A new specially designed needle significantly increases sample yield during fine needle aspiration of breast lesions

A large and increasing number of women in the western world will at some point during their life be investigated morphologically for breast cancer. Fine needle aspiration (FNA) is one morphological method which is considered to be the fastest, cheapest and the most patient-friendly approach. Nevertheless, the technique has not gained major clinical success outside of Scandinavia, mainly because of a high frequency of insufficient samples. With this in mind it is quite peculiar that standard needles which are mainly configured for blood sampling and infusion therapy, comprising large quantities of residual spaces, are used. In this study we have developed and tested a new needle dedicated for FNA, which is intended to abate this drawback by increasing the sampling yield by changing the tip angle, the cannula wall-thickness and the storage compartment. In total, 499 consecutive aspiration procedures of palpable breast lesions were performed to compare the new needle (outer diameter 0.6 mm) with standard needles (outer diameters 0.6 mm and 0.7 mm). The new needle provided three times more material than did standard needles of the same diameter. Surprisingly, the new needle also provided more material than the standard 0.7 mm needle, which increased up to almost twice the material in cases with no material in the syringe. The frequency of tests with sparse harvested material (<4 mg) was less with the new needle (9%) compared to its standard counterpart (35%). The presented results were obtained by a very skilled sampling operator. Thus for the average sampling operator who probably obtains more samples in the spare range, the new dedicated FNA needle should have even more added value.     

Comparative study of fine needle aspiration and fine needle capillary sampling of thyroid lesions

OBJECTIVE: To investigate whether fine needle capillary (FNC) sampling gives quantitatively and qualitatively superior cytologic material as compared to the conventional technique of fine needle aspiration (FNA) when performed by a single aspirator. STUDY DESIGN: Cross-sectional diagnostic test evaluation study. FNA and FNC were performed by a single operator on 200 diffuse and nodular thyroid lesions. RESULTS: A statistically significant difference in favor of FNC was observed for the parameter amount of cellular material. For the rest of the parameters--background blood or clot, degree of cellular degeneration, degree of cellular trauma and retention of architecture--the average score favored FNC but was not statistically significant--i.e., smears prepared from FNC displayed cellular material that was more concentrated, less damaged and less likely to be obscured by blood. CONCLUSION: Although FNC sampling was diagnostic in a greater number of cases than FNA sampling, this study did not prove a clear superiority of FNC over FNA. Until greater experience shows clear sampling superiority of FNC alone, rather than performing only FNA in diffuse or nodular thyroid lesions, incorporating FNC into the second puncture will definitely improve the quality and quantity of material at the patient's first visit.     

Comparative cytology of mucocelelike lesion and mucinous carcinoma of the breast in fine needle aspiration

OBJECTIVE: To study the fine needle aspiration cytology (FNAC) features of mucocelelike lesion (MLL) of the breast and to compare them to those of mucinous carcinoma. STUDY DESIGN: The fine needle aspiration (FNA) smears of 7 cases of histologically proven MLL (2 malignant and 5 benign, including 4 associated with atypical ductal hyperplasia) were reviewed and compared to those of 14 mucinous carcinoma cases. RESULTS: In all cases, grossly visible thick, mucoid material was obtained from FNA. The most important features for distinguishing benign MLL from mucinous carcinoma were: (1) scant cellularity; (2) no or rare single, intact tumor cells; (3) tumor cells arranged in cohesive monolayers; and (4) absence of significant nuclear atypia. In contrast, mucinous carcinoma in general showed higher cellularity; abundant single, intact cells; three-dimensional cellular clusters in most cases; and nuclear atypia ranging from mild to severe. CONCLUSION: Mucinous lesions of the breast should be divided into MLL and frank mucinous carcinoma based on FNAC. However, FNAC diagnosis of malignant MLL has yet to be defined. Excisional biopsy is advised for all hypocellular cases for further separation into benign and malignant MLL and to rule out the possibility of hypocellular mucinous carcinoma.     

Cytologic diagnosis by transthoracic fine needle sampling without aspiration

The cytologic findings of transthoracic fine needle sampling without aspiration (fine needle capillary [FNC] sampling) are reported. Eleven patients were examined by FNC sampling while four were examined by the classic fine needle aspiration (FNA) method. In contrast to FNA sampling, FNC sampling produced less patient trauma and admixture of the sample with blood, while giving a better perception of the tumor and its consistency. The quality of the samples obtained by the FNC technique was equal to that of the FNA samples. The results demonstrate that fine needle sampling without aspiration may be used in the study of deep-seated as well as of superficial organs.     

Choriocarcinoma metastatic to the breast diagnosed by fine needle aspiration.

Fine needle aspiration (FNA) was used to study nodules in the left breast of a patient with a previous history of uterine choriocarcinoma. The FNA smears contained numerous malignant mononucleated cells and multinucleated giant cells. The cytologic diagnosis was metastatic choriocarcinoma, which was confirmed by histologic study of excised tissue. That diagnosis would have been difficult to make cytologically if the previous history had not been known; the differential diagnosis of multinucleated giant cells in an aspirate from a breast mass is discussed.     

Statistical approach to fine needle aspiration diagnosis of breast masses

A statistical algorithm was used for recursively partitioning a consecutive series of 37 benign and 69 malignant fine needle aspirates to produce a decision tree for diagnosing breast masses. Optimal separation between benign and malignant cytology was accomplished by evaluating clump characteristics when clumps were present and evaluating cell integrity when clumps were absent. The 1.5% false-negative and 9.7% false-positive rates obtained through this scheme are better than those reported for most series.     

Ultrasound-guided fine needle aspiration cytodiagnosis of leiomyosarcoma metastatic to the breast. A case report

BACKGROUND: Leiomyosarcomas are characterized by slow growth and late metastasis and most often involve the lung, liver and subcutaneous tissue. Metastasis to the breast is rare, with only four cases published in the English-language literature to date. Because of its rarity and the prolonged time interval between the diagnosis of the primary tumor and involvement of distant sites, accurate diagnosis of these tumors can be challenging. Evaluation of the cytomorphologic features of the tumor, ancillary immunocytochemical staining and detailed medical history of the patient are essential to making a correct diagnosis. CASE: A case of leiomyosarcoma metastatic to the breast occurred in a 60-year-old woman whose primary uterine leiomyosarcoma had been resected 10 years before the diagnosis of the metastasis. Fine needle aspiration performed with ultrasound guidance yielded a moderately cellular specimen composed of minimally pleomorphic spindle cells with smooth, blunt-ended nuclei arranged in an interlacing pattern. Immunocytochemical staining for muscle-specific actin confirmed the smooth muscle origin of the neoplasm. CONCLUSION: The results of cytomorphologic analysis and immunocytochemical staining performed after fine needle aspiration and the patient's history of primary uterine leiomyosarcoma allowed us to correctly diagnose metastasis to the breast and avoided inappropriate management of the metastasis as a primary tumor.     

Automated breast cancer diagnosis based on fine needle aspiration

OBJECTIVE: To design and analyze an automated diagnostic system for breast carcinoma based on fine needle aspiration (FNA). STUDY DESIGN: FNA is a noninvasive alternative to surgical biopsy for the diagnosis of breast carcinoma. Widespread clinical use of FNA is limited by the relatively poor interobserver reproducibility of the visual interpretation of FNA images. To overcome the reproducibility problem, past research has focused on the development of automated diagnosis systems that yield accurate, reproducible results. While automated diagnosis is, by definition, reproducible, it has yet to achieve diagnostic accuracy comparable to that of surgical biopsy. In this article we describe a sophisticated new diagnostic system in which the mean sensitivity (of FNA diagnosis) approaches that of surgical biopsy. The diagnostic system that we devised analyzes the digital FNA data extracted from FNA images. To achieve high sensitivity, the system needs to solve large, equality-constrained, integer nonlinear optimization problems repeatedly. Powerful techniques from the theory of Lie groups and a novel optimization technique are built into the system to solve the underlying optimization problems effectively. The system is trained using digital data from FNA samples with confirmed diagnosis. To analyze the diagnostic accuracy of the system > 8,000 computational experiments were performed using digital FNA data from the Wisconsin Breast Cancer Database. RESULTS: The system has a mean sensitivity of 99.62% and mean specificity of 93.31%. Statistical analysis shows that at the 95% confidence level, the system can be trusted to correctly diagnose new malignant FNA samples with an accuracy of 99.44-99.8% and new benign FNA samples with an accuracy of 92.43-93.93%. CONCLUSION: The diagnostic system is robust and has higher sensitivity than do all the other systems reported in the literature. The specificity of the system needs to be improved.     

Application of the probabilistic approach to reporting breast fine needle aspiration in males

OBJECTIVE: To apply the probabilistic approach to a series offine needle aspiration (FNA) samples of male breast lesions and determine the accuracy and reproducibility of this method of reporting in men. STUDY DESIGN: All male breast surgical specimens with a preoperative breast FNA at our institution from 1994 to 2005 were identified. The FNAs were blindly reviewed by 2 groups of observers and classified in 1 of 5 categories using published reporting guidelines: positive, suspicious, atypical, proliferative without atypia and unremarkable. The histologic and cytologic diagnoses were correlated. The interobserver variation was determined. RESULTS: A total of 138 FNAs were performed for 123 male patients. Histologic correlation was available for 23 satisfactory FNAs. A total of 11 of 11 carcinomas (100%) were classified as positive, suspicious or atypical. Of 12 benign masses, 11 (91.6%) were classified as proliferative without atypia or unremarkable. One case of gynecomastia was classified as atypical by 1 observer but deemed not atypical with consensus review. The kappa statistic for benign and atypical/suspicious/malignant categories was 0.90. CONCLUSION: Based on this series, the probabilistic approach can be applied to the reporting of FNAs of male breast lesions. Gynecomastia may result in an atypical cytologic diagnosis.     

Diagnostic pitfalls in fine needle aspiration cytology of atypical apocrine metaplasia in a breast lesion. A case report

BACKGROUND: Apocrine metaplastic cells are frequently encountered in fine needle aspirates of breast lesions. Atypical apocrine metaplastic cells with signet ring features can also occur, and their presence may present a diagnostic dilemma in the differentiation of benign versus malignant lesions. CASE: A fine needle aspirate of a 2.5 x 1.0-cm, subareolar mass in a 47-year-old female showed atypical cells with signet ring morphology. Also present were clusters of cells that were enlarged and showed nuclear atypia, prominent nucleoli and cytoplasmic granules. Papillary cohesive clusters of ductal cells were also identified. The fine needle aspiration diagnosis was mucinous carcinoma. The nodule was excised, and the histologic diagnosis was sclerosing ductal papilloma with atypical apocrine metaplasia. CONCLUSION: Atypical apocrine cells can be misinterpreted as mucinous carcinoma or usual duct adenocarcinoma on fine needle aspiration cytology. We present clues that may help in rendering the correct interpretation.     

Melanoma metastatic to the breast: utility of fine needle aspiration and immunohistochemistry

OBJECTIVE: To describe the morphologic spectrum of metastatic malignant melanoma (MM) cells involving the breast and to explore the diagnostic utility of HMB45, Mart-1, Melan-A and T311 (antityrosinase) antibodies in fine needle aspiration material of MM metastatic to the breast. STUDY DESIGN: Cytologic material from 21 cases (18 women) was reviewed for cytomorphology (epithelioid, spindled, mixed) and immunocytochemical staining attributes for Mart-1, HMB45, T311, Melan-A and cytokeratin based on tissue availability. RESULTS: Seventeen cases (81%) demonstrated epithelioid cell morphology, with 14% exhibiting mixed and 5% spindled morphologies. All 21 cases (100%) were immunoreactive with Mart-1 antibody, with 81% (17/21) immunoreactive for HMB45. In 38% of cases there was a similar percentage of cells immunoreactive for Mart-1 and HMB45, while 48% showed a higher percentage of cells immunoreactive for MART-1 than HMB45. Immunoreactivity with T311 was seen in 8 of 11 cases tested (73%). All six cases tested (100%) were immunoreactive with Melan-A. Staining for cytokeratin was negative in all eight cases tested. CONCLUSION: Because the majority of MM metastatic to the breast shows epithelioid cell morphology, it may mimic primary breast carcinoma. Mart-1 should be part of the immunocytochemical panel utilized to confirm the diagnosis of MM metastatic to the breast.     

Application of liquid-based preparation to fine needle aspiration cytology in breast cancer

OBJECTIVE: To examine the performance of liquid-based cytology (LBC) in breast cytology to confirm the diagnosis of carcinoma. STUDY DESIGN: Using cell clusters directly scratched from surgically removed tumor masses, we examined the immunocytochemistry, molecular biology and cytomorphology of the specimens. RESULTS: LBC was very useful for gene analysis and evaluating the immunocytochemistry. The cytologic features of LBC were slightly different from those ofa conventional aspiration cytology smear. CONCLUSION: LBC is a promising method for improving the standardization ofpreparations in breast cytology, although care should be taken to account for its characteristic cytologic features. The quantitative analysis of HER-2 mRNA correlated with the results of immunohistochemistry.     

Carcinoid tumour of male breast diagnosed by fine needle aspiration

A primary carcinoid tumour of the breast in a 66-year-old man was diagnosed by fine-needle aspiration cytology. The nature of the lesion was proved by histochemical and immunocytochemical studies. The importance of a conclusive diagnosis is discussed and the value of immunocytochemical analysis as an aid to cytomorphologic diagnosis is demonstrated.