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.     

Fine Needle Aspiration Cytology of Breast In Invasive Carcinoma of Tubular Type and In Radial Scar/Complex Sclerosing Lesions

Fine needle aspirates (FNA) from 31 invasive carcinomas of tubular type and 22 radial scar/complex sclerosing lesions (RS/CSL), diagnosed in Edinburgh between 1986 and 1991, were reviewed. the lesions in this study varied in size and palpability at presentation, but are of increasing interest in the differential diagnosis of non-palpable areas of increased mammographic density. In agreement with previously published information^1'5'8, it was found that the tubular cancers were usually selected for biopsy following aspiration, but less often definitively diagnosed as malignant. Nearly 50% of the RS/CSL group were correctly reported benign on cytology, but in 40%, biopsy was recommended to exclude malignancy. In addition, cytological features helpful in suggesting malignancy in aspirates from tubular cancers, also raised suspicion in aspirates from the RS/CSL group, with a risk of overdiagnosis of cancer.     

Fine Needle Aspiration Cytology of Collagenous Spherulosis of the Breast

We present a case of a 45-year-old woman with a benign breast lump in which collagenous spherulosis was an incidental finding. Since collagenous spherulosis has a similar appearance to adenoid cystic carcinoma of breast on fine needle aspiration cytology, the two conditions can easily be confused. The problem of making this important distinction is discussed.     

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.     

Standardization of fine needle aspiration cytology of the breast – comparison of Auto Cyto Fix and conventional smears

In Japan, there are some problems with fine needle aspiration (FNA) cytology of the breast, such as insufficient smeared cells, air-drying artefact and excessive erythrocytes. Liquid-based cytology has been found to solve these problems. Equipment for such preparations has been developed, but can be expensive to purchase and operate. We developed Auto Cyto Fix 1000 (ACF), which is inexpensive and automatically smears and fixes cells. The purpose of this study was to compare the various cytological features of conventional and ACF specimens. We evaluated whether the ACF method would be able to replace the conventional method. Forty-eight FNA specimens of breast were studied. All specimens were prepared by the direct smeared (DS) and ACF methods and evaluated for unsatisfactory cell collection, air-drying artefacts, background findings and epithelial cell findings. Although ACF specimens were prepared using the cells remaining in the needle and syringe after preparing DS specimens, the cellularity of two of the ACF specimens was better than that of the corresponding DS specimens. ACF specimens never showed air-drying artefact. Unlike DS specimens, which have many erythrocytes in the background, erythrocytes were filtered out and the background of ACF specimens was clean. We believe that many problems attributable to conventional FNA specimen preparation have been solved in this study. Preparation using the ACF apparatus can reduce running costs and can be used to prepare FNA specimens of the breast for cytological examination as an alternative to the conventional method.     

Fine needle aspiration (FNA) cytology of the breast: the influence of unsatisfactory samples on patient management

FNA continues to play an important role in the management of patients with breast lesions. However, the reliability and efficiency of the FNA service depends heavily on the quality of the specimens. We have audited the rate of 'inadequate FNAs' at intervals over the last 5 years and related our findings to the clinical expertise of the aspirator. We have also correlated the rate of inadequate FNAs with the percentage of patients who had an FNA preceding a definitive diagnosis of cancer. We report trends in the rate of inadequate samples, and subsequent diagnosis of cancer, over a 5‐year period. The percentage of breast FNA samples reported as inadequate was 46.8% in 1988–89, falling to 20% in 1991–92 with the introduction of an FNA clinic, and rising to 30.6% in 1993. The rates of cancer following inadequate FNA were 15.7%, 16.1% and 4.2%, respectively, and the percentage of patients with cancer having a preceding inadequate FNA were 37.5%, 13.2% and 7.1%. Possible explanations for the apparent paradox between increasing numbers of inadequate FNA specimens and a falling breast cancer rate are discussed.     

United Kingdom national audit of breast fine needle aspiration cytology in 1990–91-organization and level of activity

A survey amongst members of the British Society for Clinical Cytology (BSCC) was performed in 1990 and 1991 into their experience of fine needle aspiration (FNA) cytology of the breast. Here we present the findings of that part of the survey covering organizational aspects of the service and methods of specimen handling. the replies demonstrate differences in approach to many of the topics covered. There is a preference for the examination of direct smears (rather than cytospins) with air dried Giemsa staining and wet fixation Papanicolaou staining finding nearly equal favour. Some perceived problems were highlighted, including availability and funding of training and quality assurance as well as facilities for liaison between pathologists, clinicians and radiologists.     

Immunocytochemistry In the Assessment of Ps2 Protein Expression In Fine Needle Aspiration Cytology From Breast Carcinoma

pS2 protein is a cysteine-rich polypeptide, of unknown function, the expression of which is induced in the human cancer cell line MCF-7 by oestrogen. the availability of a murine monoclonal antibody to human pS2 protein has prompted us to evaluate its expression in 47 cases of primary breast carcinoma. Using a double indirect immunoperoxidase technique, we compared the expression of pS2 protein in fine needle aspiration (FNA) cytology smears with that in formalin-fixed, paraffin-embedded sections from subsequently excised tumours from the same patients. We also compared the expression of pS2 protein and oestrogen receptor (ER) status using immunocytochemical assay (ER-ICA) in formalin-fixed, paraffin-embedded sections from 22 primary breast carcinomas. We found the application of immunocytochemistry in the assessment of pS2 protein expression in FNA cytology to be a reliable and cost-effective technique, having a sensitivity of 84% and a specificity of 100%. There was also a good correlation between the expression of pS2 protein and ER status.     

Metastatic breast cancer: mechanisms and opportunities for cytology

Despite significant advances in diagnosis, surgical techniques, general patient care, and local and systemic adjuvant therapies, metastatic disease remains the most critical condition limiting the survival of patients with breast cancer. Therefore, the development of effective treatment against late‐arising metastasis has become the centre of clinical attention and is one of the current challenges in cancer research. A deeper understanding of the metastatic cascade is fundamental, and the need for repetitive tumour assessments for the evaluation of tumour evolution is a relatively new practice in routine medical care. As such, fine needle aspiration cytology (FNAC) is ideally placed to monitor biological changes in metastasis that may affect treatment and response. As FNAC is a minimally invasive method, it can be performed repeatedly with relatively little trauma, and selective ancillary tests can be applied to FNAC specimens, including for tumour whose primary nature is known. Herein, we review how the linear and parallel models explain metastatic dissemination, thus influencing therapeutic and clinical decisions, and how cytology, together with immunocytochemistry and molecular analysis, can be a tool for routine clinical practice and clinical trials aimed at metastatic disease with a special emphasis on breast cancer.     

Neuroendocrine ductal carcinoma in situ of the breast: cytological features in 32 cases

T. Kawasaki, S. Nakamura, G. Sakamoto, T. Kondo, H. Tsunoda‐Shimizu, Y. Ishii, T. Nakazawa, K. Mochizuki, T. Yamane, M. Inoue, S. Inoue and R. Katoh
Neuroendocrine ductal carcinoma in situ of the breast: cytological features in 32 cases Objective: The purpose of this study was to clarify the cytological features of neuroendocrine ductal carcinoma in situ (NE‐DCIS) of the breast. Methods: We analysed the cytopathological findings in 22 fine needle aspiration (FNA) smears and 17 nipple discharge smears obtained from 32 Japanese patients with NE‐DCIS. Results: The background of the FNA smears was clear (59%), mucoid (23%), haemorrhagic (14%) or necrotic (5%). Most of the FNA smears (95%) showed high cellularity. Characteristically, NE‐DCIS cells were loosely arranged in three‐dimensional solid clusters or singly dispersed. Well‐developed vascular cores with or without malignant cells were occasionally recognized. The tumour cells were polygonal or spindle‐shaped with a fine granular, abundant cytoplasm. Nuclei with finely granular chromatin were round or oval and often eccentrically located (plasmacytoid appearance). Mitotic figures were infrequent. Nuclear grade was estimated to be low in 86%. Most nipple discharge smears had fairly low cellularity with poorly preserved cell clusters in a markedly haemorrhagic background, although two (12%) were extremely cellular with cytological characteristics similar to those of the FNA smears. Pre‐operative cytological malignant diagnoses were made in 42% of FNA smears and 0% of nipple discharge smears. Immunohistochemistry for neuroendocrine markers (chromogranin A and synaptophysin) confirmed the neuroendocrine nature of this tumour in adequate cytological specimens. Conclusions: NE‐DCIS has distinctive cytological features and can therefore be diagnosed as a neuroendocrine tumour in most FNAs and some nipple discharge smears by cytological examination employing immunohistochemical techniques. We emphasize that a breast lesion with these features may be in situ and not invasive, and also that there is a risk of under‐diagnosis.     

Pure and mixed mucinous carcinoma of the breast: fine needle aspiration cytology findings and review of the literature

J. Cyrta, F. Andreiuolo, S. Azoulay, C. Balleyguier, C. Bourgier, C. Mazouni, M.‐C. Mathieu, S. Delaloge and P. Vielh
Pure and mixed mucinous carcinoma of the breast: fine needle aspiration cytology findings and review of the literature Objective: Mucinous (colloid) breast carcinoma accounts for 1–6% of all breast cancer. It comprises pure mucinous tumours and mixed infiltrating ductal carcinomas with a mucinous component. As this latter mixed form has a worse prognosis than pure colloid carcinoma, making this diagnosis on fine needle aspiration cytology (FNAC) might influence the choice of treatment. Methods: We report a consecutive series of 22 cases consisting of 17 mixed and five pure mucinous carcinomas diagnosed by cytology and verified on histopathology. Patients underwent FNAC at the one‐stop clinic of our institution during a 7‐year period of time. Cytological findings were evaluated by a semi‐quantitative method and included percentage of smear surface occupied by mucin, shape of cell groupings, size and outline of tumour nuclei as well as presence or absence of nucleolus. Results: Three of five pure mucinous carcinomas displayed at least two of the following features: abundant mucin, small nuclei and/or regular nuclear outlines. Sparse mucin, large nuclei, irregular nuclear outlines or the presence of nucleoli were found in 7 out of 17 mixed mucinous carcinomas but not in pure tumours. Conclusion: Cytopathological identification of patients with pure mucinous carcinomas may be performed in a limited number of cases.     

Fine needle aspiration cytology in the work-up of mammographic and ultrasonographic findings in breast cancer screening: an attempt at differentiating in situ and invasive carcinoma.

This study evaluated the results of fine needle aspiration cytology (FNAC) from the first four years of organized mammography screening for breast cancer in Oslo, particularly our policy in differentiating in situ and invasive carcinoma. Lesions were aspirated directly, ultrasound guided, by stereotaxic device or biopsy localization plate. All lesions were aspirated by cytopathologists working with the radiologists at the breast diagnostic centre. Smears were evaluated immediately for assessment of adequacy and a preliminary diagnosis was given to the surgeon. When FNAC revealed malignancy, diagnostic terms were as follows: (1) invasive carcinoma; (2) ductal carcinoma in situ of comedo type (high nuclear grade), cannot evaluate infiltration; (3) ductal carcinoma in situ of low nuclear grade and (4) papillary tumour, cannot evaluate infiltration. There were 953 cases, 70% of which were nonpalpable. Insufficient material was obtained in 5.8%. Absolute and complete sensitivity were 81% and 91%, respectively. Specificity was 85%. There were 448 histologically proven carcinomas. 383 of these were invasive. 362 carcinomas (in situ and invasive) (80.8%) were diagnosed directly on FNAC. Distinction between invasive and in situ carcinoma was possible in 294 of 320 directly diagnosed invasive carcinomas (91.8%). PPV of a diagnosis of invasive carcinoma was 97%. Our data showed that definitive cytological diagnosis of invasive carcinoma was possible in more than 90% of fully diagnostic smears and allowed definitive primary surgery in these women.     

UK national audit of breast fine needle aspiration cytology in 1990–91: diagnostic criteria

A survey into the practice of fine needle aspiration cytology of the breast amongst members of the British Society for Clinical Cytology in 1990 and 1991 was performed. This paper presents their reported use of diagnostic categories in reporting and the criteria found useful in the diagnosis of benign and malignant disease. A wide variety of diagnostic categories are in use. the criteria used in diagnosis largely follow recommendations found in standard textbooks, but some less well recognized features were also suggested.     

Fine needle aspiration (FNA) cytology of adenoid cystic carcinoma and adenomyoepithelioma of breast: two lesions rich in myoepithelial cells

Adenoid cystic carcinoma and adenomyoepithelioma are relatively rare, but well described, breast lesions. The FNA cytology features in two cases of mammary adenoid cystic carcinoma and two cases of adenomyoepithelioma are described. In both cases of adenoid cystic carcinoma, aspirates consisted of tightly cohesive clusters of cells arranged around spheres and interconnecting cylinders of acellular material. The two aspirates of adenomyoepithelioma were composed of large tightly cohesive clusters of cells associated with small amounts of stromal material. In all four aspirates a dual population of epithelial and myoepithelial cells could be identified within cellular aggregates, and numerous bare nuclei were present. Histology revealed the characteristic features of adenoid cystic carcinoma and adenomyoepithelioma. Immunohistochemical staining of histological sections for S‐100 protein and alpha‐smooth muscle actin confirmed the presence of large numbers of myoepithelial cells within all four lesions, providing indirect evidence that bare nuclei in breast aspirates represent myoepithelial cells. The presence of a dual population of epithelial and myoepithelial cells and of numerous bare nuclei within a breast aspirate is generally indicative of a benign lesion. This is not always the case, as adenoid cystic carcinoma is a malignant tumour, and adenomyoepithelioma, while generally exhibiting benign behaviour, is capable of local recurrence and distant metastasis.     

The varied presentation of metastatic melanoma in fine needle aspiration cytology of the breast

D. L. Ribu, P. W. Shield and J. F. Bligh
The varied presentation of metastatic melanoma in fine needle aspiration cytology of the breast Objective: To identify cytomorphological patterns of metastatic melanoma (MM) in breast fine needle aspiration (FNA) specimens and highlight the differential diagnoses and features most useful in identifying MM. Methods: The clinical, radiological and FNA findings of 16 cases were reviewed. Cytological features evaluated related to cell arrangement, size and shape of cells, nuclear and cytoplasmic features, and the presence or absence of necrosis. Results: The series consisted of 14 females and two males, ranging in age from 24 to 83 years (mean = 50 years). A previous history of melanoma was available in 12/16 (75%) cases at the time of FNA reporting; however the clinical/radiological impression in 4/16 cases was of a breast cyst. The cases were classified into six morphological variants: classical (8/16), pseudopapillary (3/16), spindle‐cell (1/16), melanin‐rich (1/16), pleomorphic (2/16) and lymphoma‐like (1/16). The varying patterns raised a wide range of differential diagnoses; however, discohesion, binucleation and granular cytoplasm were the major features seen in 94% of all cases. In 14/16 cases (88%), plasmacytoid cells, prominent nucleoli and cytoplasmic vacuolation were identified. Melanin and multinucleation were detected in 44% of cases and intranuclear cytoplasmic invaginations in 63%. Necrosis was present in more than half of the cases (56%). Conclusion: MM should be considered in the differential diagnosis of breast FNA specimens when atypical cells are seen that present as plasmacytoid cells in a dispersed or pseudopapillary pattern, or as spindle, pleomorphic or pigmented cells. These features, combined with clinical history and immunocytochemistry, may assist in correctly identifying MM and directing optimal treatment.     

Fine needle aspiration cytology of thyroid nodules: how accurate is it and what are the causes of discrepant cases?

Fine-needle aspiration cytology (FNAC) is widely accepted as the most accurate, sensitive, specific and cost-effective diagnostic procedure in the assessment of thyroid nodules and helps to select people preoperatively for surgery. The purpose of this study was to evaluate the results of thyroid FNAC in our institution and to determine the reasons for discrepancies between the cytological and histological diagnosis. We evaluated the cytological and histological results of 254 FNACs obtained from 231 patients who underwent subsequent thyroid surgery. All of the material was blindly reviewed for quality control, by one experienced cytopathologist. All FNACs were carried out under ultrasound guidance. The cytological diagnosis was classified as benign, suspicious, malignant or unsatisfactory. The definitive histological study showed benign lesions in 195 of the 231 patients (84%). A benign diagnosis based on FNAC was correct in 105 of the 108 benign cases (97%). FNACs diagnosed as 'suspicious' resulted in a distribution of 49 benign (79%) and 13 malignant (21%) diagnoses. FNAC showed malignancy in 34 cases (13%) and in only one case did the final histology differ from cytology (correlation 97%). The percentage of FNACs that were inadequate for diagnosis was 20%. Review of cytological and histological slides did not lead to any change in the original diagnosis. Our study revealed a cytological-histological discrepancy (2%) in only 4 out of 231 cases over a period of 10 years, due to either a diagnostic or sampling error.     

Cytological diagnosis of filarial infection in an endemic area where screening and prophylaxis is in place

P. Singh, Anshu and N. Gangane Cytological diagnosis of filarial infection in an endemic area where screening and prophylaxis is in place Objective: Filariasis has a worldwide distribution. However, the disease is often overlooked or misdiagnosed because of its unusual presentations and there may be false‐negative results in endemic areas. This study was carried out to assess the role of cytology in the demonstration of filarial parasites in an area where screening and prophylaxis are in place. Methods: This study was carried out in Wardha district in central India, which is endemic for filarial infection. A total of 9182 smears of cases undergoing cytological evaluation were routinely screened at the time of reporting for the presence of adult filarial worm, microfilarial larvae or their fertilized and unfertilized eggs, irrespective of their original clinical diagnosis. Results: Microfilariae were found incidentally in fine needle aspiration (FNA) smears of patients presenting with other clinical conditions. Smears of seven cases were found to be positive for microfilaria. Four cases presented with subcutaneous nodules in the upper arm, two cases were seen incidentally in axillary lymph node aspirates and microfilariae were found in the pleural fluid in one case. Another case was suspected to have breast cancer, but aspirates from the axillary area showed lymphatic obstruction considered to be due to filariasis. Conclusion: FNA cytology is an inexpensive, simple and easy procedure for detecting microfilariae. Detection of microfilariae may not be common even in endemic areas as screening and prophylaxis is routinely performed, and patients may show atypical presentations such as subcutaneous nodules. We believe that careful screening of FNAs, especially those from subcutaneous swellings, as well as serous fluids, is very important in a filariasis‐endemic zone.     

Evaluation of accuracy of fine needle aspiration cytology in BI‐RADS3 category breast lesions: cytohistological correlation in 337 cases

C. Engohan‐Aloghe, N. Hottat, J. Cosaert, R. Boutemy, I. Fayt and J.‐C. Noël
Evaluation of accuracy of fine needle aspiration cytology in BI‐RADS3 category breast lesions: cytohistological correlation in 337 cases Objective: To evaluate the accuracy of fine needle aspiration cytology (FNAC) in BI‐RADS3 breast lesions. Methods: Between January 2004 and December 2007, 337 cases from BI‐RADS3 lesions underwent FNAC. Three to six needle passes were made on each patient. In 67 cases (20%) a histological biopsy was performed. Cytological and histological interpretations were performed by the same pathologist. Results: The histological diagnosis showed that 88% (59/67) of BI‐RADS3 breast lesions were benign. Only 6% (4/67) were malignant, consisting of ductal carcinoma in situ and infiltrating ductal carcinoma. Conclusion: BI‐RADS3 lesions remain disruptive in their management. However, the correlation between cytology and histology showed that most of these lesions were benign and that finally FNAC remains a useful and accurate test in the management of these lesions.