (elements had either all malignant or all benign results). The triple test was 100% accurate in the diagnosis of palpable breast lesions when all three elements were concordant. Based on these results, we recommend elimination of the confirmatory open biopsy, which will result in reduced expenses and morbidity compared with open biopsy.

The reliability of fine-needle aspiration cytology (FNAC) of breast masses in males could be compromised by lack of experience because breast carcinoma is rare in males and FNAC is not often used. In addition, FNAC of the more often encountered gynecomastia may lead to overdiagnosis. Therefore, in the current study the authors evaluated their experience with FNAC of breast masses occurring in males. A total of 153 FNACs of the male breast obtained between 1985 until the end of 2000 were retrieved from the electronic files of the study institution. A total of 141 FNACs were taken from unilateral lesions in men age > 24 years, the group of men believed to be most at risk for breast carcinoma. Histologic follow-up was retrieved from the same files and was available for 72 FNACs. For specimens without histologic follow-up the nationwide pathology database was consulted and no cases of breast carcinoma were found. The inadequate rate was 13%. When inadequate FNACs were included in the calculations, the sensitivity was found to be 87% and the specificity 78%. When the inadequate FNACs were excluded from the calculations the sensitivity was reported to be 100% and the specificity 89%. The positive predictive value of a diagnosis of malignancy was 100%. During the study period the authors' institution examined approximately 10,000 FNAC specimens from male and female breasts and 399 resection specimens from the breasts of men age > 24 years with unilateral lesions. In this last group, preoperative FNAC reduced the benign-to-malignant ratio from 19.8:1 to 3.5:1. FNAC of the male breast is a reliable procedure in a setting in which sufficient numbers of FNACs of the breast are examined. The authors believe FNAC should be used more often in the preoperative evaluation of breast lesions occurring in males.

Introduction: Breast cancer affects 2.1 million women each year and is the most common cancer among females, followed by lung, colorectum, uterus, and cervix. Breast cancer accounted for 6,26,679 (6.6%) deaths in 2018. Breast cancer incidence is on the rise in every part of the globe, including developed countries. Fine Needle Aspiration Cytology (FNAC) shows high sensitivity, specificity, and accuracy in evaluation of breast lesions. FNAC is part of the triple test and is the gold standard for assessment. The new reporting system for breast FNAC, proposed by the International Academy of Cytology (IAC) Yokohama Breast Cytopathology System, has standardised the reporting system to categorise breast lesions and as unmasked the diagnostic dilemma faced by reporting cytopathologist. Aim: The study aimed to categorise the samples according to IAC Yokohama Breast Cytopathology System and assess the Risk of Malignancy (ROM) for each category and increase the diagnostic yield of breast FNAC. Materials and Methods: A retrospective cohort study included 1,467 breast FNAC cases, which were retrieved and reclassified based on the newly proposed IAC Yokohama System into five categories during January 2017-December 2018 in Kidwai Memorial Institute of Oncology (KMIO), Bangalore. Histopathology correlation was done, and the Risk of Malignancy (ROM) was assessed whenever possible. The study results were analysed using Microsoft excel 2007, sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), and accuracy ratios were calculated using the MedCalc diagnostic test evaluation calculator, keeping histologic diagnosis as the gold standard. Results: Re-categorisation of 1,467 cases was done according to the Yokohama breast cytopathology system as insufficient material, benign, atypical, suspicious for malignancy, and malignant. The histopathology diagnosis was available in 1,069 cases. The respective ROM for each category was, 7.6% for category 1 (Insufficient), 15.26% for category 2 (Benign), 65.38% for category 3 (Atypical), 83.33% for category 4 (Suspicious) and 99.18% for category 5 (Malignant). Considering malignant cases as positive, sensitivity-86.75%, specificity-97.32%, PPV-99.19%, NPV-66.06% and accuracy of 88.96% was deduced. Conclusion: It is recommended to incorporate the IAC Yokohama system to categorise breast cytopathology with uniform terminologies. This will help diagnose breast lesions more consistently and accurately, which in turn helps the clinician manage the disease and predict the ROM and the patient outcome.

Background: Benign and malignant lesions of breast are one of the most common causes of palpable masses seen in women. Fine-needle aspiration cytology (FNAC) is the important modality of diagnosis of breast lumps. Previously, there were no uniform criteria for reporting breast FNAC. To overcome this problem, the newly designed system – International Academy of Cytology (IAC) – Yokohama system of reporting was implemented in 2016. The system offers a structured report to the patient. Aims and Objectives: This study aims to categorize breast FNAC according to the IAC – Yokohama system of reporting, to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of the test, and to analyze the cytomorphological spectrum of various breast lesions. Materials and Methods: A total of 210 patients presenting with breast lump in cytology section were subjected to FNAC using a 22 gauge needle under all aseptic precautions. Detailed clinical history was taken. All cytology and histopathology examination slides (wherever available) were thoroughly studied. FNAC smears were reported using IAC – Yokohama system of reporting. Results: In our study, benign category (C2) was most commonly seen in 73.33% of cases, followed by 10.48% of cases of atypical probably benign (C3), 2.38% of cases were reported as suspicious (C4), and 11.43% of cases were reported as malignant (C5). Cytohistopathological concordance was seen in 38 cases (88.4%) whereas five cases were reported as discordant. Sensitivity and specificity of the test for the diagnosis of malignancy were 81% and 100%, respectively. PPV was 100%. NPV was 90.90%. Diagnostic accuracy of the test was 93.47%. Conclusion: The newer IAC – Yokohama system of reporting of breast FNAC is simple, has clear diagnostic criteria hence boost up the confidence as well has uniformity of reporting by cytopathologist, and increases the understanding and uniformity in assessment by the attending clinician which help in improving the communication between the pathologist and the treating clinician.

Background: Benign and malignant lesions of breast are one of the most common causes of palpable masses seen in women. Fine-needle aspiration cytology (FNAC) is the important modality of diagnosis of breast lumps. Previously, there were no uniform criteria for reporting breast FNAC. To overcome this problem, the newly designed system – International Academy of Cytology (IAC) – Yokohama system of reporting was implemented in 2016. The system offers a structured report to the patient. Aims and Objectives: This study aims to categorize breast FNAC according to the IAC – Yokohama system of reporting, to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of the test, and to analyze the cytomorphological spectrum of various breast lesions. Materials and Methods: A total of 210 patients presenting with breast lump in cytology section were subjected to FNAC using a 22 gauge needle under all aseptic precautions. Detailed clinical history was taken. All cytology and histopathology examination slides (wherever available) were thoroughly studied. FNAC smears were reported using IAC – Yokohama system of reporting. Results: In our study, benign category (C2) was most commonly seen in 73.33% of cases, followed by 10.48% of cases of atypical probably benign (C3), 2.38% of cases were reported as suspicious (C4), and 11.43% of cases were reported as malignant (C5). Cytohistopathological concordance was seen in 38 cases (88.4%) whereas five cases were reported as discordant. Sensitivity and specificity of the test for the diagnosis of malignancy were 81% and 100%, respectively. PPV was 100%. NPV was 90.90%. Diagnostic accuracy of the test was 93.47%. Conclusion: The newer IAC – Yokohama system of reporting of breast FNAC is simple, has clear diagnostic criteria hence boost up the confidence as well has uniformity of reporting by cytopathologist, and increases the understanding and uniformity in assessment by the attending clinician which help in improving the communication between the pathologist and the treating clinician.

The current practice of “Fine Needle Aspiration Cytology (FNAC) has established itself as an important modality in the diagnosis and management of superficial and deep seated lesions throughout the body. With this wide employment of FNAC, the cytopathologists play a pivotal role in the management and therapeutic decisions that are based on the diagnosis of these limited FNAC samples. Furthermore, the use of FNAC samples for biomarker research is advancing rapidly and is being widely investigated and applied for the treatment and prognostic purposes. In this special issue, we have made an attempt to provide a “flavor” of the current practice of FNAC with an emphasis on correlation of tissue biopsies with PET results, FNAC of breast, liver, pulmonary, and head and neck lesions. Similarly, the use of FNAC in the diagnosis of Langerhans cell histiocytosis, neuritic leprosy, and granulomatous inflammation is also discussed. With the increasing use of image-assisted FNAC, pathologists are now an integral part in the diagnosis and management of the deep seated lesions. In lieu of this, it has become important for the pathologists to be aware of the limitations of different imaging techniques. The paper on the correlation of tissue biopsies with PET results discusses the limitations of an increased SUV value on PET scan. The use of fine needle aspiration cytology has been proven to give fast, economical, and valuable diagnosis of palpable breast lumps. In this issue, the role of FNAC in the evaluation of breast lump in a high patient volume center is addressed with emphasis on the importance of skill and training for both pathologists and technicians to prevent suboptimal sampling, thus, increasing the reliability of the procedure. Another important but not commonly discussed aspect of breast FNAC—the nonmalignant categories—is also addressed, with a review of the cytomorphology of benign breast lumps, some of which could be mistaken for malignancy due to the diaphanous appearance and overlapping cytologic features. The false negative and false positive FNAC is further discussed in detail so as to avert misinterpretation. These provide practical information for readers when dealing with FNAC of breast lesions. The paper on liver FNAC covers various aspects and discusses the role of FNAC in liver lesions. There is an active debate about the preoperative/pretransplantation diagnostic role of FNAC of hepatocellular carcinoma (HCC) and precursor lesions, especially in the face of advances in dynamic imaging techniques. New trends in personalized molecular targeted therapy require better characterization and prediction of HCC behavior. FNAC biopsy technique is still the most minimally invasive approach for the procurement of tumor and peritumoral tissue for molecular studies. Thus, in the near future, hepatic FNAC is likely to become a point of care in the management of HCC patients, especially inoperable cases. In the current era of personalized medicine, the FNAC diagnosis of nonsmall cell carcinoma for a pulmonary nodule is no longer considered an adequate diagnosis. Pathologists are often required to further subclassify these in to adenocarcinoma and squamous cell carcinoma. With the increasing use of image-assisted FNAC including endobronchial ultrasound guided FNAC (EBUS-FNA), cytologic or small biopsy material has become the only form of tissue available for diagnosis. The paper on FNAC of pulmonary lesions reviews the current concepts in the suitability and accuracy of FNAC in lung cancers including diagnosis, classification, use of ancillary techniques, and prognostic marker assessment. FNAC is a valuable technique in the workup of nodules and masses arising within the head and neck region. It is primarily utilized to confirm or exclude the diagnosis of malignancy involving head and neck organs especially lymph nodes, thyroid, and salivary glands. It has been shown that FNAC of salivary gland lesions is a valuable way to preoperatively assess lesional tissue, determine the need for surgical intervention, and assist in planning the appropriate surgical approach prior to resection. In this issue, the manuscript on cytologic diagnosis of mucoepidermoid carcinoma discusses the role of FNAC in the diagnosis of mucoepidermoid carcinoma (MEC), the common malignant tumor affecting parotid gland. In addition, it also brings forth how the rare and recently described oncocytic variant can pose problems in the diagnosis of MEC. In conclusion, this special issue includes a potpourri of topics which provides a thoughtful glimpse into various techniques, diagnostic ability, and limitations of the current practice of FNAC. Darshana Jhala Aileen Wee Gary Tse Zubair Baloch

There are many merits to fine needle aspiration cytology (FNAC) in evaluation of palpable breast lesions. We set out to determine the concordance of breast FNAC interpretation with subsequent surgical pathology in the resource-limited healthcare setting of rural Kenya. African Inland Church Kijabe Hospital electronic pathology files were retrospectively reviewed from 1/1999-9/2017. All breast FNAC cases and subsequent surgical pathology specimens were identified. FNAC interpretations were categorised according to the International Academy of Cytology Yokohama codes: insufficient; benign; atypical favour benign; suspicious favour malignant; and malignant. Surgical pathology results were categorised as benign or malignant. In total, 695 breast FNACs were identified. A total of 219 (31.5%) had subsequent surgical pathology. Average patient age was 39years (range 13-88); 95% were female. Nearly all (98%) lesions were palpable. FNAC interpretive categorisation was as follows: 20 (9%) insufficient, 103 (47%) benign, 16 (7%) atypical, 24 (11%) suspicious and 56 (26%) malignant. On histopathology, there were 141 (64%) benign cases and 78 (36%) malignancies (Table1). The sensitivity of FNAC for detecting malignancy was 85%; specificity was 75%. Positive and negative predictive values were 69% and 88%. Diagnostic concordance between FNAC and histopathology was 79%. For definitively diagnostic FNAC categories, diagnostic concordance was 89%. On histopathology, malignant diagnoses were given in 0 insufficient, 12 (12%) benign, 4 (25%) atypical, 11 (46%) suspicious and 51 (91%) malignant cases. There were five false-positive cytopathology interpretations and 12 false-negatives. FNAC remains a valuable tool in evaluation of palpable breast lesions in resource-limited healthcare settings.

Introduction: Breast cancer is the most common cancer diagnosed in women worldwide. These rising trends have emphasized the need of prompt detection, effective clinical evaluation, and exact diagnosis of the breast disease. Aim: To analyze and compare the sensitivity, specificity, and predictive values and accuracy of ultrasonography (USG) and fine needle aspiration cytology (FNAC) in diagnosing malignant breast lump. Materials and methods: A cross-sectional, prospective study was done. One hundred sixteen female patients attending surgery department with breast lump were included. After complete clinical evaluation of the lump, all patients underwent USG and FNAC examination for diagnosis of the lump, and further subjected to excisional biopsy/definitive surgery, the results of which were further compared with the histopathological results to determine the accuracy, sensitivity, specificity, and predictive values of FNAC and USG. Results: Out of 116, 61 (52.58%) benign lesions were found while the remaining 55 (47.41%) resulted to be malignant lesions on histopathological examination (HPE). Ultrasonography reported 46 true positive, 60 true negative, and 4 false negative cases with 6 inconclusive reports; whereas, FNAC reported 47 true positive, 61 true negative, and 6 false negative cases with 2 inconclusive reports. There were no false positive cases detected by USG and FNAC. Thus, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for USG was found to be 92, 100, 100, 93.75, and 96.36% (χ2-value = 94.88, p-value = 0.0001,S) and values of 88.68, 100, 100, 91.04, and 94.73% were obtained for FNAC respectively (χ2-value = 92.04, p = 0.0001,S). Conclusion: In diagnosing malignant breast lesion, USG and FNAC are 100% specific. Although USG appears more sensitive than FNAC, the percentage of indeterminate report is higher with USG.

To determine the differential diagnostic value of high molecular cytokeratin 34betaE12 as a benign marker in mammary lesions. 90 cases (30 benign non-proliferative diseases, 20 benign proliferative diseases, 10 intraductal carcinomas and 30 invasive carcinomas) were collected, all of which had undergone fine needle aspiration cytology (FNAC) examination and a follow-up operation. Immunohistochemical staining was performed using monoclonal antibodies against 34betaE12 on FNAC smears and the follow-up paraffin sections. SPSS 10.0 software was applied to analyze the differential diagnostic value of 34betaE12 in benign and malignant mammary lesions. (1) No significant difference was found in the expression of 34betaE12 between benign non-proliferative and proliferative disease. (2) A significant difference was found between the expression of 34betaE12 in mammary benign disease and mammary carcinoma. 66.7% and 66.3% of the carcinoma cases showed either lack of 34betaE12 expression or had only a few isolated 1+ cells which were cytoplasmic positive for 34betaE12 immunoreaction on FNAC smear and paraffin section respectively. The remaining 33% of cases having 2+ to 3+ cells mainly displayed cytoplasmic granular positive reaction rather than strong membranous and cytoplasmic positive reaction as benign lesions. In contrast with carcinoma, most benign lesions showed strong immunoreaction of 2+ to 3+ and especially exhibited complete strong membranous and cytoplasmic positive reaction on paraffin section, their positive expressive character differed from those of carcinoma. The positive rates on FNAC smear and paraffin section were 100% and 78% respectively. (3) Certain types of intraductal carcinoma, including low grade cribriform, papillary and solid type either lacked 34betaE12 expression or revealed a few isolated 1+ cells with cytoplasmic positivity for 34betaE12 immunoreaction. Pronounced immunoreaction of 3+ was only seen in high grade comedotype intraductal carcinoma. 34betaE12 may serve as a marker of benign mammary disease for differential diagnosis. When there is a total or predominant lack of 34betaE12 expression, the possibility of carcinoma should be strongly considered. If 34betaE12 is expressed diffusely in the suspicious area with a strong membranous staining in particular, a benign proliferative process rather than carcinoma must be considered.

AIMS: To evaluate the correlation of fine needle aspiration (FNA) cytology and frozen section biopsy in the diagnosis of thyroid nodules. METHODS: The medical records of 662 patients who underwent...

Introduction: Breast carcinoma is the most common malignancy in women. Fine needle aspiration Cytology (FNAC) is an important component of triple approach for diagnosing breast lesions and is highly sensitive, specific, rapid and easy to perform. FNAC has an important role in the preoperative evaluation of breast lesions and deciding treatment. Materials and Methods: The present study was carried out among 350 patients who presented to a tertiary care hospital in North Malabar during a 4 year period from June 2013- June 2017. All cases that presented with breast lump were evaluated with FNAC and the lesions were categorised as C1- C5 as per National Health Service Breast screening programme (NHSBSP) reporting criteria. In 240 cases cytohistopathological correlation was obtained and diagnostic accuracy of FNAC was determined. Aims: To study the spectrum of benign and malignant breast lesions and the efficacy of FNAC as a diagnostic tool by correlating with histopathological findings. Results: Statistical analysis showed that sensitivity of FNAC was 99.46% in benign lesions and 96.2 % in malignant lesions. The specificity and positive predictive value of malignant lesions were 99.46% and 98.07% respectively and that of benign lesions were 96.2% and 98.93% respectively. Conclusions: FNAC serves as a rapid and reliable tool for evaluation of breast lumps with high sensitivity and specificity. However, grey zone lesions of breast which shows atypical / suspicious morphology needs confirmation by biopsy. Keywords: Fine needle aspiration cytology, Breast lumps, Histopathology, Correlation.

The triple test, i.e., cytology combined with clinical and radiological findings, is the goal for accurate assessment of palpable breast lesions. Because of the limitations of fine-needle aspiration cytology (FNAC), its utility has somewhat decreased nationwide. We have been using a combination of physical examination, radiological modalities, and FNAC for the diagnosis of palpable/nonpalpable breast mass lesions for the last 23 years. Our institutional experience of the last 10 years is presented here, using FNAC of breast lesions along with an analysis of the diagnostic accuracy. 4956 breast aspirates in 4860 cases were collected from the computer database of Haydarpasa Numune Education and Research Hospital in Istanbul, Turkey. Most of the FNACs were performed under ultrasound guidance and FNAC procedures were performed by radiologists and pathologists who used 22 gauge needles. Cytological diagnoses were classified as "unsatisfactory", "benign", "malignant", "atypical/probably benign", "atypical/probably malignant", and "atypical/NOS" (not otherwise specified) and were compared to the histopathological diagnoses obtained from core needle biopsy, lumpectomy or mastectomy to give an assessment of the diagnostic performance of FNAC in 733 aspirates. The sensitivity, specificity, accuracy, positive and negative predictive value, false positive, and false negative rates of FNAC were 98.02, 90.58, 95.97, 96.48, 94.54, 2.6, and 1.4%, respectively. This study once again shows that FNAC is a reliable method for the initial evaluation and diagnosis of breast masses. In case of any suspicious conditions, FNAC, and core biopsy are considered complementary to one another.

Introduction: To evaluate and compare the respective roles of fine needle aspiration cytology and core biopsy for diagnosis of symptomatic breast lesions.Methods: Retrospective study on 589 breast fine needle aspiration cytology (FNAC) cases and 88 core biopsies (CB) with no associated FNAC, performed between January and December 2004. A computer database was searched for initial results, subsequent investigations and outcomes.Results: Of the cases that had FNAC performed as an initial investigation, the final diagnosis was reached by FNAC alone in 81.8% of cases. Of these, 59.2% were benign, 6.1% malignant and 2.4% remaining suspicious with 14.1% inadequate samples. There were 31 cases reported as suspicious (C3/C4) on FNAC, of these 14% of C3 and all of C4 were malignant on CB. Of the 86 cases that had both FNAC and CB, CB improved on the FNAC diagnosis of malignancy in 19.8% of cases, half of which were considered inadequate on FNAC. The positive predictive value of malignant cases was 100%, and the negative predictive value 98%. The absolute sensitivity of FNAC in this study was 65% and complete sensitivity 72%. The false negative rate was 8% and false positive rate 0%. The diagnosis of 88 CB without FNAC showed 37.5% to be malignant and 60.2% as benign, with 2.3% as inadequate biopsies.Discussion: FNAC remains the first line investigation in symptomatic breast lesions. Its best use is in the diagnosis of benign disease which constitutes over two thirds of patients in our practice. In suspicious and clinically malignant lesions, it is complemented by CB which may provide additional information relevant to management. In conclusion, the majority benign findings in our patients who had CB without prior FNAC, does not justify the use of CB as a first line investigation. CB is indicated in cases of inadequate or suboptimal FNAC. The continuous use of suspicious categories (C3/C4) in breast cytology is justified by the subsequent outcomes, both benign and malignant.

Background: With increased awareness about breast cancer, many women with breast lumps are attending clinics. Though benign breast lumps are most common, they may be associated with morbidity and have become cause for concern to patients. Triple assessment by clinical, radiological and pathological examination is a standard approach in the evaluation of breast lumps. Even in cases of benign breast diseases, multimodality tests are being preferred to give reassurance to patients. This study was aimed to study distribution of various benign breast lumps in relation to age at presentation, to identify sensitivity and specificity of clinical breast examination, Ultrasonography (USG) and Fine needle aspiration cytology (FNAC) methods in the evaluation of benign breast lumps and to compare with final histopathological diagnosis.Methods: A retrospective study was conducted in department of general surgery at Malla Reddy institute of medical sciences, Hyderabad from August 2013 to July 2017. 202 females with benign breast lumps were evaluated by clinical breast examination, ultrasonography (USG) and Fine needle aspiration cytology (FNAC) methods. All patients underwent excision biopsy of lump. Final histopathological report was taken as reference standard.Results: Fibroadenoma was most common in 2nd decade. Clinical breast examination and USG showed good sensitivity but less specificity than FNAC. FNAC showed both good sensitivity and specificity. There was very good degree of agreement between FNAC and histopathological diagnosis (Kappa=0.911).Conclusions: Good clinical examination can give accurate preoperative diagnosis of benign breast lumps. Triple assessment by clinical breast examination, USG and FNAC can be useful in the evaluation of benign breast lumps.

Fine-needle aspiration cytology in the diagnosis of primary breast cancer.