Study of predictive value of FNAC in comparison to excisional biopsy in palpable breast lumps at a tertiary hospital

 

Harshagouda Naganagoudar^1*, Basavaraj Yenagi²

 

Abstract              Background: Fine needle aspiration cytology has become an increasingly popular technique utilized in the diagnosis of palpable breast masses owing to its distinct advantages of being sensitive and specific, expedient, economical and safe. The purpose of this study is to evaluate our experiences with fine needle aspiration cytology in a series of patient and compare the diagnostic accuracy of fine needle aspiration cytology with postoperative histopathology. Material and Methods: Present study was single-center, prospective, observational study, conducted in patients age group between 10-70, coming to surgical OPD with palpable breast lumps underwent fine needle aspiration cytology and excisional biopsy. Results: In present study, mean age for the benign lesions was 27.7 ± 6.5 years as compared to mean age for the malignant lesions as 49.9 ± 11.4 years. The most common age group for benign lesions was between 21 to 30 years and for the malignant lesion was 51 to 60 years. The size of the breast lump ranged from 2 to 10cms. The benign lesions ranged < 5 cms. 72.22% of the benign lesions were less than 5cms. Malignant lesions were ranged between 4 to 10cms in its greatest diameter. 84.4% of the malignant tumors measured 5 to 10cms in its greatest diameter. FNAC diagnosis was of benign report (20 cases), 29 cases as malignant and 1 as suspicious lesions. Histopathological reports of benign lesions (n=18) were fibroadenoma (83.3 %), fibrocystic disease (5.6 %), serous cystadenoma (5.6 %) and fatty degeneration (5.6 %). Malignant lesions (n=32) were reported as infiltrating duct carcinoma (81.3 %), lobular carcinoma (12.5 %), comedo carcinoma (noninfiltrating) (3.1 %) and comedo carcinoma (3.1 %). The predictive value of the fine needle aspiration cytology of the palpable breast lump was sensitivity (93.54%), specificity (100 %), positive predictive value (100 %), negative predictive value (90 %) and accuracy (98%). Conclusion: The fine needle aspiration cytology has distinct advantages over excisional biopsy of being sensitive, specific, expedient, economical and safe.

Keywords: breast carcinoma, FNAC, excisional biopsy, palpable breast lumps

 

INTRODUCTION

Fine needle aspiration cytology has become an increasingly popular technique utilized in the diagnosis of palpable breast masses owing to its distinct advantages of being sensitive and specific, expedient, economical and safe.¹ It is commonly used as a part of diagnostic triad, which in addition to the fine needle aspiration cytology includes clinical breast examination and mammography. In recent time the fine needle aspiration cytology has largely replaced excisional/incisional breast biopsy. The advantage in FNAC being it can be carried out as a op procedure ,economical and the treatment can be planned out if the cytology is suggestive of malignancy.^2,3 This has been confirmed by earlier several studies that aspiration cytology is superior to tru-cut needle biopsy in establishing the diagnosis of clinically suspicious breast masses, however the sensitivity can be improved by increasing the number of core taken.^3,4 The purpose of this study is to evaluate our experiences with fine needle aspiration cytology in a series of patient and compare the diagnostic accuracy of fine needle aspiration cytology with postoperative histopathology.

 

MATERIAL AND METHODS

Present study was single-center, prospective, observational study, conducted in NMCH and RC, RAICHUR between September 2012-September 2013. Study was approved by institutional ethical committee.

Inclusion criteria: Patients age group between 10-70.,coming to surgical OPD with palpable breast lumps.

Exclusion criteria: Patients in the age group below 10 and above 70. Male patients with a lump in the breast.

In outpatient department a detailed history and thorough physical examination of the patient having palpable breast lump was carried out and entered in the proforma. The patient was informed about the procedure and informed consent was obtained from the patient before subjecting to fine needle aspiration cytology of the breast lump.

The standard procedure was followed, making use of a 10ml syringe bearing a 22-gauze needle (external diameter of 0.6mm). The specimen was expressed on to a glass slide and then immersed in a fixative 95% methyl alcohol. The slides were stained with Papanicolaou or giemsa stain. The interpretation of the slide was made by the same cytopathologist. The clinicocytological diagnosis was based upon palpation of the mass, degree of resistance at the aspiration biopsy, combined with microscopic examination of the aspirated cells. The final cytological report was described as malignant, suspicious, benign or unsatisfactory (inadequate) due to insufficient epithelial cells being present. The patients were informed about the cytological diagnosis. If the lumps on the cytological examination was reported as malignant, then mastectomy or modified radical mastectomy was performed and the specimen sent for the histopathological confirmation of the diagnosis. In those cases, which were reported as suspicious of malignancy, they underwent intraoperative rapid haemotoxylin and eosine staining for confirmation of malignancy before underwent modified radical mastectomy and histopathological confirmation. Accuracy of the needle tip in localizing the tumor in fine needle aspiration cytology was also studied by comparing the normal glandular aspirate with tumor cell aspirate. Since the fine needle aspiration was done for palpable tumor ultrasound guidance was not followed and repeat fine needle aspiration was carried out before open/excision biopsy if the pathologist report the cytology slide as "inadequate". Statistical analysis was done using descriptive statistics.

 

RESULTS

In present study, mean age for the benign lesions was 27.7±6.5 years as compared to mean age for the malignant lesions as 49.9±11.4 years. The most common age group for benign lesions was between 21 to 30 years and for the malignant lesion was 51 to 60 years.

 

Table 1: Age distribution

All the 50 patients complained of lump in the breast. The other symptoms were pain in the lump (62%), discharge per nipple (38%) and lump in the axilla (22%). 28 patients complained of lump in the left breast whereas 22 patients complained of lump in the right breast.

Among 50 patients, 2 patients of breast lump were having family history of breast carcinoma (in mother). One patient was having lump in the left breast, which was diagnosed as carcinoma who has previously underwent modified radical mastectomy for her right breast carcinoma 5 years back.

 

 

Table 2: Other Characteristic

The size of the breast lump ranged from 2 to 10cms. The benign lesions ranged < 5 cms. 72.22% of the benign lesions were less than 5cms. Malignant lesions were ranged between 4 to 10cms in its greatest diameter. 84.4% of the malignant tumors measured 5 to 10cms in its greatest diameter.

Table 3: Size of lumps

FNAC diagnosis was of benign report (20 cases), 29 cases as malignant and 1 as suspicious lesions.

 

Table 4: FNAC diagnosis

Histopathological reports of benign lesions (n=18) were fibroadenoma (83.3%), fibrocystic disease (5.6%), serous cystadenoma (5.6%) and fatty degeneration (5.6%). Malignant lesions (n=32) were reported as infiltrating duct carcinoma (81.3%), lobular carcinoma (12.5%), comedo carcinoma (noninfiltrating) (3.1%) and comedo carcinoma (3.1%).

 

Table 5: histopathological reports

The results of the fine needle aspiration cytology of the 20 cases of benign report by fine needle aspiration cytology, 18 were confirmed by histopathology. False negative were 2 cases. False positive was zero. one of the case had unsatisfactory sampling 2^nd sample revealed it as fibroadenoma later confirmed by HPE. Total 32 cases of malignant lesions, fine needle aspiration cytology reported 29 as malignant, 2 as benign and 1 as suspicious lesions. False negative was 2 and false positive was zero.

 

Table 6: The correlation between cytological and histological diagnoses

The predictive value of the fine needle aspiration cytology of the palpable breast lump was sensitivity (93.54%), specificity (100%), positive predictive value (100%), negative predictive value (90%) and accuracy (98%).

 

 

Table 7: predictive value of the fine needle aspiration cytology

 

DISCUSSION

In our study we had 18 benign lesions (36%), fibroadenoma being the most common benign lesion that presents for needle aspiration. This has been confirmed in other series also. Fibroadenoma form the 83.33% of the benign lesion aspirated for cytology in our study. The key to the diagnosis of fibroadenoma is the detachment of oval naked nuclei from the cell clusters and sheets.⁵ Fibroadenoma has been considered a significant cause for the false positive diagnosis. The overall activity of the epithelial cell in this tumor is probably the reason. We had no cases of false positive reports in our study. Fibrocystic disease includes chronic cystic mastitis, mammary dysplasia and mazoplasia.⁶ Mammography is of little aid in the densely aortic breasts because micro calcification and increased vascularity are present both in chronic fibrocystic disease and carcinoma. Fatty degeneration and necrosis is not a lesion of the epithelial tissue and has no malignant potential, but can mimic cancer by producing a mass, a density lesion on mammography that can calcify and surrounding distortion of the normal breast architecturel.⁴ Breast carcinoma is one of the most common malignancies among women. The breast lump is usually discovered by the patient. In premenopausal women, up to 80% are benign, where as in patients over the age of 60 approximately 90% of the breast lump are malignant. In our study we had 32 malignant lesions (64%), infiltrating ductal carcinoma being the most common malignant lesion that presented for needle aspiration. It forms the 84.3% of the malignant lesion aspirated for cytology. Although its incidence peaks in the postmenopausal women, it is seen as early as in the second decade. For cytology it appears as much cellular smear, often with necrotic background, monomorphic cell population with variable cell pattern including conspicuous loss of cellular cohesion, numerous isolated single cells and variable degree of anisonucleosisll The overall sensitivity of fine needle aspiration cytology in diagnosing the palpable breast lump in our study was 93.54%, specificity was 100%, positive predictive of 100% and negative predictive value of 90%. In other study, sensitivity was 98%, specificity was 97%, positive predictive value was 99% and negative predictive value was 86%.¹ This high rate of accuracy in fine needle aspiration cytology permitted us for definite preoperative planning and discussion with the patient in whom the fine needle aspiration is positive or suspicious for malignancy.⁷ Fine needle aspiration cytology compliments clinical and radiological diagnosis; thus triple assessment has been reported to produce 99% accuracy for benign and malignant lesion. The diagnostic accuracy of clinical examination, mammography and fine needle aspiration cytology was compared with the definitive histological findings. Comparative study of all 3 diagnostic techniques in the diagnosis of breast tumor has shown that the accuracy of 99% can be achieved.⁸ False negative rate in our series was 6.46%, which is comparable to various other series, which quoted false negative rate of 1-31% with average range of 10%.⁹ A negative or failed aspiration reported in respect of a breast lump is best regarded as a non-report and repeat biopsy is sensible. Cytology should not over rule other diagnostic information but it may direct a clinician into the excision biopsy. The unsatisfactory specimen rate for benign lesion was 5%, whereas for malignant lesion was 0%. The proportion of inadequate sampling as reported by different studies varies from 9 to 18%14. Our study result is comparable to study of Zarbo et al.,¹⁰ who had reported that 17% of 2,254 aspirates in his institutional study were unsatisfactory for evaluation. Franzen and Zajicek in a review of 3479 consecutive breast aspirates found no evidence of seeding along the needle tract.¹¹ This is not surprising as the needle tract is invariably removed with definitive surgery.

The use of fine needle aspiration cytology as the main and direct indicator for mastectomy (without the needle for biopsy) remains controversial. The major concern is the danger of a false positive diagnosis, leading to unwarranted mastectomy. Since the false positive report is very rare (in our study it is zero), in the centers where the surgical staff is accustomed to performing mastectomy on the basis of fine needle aspiration cytology for diagnosis of cancer, there is necessary for a high level of confidence in and rapport with the cytopathologyst. The danger of misdiagnosis of a cancer is studiously avoided by maintaining a cautious and conservative threshold for diagnosing a cancer. A diagnosis of suspicious for cancer must be confirmed by an open biopsy or intraoperative frozen section or rapid hemotoxyline and eosine staining (depending on availability). Since the accuracy of the needle tip in localizing the lump is very high (98%), the diagnostic accuracy of fine needle aspiration cytology can be increased by performing repeat aspiration on the lump for which previously being reported as inadequate or unsatisfactory sampling before advising for open biopsy.

 

CONCLUSION

The fine needle aspiration cytology has become an increasingly popular technique utilized in the diagnosis of palpable breast masses owing to it distinct advantages of being sensitive, specific, expedient, economical and safe. It greatly compliments the clinical and radiological examination and permits rapid diagnosis in more than 95% of the cases. Thus it is commonly used as a part of diagnostic triad in case of breast lump, which in addition to fine needle aspiration cytology includes clinical breast examination and mammography.

 

REFERENCES

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