In this issue of Cancer Cytopathology, Manfrin et al1 describe the quality performance results of fine-needle aspiration biopsies performed in their Breast Cancer Screening Program in Verona, Italy. Not surprisingly, because they have an integrated radiopathologic program with pathologists on the premises who perform real-time immediate assessments of fine-needle aspiration biopsies and are able to discuss these results with the radiologists, their results are very accurate.
Nearly 20 years ago, we created a multidisciplinary cytodiagnostic center that included onsite radiologists and pathologists. The radiologic aspect provided breast imaging services, which comprised mammograms, ultrasounds, and stereotactic fine-needle aspiration biopsies and core needle biopsies, and has since progressed to include digital mammograms, breast ultrasonography, breast magnetic resonance imaging (MRI) scans, ultrasound-guided fine-needle aspiration biopsies, ultrasound-guided core needle biopsies, stereotactic-guided core needle biopsies when necessary, and breast MRI-guided core needle biopsies. The service includes fine-needle aspiration biopsies of all palpable masses (which are performed by the pathologist), mainly those of the breast, thyroid, lymph node, salivary gland, and soft tissue. All fine-needle aspiration biopsies, whether they are performed by the pathologist directly or by the radiologist under imaging guidance, are stained and assessed immediately and the majority of the time a diagnosis is rendered within approximately 10 minutes of the aspiration. The results are given to the patient or to their physician. For all diagnoses of breast cancer, there is a team comprised of radiologists, pathologists, oncologists, breast surgeons, plastic surgeons, radiation oncologists, social workers, genetic counselors, and research assistants that meet weekly to discuss prospective management planning.
At the beginning of our program, we performed approximately 800 fine-needle aspiration biopsies per year. In 2007, the Leslie Simon Cytodiagnosis and Breast Care Center evaluated 41,000 patients and performed 5300 fine-needle aspiration biopsies, of which approximately 3000 were fine-needle aspiration biopsies of the breast. The breast model can be easily transferred to other organ-specific team approaches and we have been using a similar multidisciplinary structure in the diagnosis of thyroid lesions.
The experience during these 20 years matches the findings of the team from Verona. Fine-needle aspiration of the breast has been decreasingly utilized in settings outside our own or others similar to ours in the diagnosis of breast diseases because of 1) suboptimal specimens provided to cytopathologists by clinicians with inadequate training and 2) because many pathologists are more comfortable interpreting histologic specimens such as core needle biopsies. Fine-needle aspiration biopsy of the breast can play a major role in the management of breast diseases in a setting in which immediate evaluation and correlation with imaging occurs. This is important both for biopsies of nonpalpable lesions performed under imaging guidance and occasionally for palpable lesions in which a negative fine-needle aspiration will result when the lesion is found to be deeper than the clinical impression. A review of the imaging studies at the time of the procedure will afford the opportunity to repeat the biopsy with a different approach.
It is universally accepted that cystic lesions of the breast or lesions with a cystic component are better handled by fine-needle aspiration biopsy rather than core needle biopsy. Even if uncommon, intracystic papillary and other tumors of the breast will be easily diagnosed by fine-needle aspiration biopsy.
Of note in the report by Manfrin et al1 is the low number of lesions that were biopsied by palpation. This is undoubtedly due to the fact that the radiologists perform all their fine-needle aspiration biopsies and are more comfortable aspirating even palpable lesions under ultrasound guidance. In our experience, this is only required in a few cases.
The secret to obtaining accurate results rests upon having an open mind regarding the use of different diagnostic tests, depending on the quality of the lesion in question. Fine-needle aspiration has a very unique role in the evaluation of breast symptoms, but one has to be prepared to utilize other means of diagnosis, such as core needle biopsy or needle localization biopsy when the clinical setting calls for such. Negative fine-needle aspiration biopsy findings in the setting of a clinically or radiologically suspicious lesion require further histologic evaluation. As an example, scirrhous carcinomas, and occasionally lobular carcinomas, can be difficult to aspirate. The cytopathologist, the radiologist, and the clinician must understand that the inability to make the diagnosis in these cases is not a limitation of cytopathology but in fact a call to utilize other diagnostic techniques.
The success of a breast cancer screening program such as that described in the article by Manfrin et al1 lies in the ability to provide patients with their diagnosis promptly, with a high rate of accuracy resulting from the immediate evaluation of specimens, and the willingness and ability to accommodate patients by performing whatever tests are required at the same time and setting in which an abnormal lesion is discovered, either by palpation (all patients that come for routine or diagnostic mammograms should also be examined by a nurse practitioner or physician) or on imaging studies.
The article by Manfrin et al in this issue of Cancer Cytopathology brings back to light a technique and approach that should never have lost its prominent role in the diagnosis of breast disease, and opens the door to a clear definition of what a best practice setting should be.