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May 1995, Volume 45, Issue 5

Original Article

The Value of Fine Needle Aspiration Biopsy in the Management of Breast Disease

Nadira Mamoon  ( Departments of Histopathology, Armed Forces Institute of Pathology, Rawalpindi. )
Sajid Mushtaq  ( Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi. )
Mamoon Rashid  ( Departments of General Surgery, Combined Military Hospital, Rawalpindi. )
C.M. Rafi  ( Departments of General Surgery, Combined Military Hospital, Rawalpindi. )
Amir Hussain Khan  ( Departments of Histopathology, Armed Forces Institute of Pathology, Rawalpindi. )

Abstract

Fine needle aspiration biopsy is a technique used all over the world in the diagnosis and management of breast lumps. It is safe, quick, accurate, cost effective and acceptable to the patients. We reviewed 234 fine needle aspiration biopsies performed over a period extending from 1991-1993 for diagnosis of breast lesions. Majority of the patients presented with breast lumps (89.7%). On FNAB 144 (61.4%) cases were reported as benign and 60 (25.6%) as malignant. Histological diagnosis was available in 116 cases. On comparison with open biopsy diagnosis, FNAB was found to have a sensitivity of 96.4%, a specificity of 95.5% and efficiency rate of 96.2%. The results of the study endorse the use of FNAB as an accurate and effective technique in the management of breast ailments in our set-up (JPMA 45:120,1995).

Introduction

The role of fine needle aspiration biopsy (FNAB) in the management of breast diseases has now been irrefutably established in the West1,2. This is the first investigation recommended in dealing with abreast lump and is considered to have a high rate of accuracy3-6. Different workers have shownavariety of results with accuracy ranging from 76%3 to 95%4. It has not been long since this technique was introduced in Pakistan. This study carried out at the Armed Forces Institute of Pathology in collaboration with one of the surgical units at Combined Military Hospital Rawalpindi was done to study the efficacy of this technique in our setup.

Patients and Methods

All patients presenting with breast complaints and considered suitable for FNAB by the surgeons, during the period 199 1-1993, were included inthe study. The FNAB was performed either by a member of the surgical team or a pathologist using a 5 or 10cc syringe and 21 gauge needle. No local anaesthetic was used. Upto three passes were made in each case. The slides were wet fixed in absolute alcohol for thirty minutes and then were stained with Haematoxylin and Eosin and Papanicolaou stains. Each case was reported independently by two patholo­gists. A diagnosis of malignancy was only made when both of them agreed. When there was a difference of opinion regarding malignancy the cases were reported as suspicious. The results were divided into five categories: (a) Malignant; (b) Suspicious - Suggest frozen section/excision biopsy for confirmation of malignancy; (c) Non- diagnostic - Suggest excision biopsy; (d) Benign and (e) Inadequate. Retrospectively the FNAB data was analyzed. The cytological reports were correlated with the histology in cases where biopsy results were available. The predictive value model of Galen and Gambino7 was used to calculate sensitiv­ity, specificity, positive predictive values and efficiency of FNA.B in the diagnosis of breast cancer. All cases diagnosed as being suspicious for malignancy on FNAB were categorized as true or false positive.

Results

During the period extending from 1991 to 1993, 234 FNAB were carried out forbreast lumps. Of these 211(90.1%) were done for primary diagnostic purposes and 23 (9.9%) for detection of recurrence in patients with previously diagnosed breast cancer. The age of the patients was known in 175 cases. The majority, 95(40.6%) were in 30-49 years age group. The mean age was 42 years and range from 14-86 years. One hundered and thirty (74.2%) patients were less than 50 and 45 (25.7%) above 50 years. There were four male patients and all the remaining were female.

Table I shows the mode of clinical presentation. Majority (89.7%) of patients presented with breast lumps. In three male patients the clinical diagnosis was gynaecomastia, while the fourth was suspected of having carcinoma.
The size of the lumps was known in 67 cases. Fifty (74.6%) ranged from 2-5 ems, 7(10.4%) were less than 2 ems and the remaining 10 were more than 5 cm in size. Results of FNAB are shown in Table II.

One hundred and forty-four (61 .5%) were reported as benign (Table III)

and 60 (25.6%) as malignant. Of 30 specimens reported as inadequate, 9 (8.8%) out of 102 were done at histopathology and 21(15.9%) out of 132 at surgical departments. None of the patients had any complications. Biopsy results were available in 116 cases. A compari­son of histological and FNAB diagnosis is given in Table IV.

Histological examination confinned the diagnosis of malig­nancy in all cases reported as malignant an FNAB. Two cases reported as suspicious onFNAB were benignand two reported as benign were malignant on histological examination. The performance parameters are given in Table V.

The positive predictive value was 96 .4% and efficiency was 92.7%.

Discussion

Fine needle aspiration biopsy in the management of breast disease is becoming increasingly common. The advan­tagd of safety, accuracy, efficiency and rapid availability of results have made it extremely popular1-6. It has been reported superior to Tmcut needle biopsy in establishing the diagnosis in breast lumps8. FNAB is now recommended as the first investigation to be carried out in any patient presenting with a breast lump9. Breast carcinoma is one of the commonest tumours in the female population of Pakistan10 and the majority of these patients have fairly large tumours11. 1 The sizes of the breast lumps in our patients were mostly between 2 and 5 cms in diameter with only 7 (10.4%) being less than 2 cm. The large size of the breast tumours may be responsible for adequate aspirates in 87% of our cases despite the fact that both the pathologists as well as surgeons performing FNAB had no previous experience of this technique. This is comparable with other series12-14. It is however interesting that like other workers4,12,13 a higher percentage of inadequate aspirates were reported when the aspirations were done by a surgeon than by a pathologist. The reason usually given is the continuity of the procedure of aspiration, staining and reporting when the aspirator is a pathologist. Our results (sensitivity 96.4%, specificity 95.5% and efficiency 96.2%) are comparable with the best results published in literature4-6,9 (Table V). A similar study from Pakistan also reports sensitivity of 96.5%, specificity of 96.4%andaccuracy of 96.5%15. Comparable results have also been reported by Latif et al16 in their study of fine needle biopsy without aspiration. A very high degree of accuracy despite lack of previous experience may also be attributed to the fact that all the malignant tumours in our material were mostly high grade invasive carcinomas of fairly large size. In addition, a definite diagnosis of malignancy was made only in those cases where both the pathologists examining the slides were certain of the nature of the lesion. Many of the breast lumps reported as benign on aspiration were managed conservatively and not biopsied. These included those reported as acute inflammation (ab­scess), chronic inflammation and fibrocystic disease. An attempt was made to make a definite diagnosis rather thanjust reporting as a benign aspirate. Two cases which were reported as suspicious and proved benign on histology were the only false positive ones. These were cases of fibrocystic disease. As frozen section/ex­cision biopsy had been suggested in the report the patient management was notaffected. The two false negative cases on review were found to be due to sampling error rather than an error of interpretation. Strict criteria for diagnosis of malignancy are essential if we are to keep false positive cases at a minimum16. In cases where a definite diagnosis is not possible, repeat FNAB or excision biopsy alongwith follow-up are mandatory. In order for FNAB to be effectively and accurately used as a guide to patient management, close cooperationbetween the clinicians and pathologists is essential.

References

1. Kreuzer, G. and Boquoi, E. Aspiration biopsy cytology, mammography and clinical exploration. A modem setup in the diagnosis of tumours of the breast. Acts Cytol., 976;20:3 19-23.
2. arrows, G. H.. Anderson, J., Lamb, L. et al. Fine needle aspiration of breast cancer: Relationship of clinical factors to cytology results in 689 primary malignancies. Cancer. 1986;58: 1493-98.
3. Bell, D. A., Hajdu, S. L, Urban, J. A. et al. Role of aspiration cytology in the diagnosis and management of mammary lesions in office practice. Cancer, 1983;51:1182-89.
4. Frable, W. J. Needle aspiration of the breast. Cancer, 1 984;53;67 1-76.
5.  Kline, T S., Joshi, L. P. and Neal, H. S. Fine needle aspiration of the breast: Diagnoses and pitfalls. A review of3545 cases. Cancer, 1979;44:1458-64.
6. Zajdela, A., Ghossen, N. A., Pilleron, J. P. et al. Thevalue ofaspiration cytology in the diagnosis of breast cancer; Experience of the Foundation Curie. Cancer, 1975;35:499-506.
7. Galen, R. S. and Gambino, S. R. Beyond normality: The predictive value and efficiency of medical diagnosis. New York, John Wiley and Sons, 1975.
8. Shabot, M. M., Golberg, I. M., Schick, P. et al. Aspiration Cytology is superior to Tm-cut needle biopsy in establishing the diagnosis of clinically suspicious breast masses. Ann. Surg., 1992; 196:122-126.
9. Wanebo, H. J., Feldman, P. S., Wilhelm, M. C. et al. Fine needle aspiration cytology in lieu of open biopsy in management of primary breast cancer. Ann. Surg., I 984;I 99:569-78.
10. Rasool, M. I., Iqbal, M., Malik, I. Natural history of breast cancer. A study of 17 cases. R.M J., 1989;17;18-21.
11. Zarbo, R. J., Howanitz, P. J. and Bechner, P. Interinstitutional comparison of performance in breast fine needle aspiration cytology: A Q-probe quality indicator study. Arch. Pathol. Lab. Med., 1991; 115:743.50.
12. Palombini, L., Fulciniti, F., Vetrani, A. et al. Fine needle aspiration of breast masses. A critical analysis of 1956 cases in 8 years (1976-1984). Cancer, 1988;61 ;2273-77.
13. Hammond, S., Keyham-Rafagha, S. and O’Toole, R. V. Statistical analysis of fine needle aspiration cytology of the breast. A review of 678 cases plus 4265 cases from the literature. Acts Cytol., 1 987;3 1:276-80.
14. Issac, U. and Alam, S. M. Diagnostic value of fine needle aspiration biopsy cytology of breast lesions and its correlation with open biopsy. Pak. J. Pathol., 1993;4:31-33.
15. Latif, Z., Rasool, I., Chaudhry, A. R. etal. Fineneedle biopsy withoutaspiration; A study in 130 cases of breast lumps. Pak. J. Pathol., 1 993;4:35-40.
16.  Lee, K. R., Foster, K. S. and Papillo. J. L. Fine needle aspiration of the breast. Importance of the aspirator. Acts Cytol., I 987;3 1 ;28I -84.

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