The triage role of fine needle aspiration biopsy of palpable breast masses. Diagnostic accuracy and cost-effectiveness

A total of 219 fine needle aspiration (FNA) biopsies of the breast were performed during the period 1983 to 1985 at a tertiary medical center. The series consisted of 215 women (98.2%) and 4 men (1.8%), with an are range of 14 to 90 years (mean of 46.5 years). Histologic confirmation (93 cases) or clinical follow-up for up to two years was obtained. The sensitivity of the FNA procedure was 82.2%, its specificity was 98.8%, and the overall efficiency of the test was 95.4%. The false-negative rate was 4.4%, with no false-positive diagnoses for the primary diagnosis of breast carcinoma. We have found that one of the major advantages of FNA biopsy is that it lowers costs by allowing the surgeon to triage which patients should have an outpatient excisional biopsy under local anesthesia and which patients should have a one-stage inpatient procedure with frozen section confirmation. For this triage role, suspicious diagnoses (3.2%) were included in the positive group and atypical (1.8%) and insufficient diagnoses (6.8%) in the negative group. Taking into account the FNA biopsy cost of $75, the procedure resulted in a savings per case of $262 over the cost that would have occurred if all cases had had routine inpatient biopsy and $154 per case over the cost that would have occurred with routine outpatient biopsy of all cases. Our results indicate that FNA breast biopsy is a diagnostically accurate and economical triage procedure, even when followed by an excisional or frozen-section biopsy for confirmation. The use of FNA biopsy could be expanded to a greater number of medical centers and decrease the potential for false-positive diagnoses by combining FNA biopsy with frozen-section confirmation.     

Cytologic diagnosis of reactive lymphadenopathy in fine needle aspiration biopsy specimens

Reactive or benign lymphadenopathies were cytologically diagnosed in the aspirates of 62 (23.5%) of 265 cases with enlarged lymph nodes of the head, neck or inguinal region subjected to fine needle aspiration (FNA) biopsy. The cytomorphologic features characteristic of reactive lymphadenopathy are described in detail; some of the cell patterns were suggestive of a specific disease process. The similarities of cells and cell patterns that may pose differential diagnostic problems with malignant lymphomas are pointed out. This study emphasizes the role of FNA cytology in the diagnosis of some benign conditions.     

Endoscopic fine needle aspiration biopsy

A catheter assembly that can be passed through the biopsy channel of a standard fiberoptic gastroduodenoscope was devised to permit fine needle aspiration biopsy of gastrointestinal neoplasms under direct vision of the endoscope. This technique for endoscopic aspiration biopsy was performed in ten consecutive patients with esophageal and gastric carcinomas, along with the conventional endoscopic brushing and biopsy. Endoscopic aspiration biopsy gave a positive diagnosis in all ten cases while the other two techniques gave inconclusive results in one patient with an ulcerative growth. We feel that endoscopic aspiration biopsy can be used to obtain representative samples from gastrointestinal neoplasms, and it may add to the diagnostic accuracy of endoscopic biopsy and brushing cytology.     

Combined hepatocellular-cholangiocarcinoma. Diagnostic challenge in hepatic fine needle aspiration biopsy

OBJECTIVE: To study the cytohistologic features of combined hepatocellular-cholangiocarcinoma (CHCC-CC) in fine needle aspiration biopsy (FNAB) material. STUDY DESIGN: Six hepatic FNAB cases with cell blocks (five) and hepatic resections (two) were analyzed cytohistologically and immunohistochemically. RESULTS: The six cases were diagnosed as CHCC-CC based on clinicopathologic correlation. Unequivocal hepatocellular carcinoma (HCC) cells corresponding to Edmondson and Steiner's grade 3 lesions were identified in the FNAB in three instances. Adenocarcinoma, represented by cohesive columnar cells with ovoid, basal nuclei displaying nuclear palisading, acini and/or papillary structures with variable intracytoplasmic intraacinar or brush border mucin production, was identified in all cases. Intermediate cells with hybrid/polymorphic cytologic features straddling malignant hepatocytes and glandular cells were identified in five instances. Tissue alpha-fetoprotein was negative. There was brush border and/or diffuse cytoplasmic p-carcinoembryonic antigen immunoreactivity in the glandular elements. CONCLUSION: FNAB diagnosis of CHCC-CC is possible if the clinical, cytohistologic and immunohistochemical findings support the presence of HCC and adenocarcinoma. Intermediate cells pose a great challenge to recognize and define: they tend to lose the classic cytologic features of malignant hepatocytes and acquire glandular characteristics. At the very least, there should be a high index of suspicion. These cases underscore the necessity for clinicopathologic correlation in enhancing the precision of FNAB diagnoses.     

Transvaginal fine needle aspiration biopsy.

OBJECTIVE: To assess the role of transvaginal fine needle aspiration biopsy (FNAB) in the evaluation of palpable gynecologic masses. STUDY DESIGN: Transvaginal FNABs from 1994 to 1999 were identified from the files of Barnes-Jewish Hospital. Histologic correlation was obtained using the Pathology Department's computer database. Two pathologists reviewed the pathologic samples. Pertinent clinical information was obtained by reviewing the medical records. RESULTS: Twenty-two transvaginal FNABs from 22 patients were studied. The patients' mean age was 59 years (range, 29-84). Most patients (77%) had a previous history of a gynecologic malignancy, and 73% had a previous total abdominal hysterectomy and bilateral salpingo-oophorectomy. The size of the lesion sampled was provided in 15 cases and ranged from <1 to 5.4 cm in diameter. The location of the mass was reported as follows: vaginal (10 cases), vaginal cuff (5), rectovaginal septum (2), cul-de-sac (1), fornix (1), vaginal apex (1), right side of pelvis (1), and not specified (1). The cytologic diagnoses were: negative for malignancy (10 cases), positive for malignancy (9) and unsatisfactory (3). Most cases (77%) had histologic correlation or clinical follow-up. There was one false negative and no false positive cytologic diagnosis. CONCLUSION: Cytologic interpretation of transvaginal FNAB is an effective toolfor the evaluation of palpable pelvic and vaginal masses. Its specificity and sensitivity are 100% and 88%, respectively.     

Diagnostic value of fine needle aspiration biopsy of palpable colonic masses.

OBJECTIVE: To assess the role of fine needle aspiration biopsy (FNAB) in patients with palpable colonic masses. STUDY DESIGN: FNAB was performed on 32 patients with palpable colonic masses before subjecting them to colonoscopic examination. Smears prepared from the material obtained by aspiration biopsy were examined. The results of aspiration biopsy were confirmed by histopathologic examination of the tissue obtained on colonoscopy or surgery or by a salutory response to antituberculous therapy in patients with tuberculosis of the colon. RESULTS: Twenty-nine patients had carcinoma of the colon, and three had ileocecal tuberculosis. Aspiration biopsy could correctly diagnose all the cases with malignancy and two of the three cases with colonic tuberculosis. Colonoscopy could not be performed on two patients with cancer of the colon. However, a barium enema examination revealed evidence of cecal malignancy in both patients. In the two patients diagnosed as having colonic tuberculosis by FNAB, colonoscopic biopsies revealed only nonspecific changes. There were no false positive results or complications of the procedure. CONCLUSION: FNAB is a simple, rapid and accurate method of diagnosing palpable colonic masses.     

Endoscopic ultrasound-guided fine needle aspiration of the pancreas. Diagnostic utility and accuracy

OBJECTIVE: Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) is regarded as a safe and reliable procedure for diagnosing and staging of pancreatic neoplasms. This study retrospectively evaluated both the diagnostic utility and accuracy of pancreatic EUS-FNABs and potential cytologic pitfalls when using Diff-Quik stain for on-site evaluation. STUDY DESIGN: Pancreatic EUS-FNABs performed between 1995 and 1998 were identified from the files of the Department of Pathology. All patients were studied via a linear-array ultrasound endoscope with an FNAB device. Immediate evaluation of the specimen by a pathologist using air-dried slides and Diff-Quik stain was done on all cases. An average of five passes (range, three to nine) were performed. Five cytologic categories were identified: nondiagnostic, benign, atypical, suspicious and malignant. EUS disease staging, histologic correlation and clinical follow-up were reviewed. RESULTS: Sixty-nine consecutive pancreative FNABs were evaluated in the study period. The patients comprised 38 females and 31 males with a mean age of 65 years (range, 36-83). Histologic correlation was available on 40 patients, and follow-up was available on the remaining 29. The cytologic diagnoses included: 31 malignant, 8 suspicious, 6 atypical, 20 benign and 4 nondiagnostic. Forty-three cases were true positive, 9 were true negative, 2 were false positive, and 11 were false negative. The overall sensitivity was 80% and specificity was 82%. CONCLUSION: The study showed that cytologic evaluation of pancreatic EUS-FNABs has 80% sensitivity and 82% specificity. False negative diagnosis was usually due to sampling error. A nondiagnostic cytologic diagnosis should be rendered in the absence of adequate sampling of a lesion. On-site cytologic evaluation of EUS-FNABs aids in guaranteeing specimen adequacy, and the pathologist should be trained to evaluate Diff-Quik-stained samples.     

The role of fine needle aspiration biopsy in the diagnosis of melanoma

The role of fine needle aspiration biopsy (FNAB) is discussed in the follow up of patients with the diagnosis of malignant melanoma. The review is based on literary data and the author's own material. The primary role of FNAB is to confirm metastatic or recurrent melanoma lesions. US or CT guided FNAB is valuable in the diagnosis of visceral metastases. FNAB has limited role in the diagnosis of primary melanomas except in cases with unusual clinical presentation (e.g. oral mucosa). In spite of the well-known cytology the diagnosis can be difficult due to the inherent histological variation of malignant melanomas, especially in cases with unusual localisation and amelanotic tumor presentation when immunocytochemistry is needed. The known clinical history of melanoma is very helpful.     

Evaluation of fine needle aspiration vs. fine needle capillary sampling on specimen quality and diagnostic accuracy in endoscopic ultrasound-guided biopsy

OBJECTIVE: To compare percutaneous and endoscopic ultrasound (EUS)-guided biopsy techniques. Study DESIGN: From July 2005 to February 2006, all patients referred for EUS-guided fine needle aspiration (FNA) were considered. If inclusion criteria were met, the first 2 biopsy passes were performed without suction (fine needle capillary [FNC] sampling). Two additional passes were performed using the same needle with 10 mL of applied suction (FNA). A single blinded pathologist later retrospectively evaluated each set of slides. Fifty-three patients met inclusion criteria. The study group comprised pancreatic masses (23), lymph nodes (26), subepithelial masses (3) and liver lesion (1). There were 38 malignant and 15 benign lesions. RESULTS: No statistically significant differences were found with the scoring systems considered in the study. In the subgroups of patients with pancreatic masses, lymph nodes, benign disease and malignant disease, no statistically significant outcomes were noted. CONCLUSIONS: No difference exists between quality and diagnostic accuracy of specimens obtained from EUS-guided tissue acquisition via FNC and FNA. The decision to use FNC or FNA should be left to the discretion of the individual endosonographer.     

Diagnostic accuracy of fine needle aspiration cytology of the thyroid: impact of ultrasonography and ultrasonographically guided aspiration

OBJECTIVE: To determine the impact of ultrasonography on the diagnostic accuracy of fine needle aspiration cytology (FNAC) of the thyroid. STUDY DESIGN: We compared two FNAC series. In period 1 we used neither ultrasonograph nor ultrasonographically-guided FNAC in the evaluation of thyroid nodules, while both tools were routinely applied in period 2. Moreover, in the former period all cellular follicular lesions were encountered among suspicious findings, while in period 2 we advised regular follow-up examinations instead of immediate surgery for patients with no significant atypia. The basis of follow-up examinations was ultrasonographic volumetry of the nodule and repeat FNAC on growing nodules. RESULTS: The number of FNAC, positive predictive value of FNAC, number of malignancies, sensitivity, the specificity and diagnostic accuracy were higher in period 2 as compared with period 1: 3,446 vs. 1,448; 45% vs. 16%, 39 vs. 29, 92% vs. 76%, 65% vs. 87% and 66% vs. 87%, respectively. CONCLUSION: The introduction of ultrasonography permits higher diagnostic accuracy of the evaluation process. This is achieved not only by lessening false negative reports but, more important, by decreasing false positive results.     

Thoracic fine needle aspiration biopsy versus fine needle cutting biopsy. A comparative study of 40 patients

The fine needle aspiration (FNA) biopsy findings were compared with the results of fine needle cutting (FNC) biopsy in 40 patients. The lesions (38 pulmonary nodules, 1 mediastinal mass and one lytic rib lesion) were biopsied with 22-gauge Greene and 21-gauge E-Z-EM needles through a 19-gauge needle guide. The FNA biopsy findings were based on smears and cell blocks of material obtained with the Greene needles while the FNC biopsy findings were based on tissue cores obtained by the E-Z-EM needles. In 83% of the cases, both techniques yielded specimens with similar cellularity; in seven cases, the FNA samples were more cellular. Malignancy was diagnosed in 80% of the patients: by both techniques in 26 patients, by FNA biopsy only in 5 patients and by FNC biopsy only in 1 patient. The sensitivity of FNA biopsy was higher than that of FNC biopsy (96.8% vs. 84.3%). The specificity and predictive value of positive results were 100% for both techniques. The predictive value of negative results was higher for FNA biopsy (88.8% vs. 54.5%). The majority of FNC biopsy tissue cores consisted mostly of clotted blood, lung tissue and/or fibrous tissue and did not facilitate or improve the diagnosis. Those data suggest that the contribution of FNC biopsy to the diagnosis of thoracic neoplasms is very limited and that the performance of FNC biopsy with an E-Z-EM needle in addition to or instead of FNA biopsy is not justified.     

Use of fine needle aspiration biopsy in radiofrequency ablation

OBJECTIVE: To demonstrate the utility of fine needle aspiration biopsy (FNAB) in radiofrequency ablation (RFA) of suspected metastatic tumors at various sites. STUDY DESIGN: Eighteen patients referred for RFA underwent 21 aspirations prior to the procedure. A radiologist performed the FNAB and RFA with radiographic guidance. On-site preliminary evaluation of Diff-Quik-stained smears were followed with Papanicolaou staining. A final diagnosis was rendered and compared to the preliminary diagnosis. RESULTS: Liver was aspirated in 17 cases, lung in 3 cases and pubic bone in 1. Fifteen aspirates were deemed on site as positive or suspicious for malignancy. A preliminary, on-site diagnosis of benign was given in one case and adequate with deferment for review of all slides in four others. One FNAB was unsatisfactory. All but one (patient with benign diagnosis) then immediately proceeded to RFA of the lesion. After review of additional slides, the final diagnosis confirmed metastatic adenocarcinoma in 16, hepatocellular carcinoma in 2 and metastatic squamous cell carcinoma in 1. One FNAB yielded benign hepatocytes, and one was unsatisfactory. CONCLUSION: FNAB is an accurate, safe and rapid method of confirming disease in patients just prior to undergoing RFA.     

Diagnosis of cervical chordoma by fine needle aspiration biopsy

A case of cervical chordoma diagnosed by fine needle aspiration (FNA) is presented. The cytologic criteria for differentiating chordoma from chondrosarcoma and metastatic adenocarcinoma, the main diagnostic problems, include the finding of physaliferous cells and the presence of bland nuclear features. Significantly, chordomas lack true signet-ring cells. FNA of these rare midline vertebral neoplasms, which produce pain and spinal cord compression, can greatly facilitate diagnosis and optimal treatment.     

Transcutaneous fine needle aspiration biopsy of the preepiglottic space

OBJECTIVE: To evaluate transcutaneous fine needle aspiration biopsy of the preepiglottic space for staging supraglottic squamous cell carcinoma. STUDY DESIGN: We studied 28 patients who underwent total or horizontal supraglottic laryngectomy as their main therapy modality due to supraglottic squamous cell carcinoma, followed in some cases by adjuvant radiation therapy. All the patients underwent transcutaneous fine needle aspiration. RESULTS: The cytopathologic examination of the material obtained by aspiration was compared to the histopathologic analysis of the laryngectomy specimens; the efficiency was 96.4%. The method did not cause any morbidity. CONCLUSION: Transcutaneous fine needle aspiration biopsy of the preepiglottic space is useful for preepiglottic space evaluation, with a high correlation with histopathologic results and no morbidity.