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Minimally invasive approaches for diagnosis of breast lesions and comparison with open surgery.

Introduction

Aspiration cytology has been practised for more than 50 years [1]. It was initially introduced to replace incisional biopsy, which is an invasive method. Over this period the technique has been used extensively for the diagnosis of breast lesions, and it forms an integral part of the triple approach to management of breast cancer. Although the technique is well suited to the superficial nature of breast lesions, and is highly sensitive and specific in their diagnosis, like any other techniques it has limitations that can lead to false-negative and false-positive results. Nevertheless, its role in the diagnosis of breast lesions cannot be underestimated [2-4].

In developing countries like Iraq, economical restrictions, low budget for health care, and screening programs, as well as spoiled administrations put the patients at a disadvantage because of the high cost of sophisticated diagnostic methods, thus we recommend that FNAC be used as a routine diagnostic method because of its low cost compared with the others and this policy maximizes the availability of health care to women with breast cancer [5].

"We conclude that FNAC plays an important and essential role in the management of patients with breast lesions and also offers a great potential for prediction of patient outcome, disease response to therapy and assessment of risk of developing breast cancer." And, "The reliability and efficiency of the method depends on the quality of the samples and the experience of the medical staff that performs the aspiration" [6].

Materials and methods

The materials comprised all fine needle aspirations performed at the Erbil Teaching Hospital over 24 months (October, 2005 through October, 2006). A total of 211 lesions were aspirated, the majority of them were done at the outpatient clinic. Without previous knowledge of the histo-pathologic results, the cytologic findings were reported as follows:

1. Malignant: subtyping of breast cancer was suggested whenever possible.

2. Atypical: where the cells are suspicious of malignancy but no decision can be taken.

3. Benign: when no malignant or atypical cells are seen.

4. Inadequate: when the sample is not satisfactory (for cellularity, fixation, or Staining).

For the determination of the specificity and sensitivity of the procedure, benign lesions were considered as negative.

The puncture site is prepared with diluted iodine and then alcohol. No local anesthesia was needed.

A 22- gauge needle and 10-20 ml syringe were used. Once the lesion is engaged, full vacuum is applied while the needle is moved back and forward within the mass and in different directions. The samples are then smeared on a microscope slide and are: 1) allowed to dry in air, 2) are "fixed" by spraying, or 3) are immersed in a liquid. The fixed smears are then stained with Papa-nicolaou and examined by a pathologist under the microscope.

Results and discussion

Fine needle aspirations were performed on 211 patients, of these, 209 were females and only 2 males were included in this study. The age ranged from 16 to 74 years with a mean age of 38.3 years. The mean age for patients with benign lesions was 33.7 years, and for those with malignant tumors was 45-1 years. There were 113 lesions on the right side and 98 on the left side.

Table-1 shows the results, there are 56 smears (26.6%) diagnostic for cancer, 28(12.6%) atypical, 108(52.8%) benign and 19(8%) inadequate for diagnosis.

Table 2 shows comparison between the results of FNA on 48 cases with various benign lesions with proved histologic examinations.

The overall correlation of diagnosis by FNA of breast lesions compared with histological finding is shown in table 3. Of the 56 patients who had a diagnosis of cancer by FNA, 23 had tissue diagnosis in our hospital. The others were clinically malignant and treated as such or had tissue diagnosis in other places. There was one false positive diagnosis-

Of the 108 patients with benign lesions by FNA, 47 had surgery and the diagnoses were proved histologically. 61 patients had no surgery.

The main cytologic features of the benign lesions are: overall low cell yield, sheet of ductufar epithelial cells, and single bare nuclei (Fig. 3, 4).

There were 28 patients who had atypical smears, 9 had surgery which proved to be malignant and 19 had no surgery in our hospital.

Of the 19 patients who had inadequate material by FNA, 5 had surgery in our hospital and 4 proved to be malignant.

The sensitivity of FNA in breast lesions in this study was 88.6%, and the specificity was 98%, and the overall accuracy was 94.5%. Most of the carcinomas in this study were ductal carcinoma. The cytologic features of this variant of carcinoma were easily recognized and there was a good correlation between the cytological and histological diagnosis. Only few cases (3 cases) of lobular carcinoma were included in this study. The cytologic diagnosis of this variant of carcinoma was more difficult than the ductal carcinoma. However, the smear is less 1 cellular than the ductal carcinoma and the cells are smaller in size and more uniform.

The most important cytological features of malignant tumor are high cell yield, single population of atypical epithelial cells, absence of single bare nuclei of benign type, reduced cohesiveness of epithelial cells, nuclear enlargement, atypia of variable degree, and single cells with intact cytoplasm[8]. (Fig. 1, 2.)

Analysis by an experienced cytologist is critical for accurate interpretation of FNA biopsy results[9]. In most cytology labs, the false positive rate for a diagnosis of malignancy in an FNA biopsy of a breast mass is only 1% to 2%[10]. Thus, a diagnosis of malignancy that is based on cytologic analysis of an FNA specimen may generally be believed, and definitive surgery may be planned without further biopsy[11]. Because FNA biopsy results did not distinguished between invasive and in situ breast cancer in this study, intraoperative frozen section performed in 9 cases (4%) to determine the need for axillary dissection.

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This procedure was applied, when there was a palpable mass in 98.6% of the cases. However, 3 patients (1.44%) had no palpable lesions; detected by mammography had been aspirated (figure 5). In this study the sensitivity and specificity were 88.6% and 98% respectively. These results were comparable to other similar studies (Table 4). In some particular studies when the aspirations were done by a number of clinicians and the aspirates were examined by one pathologist this has led to low sensitivity for example in a study done by

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

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Dixon et al reported a sensitivity of only 66% which is significantly lower than our study [11]. However during the second half of their study the aspirations were performed by a single aspirator using a standard procedure and aspirates were examined by two pathlogist. This has raised the sensitively from 66% to 99% [12] The effectiveness of FNA is largely operator-dependent; it requires a skilled radiologist or surgeon who has gained experience by performing several cases [13].

There was only one false positive diagnosis in our study (0.45%). The lesion was a tubular adenoma in a pregnant woman; we recommend an excisional biopsy, because the malignant change was not definitive by FNA aspiration. Hislologically, the cells were quite active with prominent and slightly atypical nuclei, mostly due to hormonal activation. The most difficult malignant tumor we faced to diagnose by FNA was the lobular carcinoma because the cells in general were smaller than the ductal carcinoma and the smear was usually lest cellular while ductal carcinoma was easily diagnosed and classified by the aspiration. Some authors believe that various histologic types of breast carcinoma cannot he diagnosed from aspiration specimens [14,15]. A very good experience in FNA cytology is required to give the exact histologic type from the aspiration specimen only; Zajicek has published the cytologic features of the various breast carcinomas [16]. In our study, a single case of malignant cystosarcoma phyllodes was included; the aspirate revealed many malignant spindle cells. The differential diagnosis of this case includes the uncommon primary sarcoma of the breast, but the presence of bland epithelial cells with malignant spindle-cells suggests the possibility of cyslusarcorna phyllodes. The mean age for patients with malignant lesions was higher than those with benign lesions (mean ages were 45.1 and 33, 7 years respectively).

Our patients with breast caner were a bit younger than in the West countries, a similar observation has been found in nearby countries[17].

The most common complication in this study was a slight bruising and tenderness of the area occurred in 5% of patients for a few days following the procedure. Discomfort should be relieved by an over-the-counter pain reliever such as Tylenol or the application of an ice-pack for short periods following her return home.

Conclusion

Minimally invasive diagnosis and treatment of early breast lesions is showing its value and this technique has replaced open surgical biopsies and is considered to be the standard procedure for the diagnosis of breast cancer. FNA is simple, accurate, reliable and almost painless procedure which can give early diagnosis of breast lumps. A mastectomy can be done if the cytologic diagnosis of cancer is definitive but if there is any doubt by the cytologic examination, a frozen section or excisional biopsy is recommended. If the cytological examination is negative for malignant cells but clinically there is suspicion of cancer, the aspiration can be repeated or a biopsy should be obtained.

Problems inherent to this technique

* Insufficient Specimen: One of the major draw back of this technique is to obtain an insufficient specimen. The rate of insufficient specimen varies from 2 to 36%.

* Reported Sensitivity ranges from 68 to 100% and the specificity from 2 to 36%.

* General Inability to differentiate In-situ from Invasive Carcinoma.

Acknowledgments

We would like to thank for their kind help, advice, slide preparations and their comments during this study preparation:

1. Professor Bdoor A. Irhym FRCPath. [London] Department of pathology. College of Medicine, University of Mousl.

2. Professor Nawal Allash, FRCPath. [London] Department of pathology, College of Medicine, University of Baghdad.

3. Dr. Sallah Abubaker, Board pathology (Iran) senior lecturer, College of Medicine, Hawler Medical University.

References

[1.] Cytology Sub-Group of the National Coordinating Committee for Breast Screening Pathology. Guidelines for cytology procedures and reporting in breast cancer screening. Sheffield: NHSBSP Publications, 1992.

[2.] Zakowski, M.F., 1994. Fine-needle aspiration cytology of tumors: diagnostic accuracy and potential pitfalls. Cancer Invest., 12: 505-515.

[3.] Zakhour, H., C. Wells, 1999. Diagnostic Cytopathology of the Breast. London: Churchill Livingstone.

[4.] Salhany, K.E., D.L. Page, 1989. Fine needle aspiration of mammary lobular carcinoma in situ and atypical lobular hyperplasia. Am. J. Clin. Pathol., 92: 22-6.

[5.] Lamb, J., T.J. Anderson, 1995. Influence of cancer histology on the success of fine needle aspiration of the breast. J. Clin. Path., 42: 73-35.

[6.] Parker, S.H., A.T. Stavros, M.A. Dennis, 1995. Needle biopsy techniques. Radiol. Clin. North. Am., 33: 1171-1186.

[7.] Ballo, M.S., N. Sneige, 1996. Can needle biopsy replace fine-needle aspiration cytology in the diagnosis of palpable breast carcinoma? A comparative study of 124 women. Cancer, 78: 773-777.

[8.] Fischer, U., L. Kopka, E. Grabbe, 1998. Magnetic resonance-guided localisation and biopsy of suspicious breast lesions. Topics in MRI, 9(1): 44-59.

[9.] Giard, R.W.M., J. Hermans, 1992. The value of aspiration cytologic examination of the breast. A statistical review of the medical literature. Cancer, 69: 2104-2110.

[10.] Editorial opinion, 1997. The uniform approach to breast fine-needle aspiration biopsy. Am. J. Surg., 174: 371-385.

[11.] Quercidella, G. Rovere, J.R. Benson, P. Childs, L. Hastings, A. Johri, 2001. Is the tangential or parallel approach to FNA cytology of breast lesions always possible and compatible with reliable sampling. Breast, 10: 352-5.

[12.] Broderick, L.S., K.K. Kopecky, H. Cramer, 2002. Image-guided coaxial fine needle aspiration biopsy with a side existing guide comput. Assist. Tomogr., 26: 292-7.

[13.] Liao, J., D.D. Davey, G. Warren, J. Davis, A.R. Moore, L.M. Samayoa, 2004. Ultrasound-guided fine-needle aspiration biopsy remains a valid approach in the evaluation of nonpalpable breast lesions. Diagn Cytopathol., 30(5): 325-31.

Professor, Head/Department of Surgery, Consultant Surgeon-College of Medicine, Hawler Medical University, Erbil Province, Iraq.

Corresponding Author: Abdulqadir Maghded Zangana, Professor, Head /Department of Surgery, Consultant Surgeon-College of Medicine, Hawler Medical University, Erbil Province, Iraq. E-mail: draqzangana@yahoo.com
Table 1: Results of FNA on 211 cases.

Type of lesion No. of cases Percentage

Malignant 56 26.6
Atypical 28 12.6
Benign 108 52.8
Inadequate 19 8.0
Total 211 100.0

Table 2: Tissue diagnosis in 48 patients with benign breast
fine needle aspirations.

Histological diagnosis No. of patients Percentage

Fibrocystic disease 14 29.16
Adenoma 10 20.8
Intraductal papiloma 4 8.33
Inflammation with fat necrosis 11 22.9
Epidermoid cyst 2 4.16
Duct ectasia 3 6.25
Lipoma 2 4.16
Gynaecomastia 2 4.16
Total 48 100%

Table 3: Correlation of cytologic and histological diagnosis
in patient's having aspiration cytology of breast lesions.

FNA diagnosis No. of patient Tissue Malignant

Malignant 56 22
Atypical 28 9
Benign 108 --
Inadequate 19 4 (false negative)
Total 211 35

FNA diagnosis Diagnosis Benign No surgery is done

Malignant 1 (false positive) 33
Atypical 19
Benign 47 61
Inadequate 1 13
Total 49 126

Table 4: The sensitivity and specificity of F.N.A cytology of
breast lesions.

Author No. of cases Sensitivity Specificity

Dixon et al, 2005 1655 66% 98%
Frable, 1994' 853 89% 97%
Knox et a1, 2004 200 95% 100%
Schultenover al, 1999 40 100% 100%
The present study 211 88.6% 98%
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Title Annotation:Original Article
Author:Zangana, Abdulqadir Maghded
Publication:Advances in Medical and Dental Sciences
Article Type:Clinical report
Geographic Code:7IRAQ
Date:May 1, 2008
Words:2285
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