|Year : 2022 | Volume
| Issue : 1 | Page : 70-75
Comparative study of fine-needle aspiration cytology and needle core biopsy in the diagnosis of breast lumps with histopathological correlation
Rizia Siddique1, Anuradha Sinha2, Moumita Adhikary3, Jyoti Prakash Phukan4
1 Department of Pathology, Naihati State General Hospital, Naihati, Kolkata, India
2 Department of Pathology, Deben Mahata Government Medical College, Purulia, West Bengal, India
3 Department of Microbiology, Barasat Government Medical College, Barasat, West Bengal, India
4 Department of Pathology, Rampurhat Government Medical College, Rampurhat, West Bengal, India
|Date of Submission||16-Jun-2021|
|Date of Acceptance||05-Nov-2021|
|Date of Web Publication||22-Apr-2022|
Jyoti Prakash Phukan
Department of Pathology, Rampurhat Government Medical College, Rampurhat, West Bengal
Source of Support: None, Conflict of Interest: None
Introduction: Diseases of breast constitute a large proportion of cases in surgical practice and need to be differentiate between benign from malignant lesions prior to definite treatment. Aims and Objective: The aim is to determine the accuracy with the benign and malignant lesions can be differentiated by fine-needle aspiration cytology (FNAC) and needle core biopsy (NCB) and to correlate the findings of NCB with histopathological diagnosis. Materials and Methods: It is a prospective study for one and half years comprising of 104 patients of breast lumps who underwent FNAC, NCB, and surgical excision followed by histopathological examination. Data have been collected and analyzed regarding sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of FNAC and NCB in comparison with histopathology (HP). Results: Out of 104 patients, the most common age group is 41–50 years (35 cases, 33.7%). The most common HP diagnosis was infiltrating ductal carcinoma followed by ductal carcinoma in situ (50 cases and 12 cases, respectively). In our study, we found FNAC has sensitivity 94.3%, specificity 100%, PPV 100%, NPV 87.9%, diagnostic efficiency 95% while NCB has sensitivity 97.3%, specificity 100%, PPV 100%, NPV 81.8% and diagnostic accuracy 97.6% in diagnosing breast lumps. Conclusion: NCB is better in comparison to FNAC in diagnosing breast lumps. However, the role of FNAC cannot be ignored in our settings especially in the diagnosis of benign breast conditions. NCB should be considered as second-line method of investigation in case of any doubt to rule out missed diagnosis of breast carcinoma.
Keywords: Breast lump, carcinoma, fine-needle aspiration cytology, histopathology, needle core biopsy
|How to cite this article:|
Siddique R, Sinha A, Adhikary M, Phukan JP. Comparative study of fine-needle aspiration cytology and needle core biopsy in the diagnosis of breast lumps with histopathological correlation. J Sci Soc 2022;49:70-5
|How to cite this URL:|
Siddique R, Sinha A, Adhikary M, Phukan JP. Comparative study of fine-needle aspiration cytology and needle core biopsy in the diagnosis of breast lumps with histopathological correlation. J Sci Soc [serial online] 2022 [cited 2022 Nov 30];49:70-5. Available from: https://www.jscisociety.com/text.asp?2022/49/1/70/343709
| Introduction|| |
Breast lumps constitute a large proportion of cases in surgical practice, and it needs to be differentiated between benign from malignant lesions prior to definite treatment. The most common presentation of breast disease is palpable mass although it is difficult to determine whether a suspicious lump is benign or malignant simply by clinical examination. Breast carcinoma is one of the most common cancer in women and is one of the leading causes of death among women worldwide.
So, for the diagnosis of breast lumps and to distinguish benign from malignant lesion fine-needle aspiration cytology (FNAC) and needle core biopsy (NCB) are done which reduces open biopsy of breast lesions. The main purpose of FNAC and NCB of breast lumps is to confirm malignancy preoperatively and to avoid unnecessary surgery in specific benign conditions. FNAC and NCB becoming very much important as preoperative diagnosis of breast cancer can be made on which basis neoadjuvant chemotherapy can be started.
FNAC of the breast is minimally invasive diagnostic procedure which often obviates an open biopsy. It is cheaper, easy to perform, and its results can be obtained within a short time. FNAC can easily distinguish between benign and malignant lesions; however, it is not able to differentiate invasive and noninvasive breast carcinoma if a malignant cell is detected. In these cases, NCB is beneficial as it can give a definite histologic diagnosis and detect invasion. NCB can be performed under clinical guidance, mammographic (stereotactic), or ultrasonic guidance. If malignancy is detected, NCB also helps in subclassification, grade, and detection of hormone receptor status.
In this background, the present study was undertaken with the following aims and objectives:
- To assess the performance of FNAC and NCB in preoperative diagnosis of breast carcinoma,
- To find out diagnostic sensitivity and specificity of FNAC and NCB in comparison to final histopathology (HP).
| Materials and Methods|| |
Study subjects and study area
The study was carried out on female patients in the department of pathology of a tertiary care teaching hospital of eastern India who were referred for breast FNAC from surgical outpatient department. The study was done from January 2015 to June 2016 after getting ethical clearance. A total of 104 patients were included in the study and every participant filled informed consent form before participating in the study.
All female patients with palpable breast lumps, of any age, who have attended menarche.
- Recurrent breast lump of previously operated case of confirmed malignancy
- Obvious malignant case with skin infiltration
- Patients getting neoadjuvant therapy
- Uncooperative patients.
The study was approved by institutional ethics committee before commencing the study. The date of ethical clearance was 13.01.2015.
After taking informed consent, detailed history was taken, and complete clinical examination done. FNAC was performed using 22 Gauge needle attached to 10 cc syringe. An average 2–3 passes done, and 5–6 smears made on slides. Slides were stained using Leishman-Giemsa stain and Papanicolaou stain.
NCB was carried out on 84 patients after FNAC procedure. Core biopsy is the procedure which is used to remove a small amount of suspicious tissue from the breast with a larger “core” (meaning “hollow”) needle. The needle was put in 6–8 times to get the samples or cores and 6–8 tissue samples were taken from different sites of lump to avoid false-negative result. After fixation in 10% formalin, sections were prepared and stained with Hematoxylin and Eosin (H and E) stain.
Histopathological examination was carried out on mastectomy and lumpectomy specimens sent from the operation theatre. Sections were made and stained with H and E stain.
For statistical analysis, data were entered into Microsoft excel spreadsheet and analyzed by SPSS version 20.0.1 (Statistical Package for Social Sciences, IBM Corporation, Armonk, NY 10504). Reports of all three procedures were collected and the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of FNAC and NCB were calculated taking histopathological reports as gold standard. The findings were deemed significant in case of P < 0.05 by employing Chi-square test.
| Results and Observations|| |
A total of 104 patients presenting with palpable breast lumps were included in this study. The maximum number of patients attended were in 41–50 years of age group (35 cases, 33.7%), followed by 51–60 years (25%) with mean age of the patient was 46.93 years [Table 1]. The maximum number of benign lesions (14 in number) occurred in 31–40 years of age group and the maximum number of malignant lesions (34 in number) occurred in 41–50 years of age group.
Most of the patients (69.2%) presented with breast lump in upper and outer quadrant followed by breast lump in central quadrant (15.4%). All the malignant cases (75 in number) presented with painless breast lump. Only 5 cases had painful breast lump and all those were benign diseases.
In our study, on FNAC 65 patients had ductal carcinoma followed by 19 patients have fibroadenoma and five patients had phyllodes [Table 2]. FNAC was not done in 5 cases, they directly go for NCB. On FNAC, 1 case of medullary carcinoma was diagnosed which was later confirmed in HP. We were not able to correctly diagnose infiltrating lobular carcinoma and mucinous carcinoma which later diagnosed on HP. The most common diagnosis in NCB in our study was infiltrating ductal carcinoma (53 cases) followed by ductal carcinoma in situ (8 cases) and benign phyllodes (6 cases) [Table 3]. There were 4 and 2 false-negative cases in FNAC and NCB, respectively [Table 4].
|Table 2: Distribution of cases according to fine needle aspiration cytology findings|
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|Table 4: Histopathology follow-up of false-negative cases on fine needle aspiration cytology and needle core biopsy|
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For malignant breast lesions, FNAC showed sensitivity and specificity of 94.3% and 100%, respectively. We found PPV of FNAC was 100%, NPV 87.9% and overall diagnostic accuracy was 95% for FNAC [Table 5].
|Table 5: Comparison of fine needle aspiration cytology findings with histopathology findings|
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While the sensitivity and specificity of NCB was 97.3% and 100% respectively. Furthermore, PPV was 100%, NPV was 81.8% and diagnostic accuracy was 97.6% for NCB [Table 6].
| Discussion|| |
Lesions of the female breast are much more common and usually take the form of palpable, sometimes painful nodules or masses. Fortunately, most are innocent, but as is well known, breast cancer is one of the most common malignancies of women worldwide. Various diagnostic modalities have been developed to evaluate the palpable and nonpalpable beast lesions with the goal of identifying a sensitive, specific, efficient, and economical approach to diagnose the nature of breast lump. Excision biopsy is the gold standard for the diagnosis of breast lump. Nowadays emphasis has been placed on methods that can give definitive diagnosis prior to surgery. In this contest, FNAC and NCB are two most important modalities that res used to obtain tissue diagnosis of the breast lesion. FNAC has the distinctive advantage that it can be performed easily during outpatient basis without the need of local anesthesia, but NCB is recently being preferred to diagnose palpable or nonpalpable breast lesions.
The present study showed majority (33.7%) of patients are in the age group of 41–50 years. The maximum number of malignant lesions (34 in number) occurred in 41–50 years of age group. Venogopal et al. in their study got majority of patients in the age group of 31–40 years and most of the malignant lesions occurred in 41–50 years of age group. Malignant breast diseases were also more prevalent in the age group of 41–50 years in a study done by Khemka et al.
In the present study, on FNAC, we found 65 (62.5%) patients with ductal carcinoma followed by 19 (18%) patients reported as fibroadenoma [Table 2]. This finding is like a study done by Ariga et al. where they had 62% malignant lesions in FNAC and ductal carcinoma being the most common malignant lesion that presented for fine-needle aspiration. Again, the most common diagnosis in NCB in our study was infiltrating ductal carcinoma (51% cases), followed by ductal carcinoma in situ (7.7% cases) [Table 3].
In this study, out of 18 cases of fibroadenoma, FNAC diagnosed as same in 15 cases and 3 cases were reported as fibrocystic disease whereas NCB diagnosed as fibroadenoma only in 2 cases, as in rest of the cases the procedure was not done, so it correlates with HP findings. Similarly, out of 2 cases of lactating adenoma, FNAC corroborates with HP findings, but NCB was not done in these cases also.
We found 65 malignant lesions (72%), ductal carcinoma being the most common malignant lesion that resented for final HP. It forms the 63.5% of the malignant lesion aspirated for cytology. In NCB, altogether malignant lesions consisting of 75.2% of all lesions. Percentage of malignant lesions raised in NCB in comparison to FNAC because most of the benign cases diagnosed in FNAC were not selected for NCB procedure.
Apart from duct carcinoma and ductal carcinoma in situ, we have found 5 cases of infiltrating lobular carcinoma on HP; but no one can be correctly diagnosed by FNAC. Out of 5 cases, FNAC was done in 3 cases and 2 of them diagnosed as ductal carcinoma, while the other case was misdiagnosed as fibroadenoma (false-negative). The cases diagnosed as duct carcinoma showed poor cellular yield of small dyscohesive clusters of atypical epithelial cells with scanty cytoplasm and many naked nuclei in the background. Relatively less cellular yield and absence of intracytoplasmic lumina lead to misdiagnosis of ductal carcinoma, not otherwise specified. There were 2 mucinous carcinomas in our study; out of which 1 case was wrongly diagnosed as myxoid fibroadenoma (false-negative) and for others, FNAC was not done. Numbers of medullary carcinomas in our study were 2, 1 was correctly diagnosed on FNAC while the other was misdiagnosed as breast abscess (false-negative). Cytology of correctly diagnosed case of medullary carcinoma showed high cellular yield of poorly cohesive malignant epithelial cell mainly in dispersed pattern and numerous scattered lymphocytes in the background. Subsequent HP study confirmed the diagnosis.
There were 4 and 2 false-negative cases in FNAC and NCB, respectively. Case 1 of false-negative FNAC was diagnosed as fat necrosis. This patient was 47 years old, presented with right breast lump with thickening of the overlying skin without lymphadenopathy. FNA revealed hypocellular smear predominately consisting of chronic inflammatory cells and foamy macrophages in a dirty granular debris background. A cytological diagnosis of fat necrosis was made. Subsequent HP examination revealed the case to be ductal carcinoma in situ with comedo necrosis. Subsequent careful examination of cytology slides after HP diagnosis showed the presence of occasional large, pleomorphic malignant ductal cells, which were missed as the background was obscured by necrotic debris. Our 2nd false-negative case was diagnosed as breast abscess with atypical repair on FNAC. This 42-year-old female presented with right breast mass 2 cm × 2 cm in diameter which was well circumscribed with restricted mobility. Cytology showed scattered atypical large ductal epithelial cells in background of chronic inflammatory cells mainly lymphocytes and few polymorphs. A diagnosis of breast abscess with atypical repair made; however, advised for excision. Subsequent excision and HP examination revealed the case to be medullary carcinoma of breast with lymphoplasmacytic and neutrophilic infiltrate. The causes of misdiagnosis were due to misinterpretation of malignant cells as regenerative atypia and fail to appreciate the importance of lymphocytic background. The 3rd false-negative case was in a 35-year-old female presented with well-defined, mobile lump which was diagnosed as fibroadenoma on FNAC. Cytosmears show clusters and cohesive fragments of ductal epithelial cells showing mild nuclear enlargement without much variation in size and presence of scanty fibrous stroma. The presence of fibrous stroma and lack of obvious atypia of ductal cells leads to erroneous diagnosis of fibroadenoma on cytology which was later found to infiltrating lobular carcinoma on HP. The last false-negative case was diagnosed as myxoid fibroadenoma. The patient was 45-year-old presented with mobile breast lump of 3 cm in diameter. FNA revealed ductal epithelial cells in cohesive clusters with mild nuclear atypia, scattered single cells in presence of scanty mucin. Subsequent HP showed mucinous carcinoma of breast. Misinterpretation of mucinous material as myxoid matrix with the absence of abundant mucin and lack of “chicken-wire” blood vessels in the smears lead to misdiagnosis of myxoid fibroadenoma. Lack of familiarity to cytologic findings of mucinous carcinoma was also a contributing factor. Fibroadenoma is also the most common cause of false-positive diagnoses in breast FNA.,, Simsir et al. found 2 cases (8%) false-negative diagnoses in FNAC; out of which one case was due to sampling error and the other one was due to interpretative error. Benoit et al. in their study of breast FNAC found 6 cases (7%) false-positive in 87 cytologically diagnosed fibroadenoma cases; while the number of false-negative cases were 4 (3%) out of 145 HP proved malignancy. They recommended that careful study of the morphology of isolated cells can avoid false negativity.
In NCB, we have encountered 2 cases of false-negative case. One case was misdiagnosed as fat necrosis, which in turn became ductal carcinoma in situ with comedo pattern of necrosis. Failure to demonstrate malignant ductal cells from the representative area leads to false-negative diagnosis. The other case was misdiagnosed as fibroadenoma of breast in a 36-year-old female, later found to be infiltrating ductal carcinoma. Scanty material with the absence of malignant ductal cells in NCB with a clinical history of mobile lump and absence of mammographic image were the contributing factors which lead to misdiagnosis. Shah et al. found overall false-negative result 9.1% consisting of 952 core needle biopsies. Overemphasis on minor microscopic findings and fail to correlate with clinical and radiological findings may be the cause of false-negative diagnosis.
In our study, the sensitivity and specificity of FNAC procedure was 94.3% and 100% respectively, while PPV, NPV, and diagnostic accuracy was 100%, 87.9%, and 95.9% respectively. While, NCB was 97.3% specific, 100% specific, 100% PPV, 81.8% NPV and has diagnostic accuracy 97.6%. We have compared sensitivity, specificity, PPV, NPV, and diagnostic accuracy of FNAC and NCB of various studies and found quite comparable results in our study also [Table 7].,,,,,,,, Saha et al. found sensitivity of FNAC and NCB 69% and 88.3% respectively which is little less than our observations however specificity of both procedures found to be 100% which is similar to our study. Garg et al. found the sensitivity and specificity of FNAC was 100% while the same for NCB was 89.67% and 100%, respectively. In most of the studies, NCB has higher sensitivity in detecting breast carcinoma than FNAC, ranging from 88.3% to 100%.,,,,,, However, few studies show contrasting results where FNAC has higher sensitivity compared to NCB.,, Most of the researchers found that specificity of both FNAC and NCB are quite similar and comparable.,,,,,,, Sharma et al., in their study found specificity of FNAC was 80% which may be due to small number of cases.
|Table 7: Comparison of various parameters in fine needle aspiration cytology and needle core biopsy in different studies|
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FNAC is a well-established procedure for the diagnosis of breast lumps especially in developing countries like us due to its low cost, easy procedure, safe, minimal risk, and no further care needed. Cytological examination of breast lumps is a rapid, economical, and valuable diagnostic tool and it should be done before any surgical procedure. FNAC can be performed in any primary care hospital where the setting of tissue processing for NCB not available. However, NCB has certain advantages over FNAC. In FNAC, lobular carcinoma cannot be consistently differentiated from ductal carcinoma, but NCB can diagnose lobular carcinoma. Again, NCB allows discrimination between in situ and invasive lesions and is a more accurate method to distinguish between invasive lobular and invasive ductal carcinoma, based on histological and immune-histochemical features. This preoperative distinction can be relevant for planning the extent of surgical approach, the choice of an adequate chemotherapy, and the risk of contralateral disease in the case of invasive lobular carcinoma.
Comparing to FNAC, NCB also has the advantage of doing the histological typing and prognostic parameters such as receptor status, proliferative activity, and ploidy. These parameters help the surgeon and oncologist to take decision on ideal treatment procedure and, also to use neoadjuvant chemotherapy.
Off course, there are certain disadvantages of NCB compared to FNAC. NCB is more invasive than FNAC, requires expertise, and needed a facility where tissue processing can be done. Patient compliance is also a matter to keep in mind.
| Conclusion|| |
We have found sensitivity, specificity, PPV, NPV, and diagnostic accuracy of both FNAC and NCB very much similar. So, with high sensitivity and specificity, FNAC can diagnose most of the malignant lesion quite accurately. NCB can be used as second-line diagnostic modality to reduce the chance of missed diagnosis. In a limited resource set up like us, FNAC should be used to diagnose nature of breast lumps. However, in a tertiary level hospital, NCB should also be performed in cases of suspected malignancy as it will help not only in diagnosis but also in assessing the prognostic parameters. Although excision biopsy and HP examination is still the gold standard.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]