Fine needle aspiration biopsy of the breast. Influence of the number of passes and the sample size on the diagnostic yield

The sensitivity of fine needle aspiration (FNA) biopsy of the breast as a function of the number of aspirations performed on any given lesion was investigated. Four separate aspirations each were performed on over 400 lesions of the breast, 93 of which yielded a cytologic diagnosis. The incremental diagnostic yields of each subsequent aspiration were tabulated. The first aspirate of the sequence gave the greatest yield, with smaller incremental yields on the second through the fourth aspirates. Benign and malignant lesions gave similar results, as did palpable and nonpalpable lesions (the latter being usually smaller in size). A mathematical extrapolation of the data indicates that three or four aspirations of any given lesion provide the optimal yield within the limits of practicality. This performance of multiple FNA biopsies is particularly important when the pathologist does not perform the biopsy, or is unable to assist in the immediate interpretation of the specimen to assess its adequacy.     

Diagnostic pitfalls in the fine needle aspiration of thyroid nodules. A study of 555 cases in Chinese patients

The diagnostic value and limitations of fine needle aspiration (FNA) were determined by examining 555 palpable thyroid nodules in Chinese patients who had a definitive diagnosis established by thyroidectomy (529 cases) or large-needle biopsy (26 cases). Of the aspirates, 97.8% were satisfactory for cytologic examination. The overall malignancy rate was 20%. FNA detected 73 (74.5%) of 98 primary malignant tumors and 9 (90%) of 10 metastatic tumors. Diagnostic errors were most commonly due to inadequate specimens and cystic lesions. Cystic fluid, present in one-third of all lesions, was associated with a malignant nodule in 13% of the cases. FNA was most valuable for detecting papillary carcinomas; it may at times suggest the likelihood of a follicular carcinoma.     

The Value of Gross Visual Assessment of Specimen Adequacy for Liquid-Based Cytology During Ultrasound-Guided,Fine-Needle Aspiration of Thyroid Nodules

Objective: Major problems of fine-needle aspiration (FNA) of thyroid nodules arise due to nondiagnostic results caused by inadequately obtained FNA specimens. The purpose of this study was to evaluate the value of visual assessment of liquid-based cytology specimens during FNA of thyroid nodules for predicting sampling adequacy.Methods: For 3 months, visual assessment of FNA specimens was used for 534 consecutive nodules in 534 patients. The FNA specimens were visually graded immediately following aspiration for each nodule, and the visual grades were classified into 2 categories: inadequate (<6 cell groups) and adequate (>6 cell groups). The cytology results were classified as diagnostic or nondiagnostic based on the Bethesda system. We compared the ultrasound features and FNA characteristics between the diagnostic and nondiagnostic results. Multiple logistic regression analysis was used to determine factors independently predictive of nondiagnostic results. We also evaluated the interobserver agreement regarding the visual assessment.Results: Visual assessment was feasible in all patients, and the nondiagnostic rate was 11.6% (62 of 534). Nondiagnostic results were more frequent in the inadequate visual assessment group (38.1%) than in the adequate visual assessment group (10.5%) (P = .001). Independent predictive factors for nondiagnostic results were inadequate visual assessment (odds ratio, 5.18), >50% vascularity (odds ratio, 3.98), and macrocalcification (odds ratio, 3.60). Interobserver agreement for the prediction of visual assessment was good (κ value, 0.767; P<.001).Conclusion: Immediate visual assessment of a specimen during FNA of a thyroid nodule is a feasible method for predicting sampling adequacy.Abbreviations: FNA = fine-needle aspiration LBC = liquid-based cytology US = ultrasound     

Fine needle aspiration of poorly defined indurated and well-defined breast lesions: a cytopathologic comparative study

OBJECTIVE: To compare the cytologic findings and diagnoses of breast fine needle aspiration (FNA) samples of well-defined lesions (WDL) with those of poorly defined indurated lesions. STUDY DESIGN: We examined 371 consecutive breast FNA specimens obtained without diagnostic image guidance. Fifty-eight lesions were described by the examining pathologists as PDILs, and the remaining 313 lesions were described as WDLs. RESULTS: Compared with WDLs, PDILs were more likely to yield hypocellular specimens deemed unsatisfactory for diagnostic evaluation (37.9% vs. 14.1%). However, a substantial number of atypical, suspicious for malignancy and malignant cases (12.1%, 5.2%, and 13.8%, respectively) were identified with PDILs. In addition, benign diagnoses were more frequently rendered with aspirates of WDLs, compared with PDILs (47.9% vs. 31.0%). In our study, FNAs of PDILs were more often diagnostic in white women < 49 years of age and in lesions measuring > 2 cm. CONCLUSION: Given the relatively high frequency of malignant, suspicious and atypical lesions detected with PDILs, FNA is a suitable first diagnostic approach for PDILs, especially considering the relatively low cost and simplicity of FNA procedures without diagnostic imaging guidance.     

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.     

Value of Repeating A Nondiagnostic Thyroid Fine-Needle Aspiration Biopsy

ObjectiveTo assess the value of repeating a biopsy when the initial thyroid fine-needle aspiration (FNA) biopsy is nondiagnostic.MethodsBetween 1990 and 2003, 4,311 thyroid FNAs were performed at the Cleveland Clinic Foundation, of which 220 (5%) were nondiagnostic. Among 189 patients whose medical records were available for retrospective review, 106 underwent a repeated FNA (FNA #2), and 14 had a second repeated FNA (FNA #3). Thyroid ultrasonography was used in the evaluation in 113 FNAs.ResultsThe first and second repeated FNAs were diagnostic in 58% (62 of 106 patients) and 50% (7 of 14 patients), respectively. The rate of malignant disease in patients with no repeated FNAs versus 1 or more repeated FNAs was 4.8% (4 of 83) versus 11.3% (12 of 106), respectively. Ultrasound-guided FNA yielded a diagnosis among 33 of 113 biopsies (29.2%), and FNA without ultrasound guidance provided a diagnosis in 30 of 159 biopsies (18.9%). Thus, the use of thyroid ultrasonography significantly improved the likelihood of establishing a diagnosis (P = 0.017). We found that repeating the FNA up to 2 times provides a diagnosis in up to 60% of cases.ConclusionThe overall prevalence of thyroid cancer in patients with nondiagnostic FNA is not trivial—8.5% in our study group of 189 patients. An aggressive approach toward nondiagnostic FNA biopsies is recommended, with performance of at least 2 repeated FNA biopsies, preferably with the help of ultrasound guidance. (Endocr Pract. 2007;13:735-742)     

Repeatedly nondiagnostic thyroid fine-needle aspirations do not modify malignancy risk

Objective: Thyroid nodules with nondiagnostic (ND) fine-needle aspirations (FNA) typically undergo repeat sampling. While repeat FNA is often diagnostic, little is known regarding the significance of repeatedly ND aspirates. Limited data suggest there is very low, if any, risk of malignancy for repeatedly ND FNAs. Study Design: We performed a retrospective analysis of ND thyroid FNAs over a nearly 6-year period at our institution to further address this question. Results: There were 834 ND thyroid FNAs, representing 694 distinct thyroid nodules. Repeat FNA was performed after an initial ND aspirate in 52% of cases (363/694); 19% (70/363) had at least one additional ND diagnosis on repeat FNA. Surgical follow-up was available for 57 cases. Malignancy was identified histologically in 21% (9/42) of nodules after a single ND FNA and in 20% (3/15) of nodules with 2 or more repeatedly ND aspirates. Accounting for all benign cytologic follow-up, the overall risk of malignancy was 4% [12/303; 3.5% (9/255) following a single ND FNA and 6.3% (3/48) after repeated ND FNAs]. Conclusion: We observed no modification of malignancy risk when repeated FNAs were ND. Clinical management for an ND aspirate should remain repeat aspiration along with clinical and sonographic correlation.     

Fine needle aspiration biopsy in the diagnosis of intrathoracic masses.

During a 3.5-year period (January 1, 1987, to June 30, 1990) 420 percutaneous fine needle aspiration (FNA) biopsies were performed on 390 patients (309 males, 81 females) suffering from one or more intrathoracic, radiologically visible lesions. Aspirations were carried out using 21- or 23-gauge Chiba needles under fluoroscopic or computed tomographic control. The aspirates were used to make minibiopsies and cytologic smears. Diagnosis was possible in 373 cases (95.64%): on the first pass in 344 cases, on the second in 28 cases and on the third in 1. In 17 cases (4.36%) the aspirate was inadequate for diagnosis. There were complications in 10 cases (2.56%) (9 pneumothorax and 1 hemophtysis) requiring intensive care. The 373 percutaneous FNA biopsy diagnoses included 256 malignant tumors (68.63%), of which 234 were primary and 22 were secondary, and 117 benign lesions (31.37%), 5 of them neoplastic and 112 nonneoplastic. Three hundred two of 373 percutaneous FNA biopsy diagnoses were followed (80.96%). One hundred twenty-three follow-ups were histologic (40.73%), including secondary tumors, which could be compared with the primary histotype. Twenty-eight follow-ups were cytologic (9.27%), and 151 were clinical (50.00%), using progression of the disease or the beginning of chemoradiotherapy as a criterion for malignancy and a stable condition or regression of the lesion with nononcologic medical treatment as a criterion for benignity. Percutaneous FNA biopsy diagnoses were confirmed in 288 cases (221 true positives and 67 true negatives) and unconfirmed in 14 (1 false positive and 13 false negatives). Specificity, sensitivity, negative predictive value, positive predictive value and total diagnostic accuracy were, respectively, 98.52, 94.44, 83.75, 99.54 and 95.36%. The histologic typing accuracy of percutaneous FNA biopsy on 70 specimens of surgically removed malignant epithelial neoplasias was 70.00%. These results confirm that percutaneous FNA biopsy is a reliable method of diagnosing intrathoracic masses and reduces the need for diagnostic thoracotomy.     

Fine needle aspiration cytology of "minimal" breast cancer

The value of fine needle aspiration (FNA) cytology in the diagnosis of "minimal" breast cancer was studied. Sixteen (76.2%) of 21 cases of invasive breast cancer less than 1.0 cm in diameter and 14 (73.3%) of 19 cases of noninvasive breast carcinoma were given a positive diagnosis by FNA cytology. One "suspicious" and the five false-negative diagnoses occurred in cases of invasive carcinoma; the reasons were considered to be either a faulty technique of needling the tumor or the presence of prominent fibrosis in the tumor. In noninvasive carcinoma, atypical cells were misdiagnosed in two of the five smears that had been originally reported as negative. The results of the retrospective analysis showed that FNA cytology had a higher accuracy in the diagnosis of small lesions than did radiologic and echographic criteria, and FNA cytology was thus used as the main criterion for deciding on the necessity for preoperative surgical biopsies.     

Diagnostic use of mean nuclear area and nuclear DNA content in preoperative breast cancer cytology

OBJECTIVE: Fine needle aspiration (FNA) cytology of breast lumps is a routine procedure, and the diagnostic accuracy can be 95%. Occasional discrepancies arise, and it would be valuable to have additional parameters for accurate diagnosis. We evaluated nuclear DNA content and mean nuclear area (MNA) using image cytometry in the diagnosis of preoperative breast cancers by FNA in those with a discrepancy between clinical, radiologic and cytologic diagnoses. STUDY DESIGN: One hundred eighteen consecutive preoperative FNA samples were evaluated for nuclear DNA and MNA and were compared to cytologic and postoperative histologic diagnoses. RESULTS: Sensitivity, accuracy and positive predictive value of routine cytology were 95%, 90%, 95% as compared to nuclear DNA (66%, 66%, 96%) and MNA (61%, 61%, 97%). Combining these 3 parameters gave a sensitivity of 97%, accuracy of 94% and positive predictive value of 99%. CONCLUSION: These results demonstrate that nuclear DNA and MNA combined with routine cytology may be useful adjuncts in preoperative breast cancer cytologic diagnosis when discrepancies arise. This may lead to better and more accurate planning of treatment regimens in preoperative breast cancer patients.     

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 diagnosis of osteitis fibrosa cystica (brown tumor of bone): a case report

BACKGROUND: Fine needle aspiration (FNA) cytologic diagnosis of bone lesions is controversial; opponents cite its low sensitivity and proponents emphasize its cost-effectiveness, specificity and rapid turnaround time. The focus of FNA cytology is most often to exclude malignancy, which may contribute to incomplete information sharing on the part of the health care team and the published low sensitivity of diagnostic cytology of osseous lesions. It is therefore incumbent upon cytopathologists to formulate a complete differential diagnosis of osseous lesions. CASE: A 72-year-old man, admitted for severe abdominal pain, underwent diagnostic computed tomography (CT) examination that incidentally revealed multiple abdominal and pelvic lytic bone lesions. CT-guided FNA of a lesion revealed bland histiocytic and spindled cells, prominent hemosiderin pigment and scattered multinucleated cells, findings consistent with osteitis fibrosa cystica. Subsequent consultation with the medical team revealed the patient's underlying secondary hyperparathyroidism. CONCLUSION: This case emphasizes the importance of correlating clinical history and radiologic findings to the accurate cytologic diagnosis of bone lesions. The benign cytomorphologic features of brown tumor should not be overlooked or be considered nondiagnostic in the hunt for suspected malignancy. FNA allowed confident exclusion of a malignant process and prevented unnecessary surgery and its inherent risks.     

Audit of 6 years' experience of breast fine needle aspiration (FNA) cytology using the cytospin method; improvement through multidisciplinary clinical audit

Audit of 6 years' experience of breast fine needle aspiration (FNA) cytology using the cytospin method; improvement through multidisciplinary clinical audit
A breast FNA cytology service for palpable breast lumps was commenced in 1989 using the cytospin method. Over the following 6 years 2314 aspirates were received. The results were audited in detail in 1990, 1991/1992 and 1994. Multidisciplinary clinical audit meetings followed each audit cycle. Practice change was agreed after each audit. Each audit cycle was followed by demonstrable improvement in the complete sensitivity of the technique, being respectively 79%, 88% and 96%. The cytospin method is a viable alternative to the conventional smear method.     

Silver-binding nucleoli and nucleolar organizer regions in fine needle aspiration cytology of the breast

Silver staining was used to demonstrate nucleoli and nucleolar organizer regions (NORs) in cytopreparations from breast fine needle aspiration (FNA) biopsies, with the resulting black dots being a combination of silver-binding nucleoli and dispersed NORs. Discrete black dots in 200 nuclei were manually counted in 25 silver-stained biopsies; the cytologic diagnoses were made on routine Papanicolaou-stained cytopreparations from the same aspirates. Although malignant breast lesions showed higher counts than did benign breast disease, an overlap of one malignant and three benign lesions occurred. Therefore, the method cannot be recommended for reliably discriminating between malignant and benign routine breast specimens obtained by FNA; it may have some value in assessing tumor behavior.     

Fine needle aspiration cytology in the management of palpable benign and malignant breast disease. Correlation with clinical and mammographic findings

Two surgeons in a health maintenance organization group practice performed 280 fine needle aspirations (FNAs) on 257 palpable breast lesions in 200 patients. The cytology was interpreted by four pathologists at a community hospital. FNA cytology had a sensitivity of 96% and a specificity of 94% in these cases; there were no false-positive diagnoses of cancer. FNA cytology improved the identification of benign disease and decreased the risk of missing cancers. FNA cytology also improved the predictive value of mammographic information and was more helpful than mammography in demonstrating the need for biopsy of small palpable lesions that turned out to be "minimal" breast cancers.     

Lipomatous lesions of the parotid gland. Potential pitfalls in fine needle aspiration biopsy diagnosis

Nine cases of benign fatty tumors of the parotid studied initially by fine needle aspiration (FNA) biopsy and subsequently diagnosed by open biopsy were reviewed. All lesions presented as enlargements of the parotid gland. The cytologic diagnoses were correct in only five of the nine cases. While four of six FNA samples from lipomas were correctly diagnosed by cytology, the other two samples were classified as inadequate. Three cases of diffuse infiltration of the parotid by mature-appearing adipose tissue were cytologically characterized as "no diagnostic change" in two cases and sialosis in one case. The clinical, radiologic, cytologic and histologic features of these tumors are described to increase the familiarity of cytologists with these lesions, which may prevent unnecessary surgical intervention in some patients.     

Serial fine needle cytology in the diagnosis of esophageal cancer

OBJECTIVE: To describe a method of registering local spread of cancer in the esophageal wall through serial endoscopic fine needle aspiration (FNA), to evaluate FNA as a diagnostic tool as compared to histologic biopsies and brush cytology, and to investigate cytologic appearances of aspirates and correlate them with survival STUDY DESIGN: Fifty-two patients with esophageal cancer were investigated with serial FNA every second centimeter from the upper esophageal sphincter aborally down to the level of macroscopic tumor. Histologic biopsies and brush cytologies were then performed. RESULTS: Of investigated cases, 33% showed malignant or suspect malignant cells from macroscopic tumor, at > or = 4 cm orally, as did 3 of 12 patients at 14 cm. FNA was more sensitive than brush cytology in establishing the diagnosis. A high ratio between the numbers of benign and malignant cells in aspirates from gross tumor tissue correlated with shorter survival (P < .03). CONCLUSION: Serial FNA can demonstrate local microscopic tumor spread in the wall of the esophagus in vivo in esophageal cancer patients. FNA is also a useful adjunct in establishing the diagnosis. Finally, evaluations of tumor cytology may have prognostic value.     

The utility of fine needle aspiration in HIV positive children

Objective:  To determine the spectrum of disease, diagnostic accuracy and adequacy of fine needle aspirates (FNA) in human immunodeficiency virus (HIV) positive children who present with mass lesions.
Methods:  Between January 1997 and December 2002, 95 FNAs were performed in 91 children aged 15 years and younger who were known to be infected with the human immunodeficiency virus (HIV).
Results:  Head and neck masses including salivary gland swellings were the most common presentation (58.9%) followed by axillary masses (25.3%). Groin masses were aspirated in six children, flank and abdominal masses in four children, buttock masses in three children, a chest wall mass in one child and a sonar guided FNA of a lung mass in one child. Eight FNAs (8.4%) proved inadequate. Reactive lymphadenopathy was diagnosed in 42 cases, mycobacterial infection in 22, four children were diagnosed with abscess, one child had a fungal infection and five were found to have non-Hodgkin's lymphoma. There were four cases each of lymphoepithelial lesion and Kaposi sarcoma. There was one case each of nephroblastoma, rhabdomyosarcoma, myeloma, melanotic progonoma and spindle cells, not otherwise specified.
Conclusion:  Fine needle aspiration in HIV positive children is a worthwhile procedure and in most instances allows a rapid diagnosis obviating the need for surgery and enabling swift treatment to be undertaken where necessary. Ancillary studies form an important diagnostic component. Universal safety precautions must be strictly adhered to.     

Fine needle aspiration cytology in the preoperative diagnosis of ultrasonically enlarged parathyroid glands

The value of fine needle aspiration (FNA) cytology in the diagnosis of ultrasonically suspected parathyroid gland enlargements was reviewed for a six-year series of cases. In 146 patients, 277 FNA biopsies under ultrasound guidance were performed on suspected enlarged parathyroid glands. Smears were routinely stained by the Pappenheim (May-Grünwald-Giemsa) method, and the Grimelius silver stain was used to demonstrate argyrophilic granules in the cytoplasm of parathyroid cells. Diagnostic material was obtained by FNA from 121 (83%) patients, whereas the aspirates were considered inadequate for cytologic diagnosis in 25 (17%) patients. For the 121 cases with adequate FNA samples, cytology diagnosed a parathyroid origin in 80 (55%) of the 146 total patients) and a thyroid origin in 41 (28%). The cytologic-histologic correlation available for 36 patients showed a cytologic sensitivity of 86%. Parathyroid lesions are frequently treated preoperatively as a disease of the thyroid; the results of this study suggest that cytomorphologic analysis of FNA samples can demonstrate the parathyroid origin of such samples, especially when a silver stain is used in addition to the routine stain.     

Fine needle aspiration cytology of cystic parathyroid lesions. A cytomorphologic overlap with cystic lesions of the thyroid

Three cases of palpable cystic parathyroid nodules examined by fine needle aspiration (FNA) cytology are reported. Two of the three aspirates were incorrectly identified as thyroid neoplasms due to the presence of papillary clusters or microfollicles and grossly golden-brown cyst fluid. Histologic examination of these two nodules revealed partially cystic parathyroid adenomas. Aspirated material from the third patient yielded clear watery fluid, which was correctly identified as consistent with a parathyroid cyst. The diagnostic difficulties in the differentiation of parathyroid adenoma from thyroid carcinoma or adenoma are discussed, as is the utilization of assays for parathyroid hormone in making the FNA diagnosis of parathyroid lesions.