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Keywords:

  • breast cancer;
  • breast diagnosis;
  • breast management;
  • breast cytology;
  • FNA;
  • core biopsy

Abstract

  1. Top of page
  2. Abstract
  3. Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions
  4. The use of image guidance for performing breast FNAC
  5. Standard reporting system for breast FNAC. Is there a need for it?
  6. Should cancer patients be managed based on FNAC diagnosis alone, without histology?
  7. Can oestrogen receptor, HER2 be assessed on FNAC material?
  8. The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic
  9. The place of core biopsy in investigation of breast lesions
  10. Conclusions and overview of the discussion forum
  11. References

Most participating countries have now adopted a triple assessment approach, i.e. clinical,imaging and pathology, to breast diagnosis, with FNAC as the first-line pathological investigation in both screening and symptomatic populations, with the exception of microcalcifications. Pathologists specialized in cytopathology are best qualified to collect and interpret FNAC samples, but this is not always possible or practical. Radiologists involved in breast imaging should ensure that they have the necessary skills to carry out FNAC under all forms of image guidance. Best results are achieved by a combination of both techniques, as shown in the image-guided FNAC in the presence of the cytopathologist. The majority of European countries use similar reporting systems for breast FNAC (C1–C5), in keeping with European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis, although some still prefer descriptive reporting only. When triple assessment is concordant, final treatment may proceed on the basis of FNAC, without a tissue biopsy. ER and PR assessment can be done safely on FNAC material. However, not all institutions may have expertise in doing this. HER-2 protein expression on direct cytological preparations is insufficiently reliable for clinical use, although its use for FISH is possible, if expertise is available. The majority of participants practise a degree of one-stop diagnosis with a cytopathologist present in the out-patient clinic. Formal recognition of the importance of the time spent outside the laboratory, both for cytopathologist and cytotechnologist, is necessary in order to ensure appropriate resourcing. The use of core biopsy (CB) has increased, although not always for evidence-based reasons. CB and FNAC are not mutually exclusive. FNAC should be used in diagnosis of benign, symptomatic lesions and CB in microcalcifications, suspicious FNAC findings and malignancies where radiology cannot guarantee stromal invasion.

Fine needle aspiration cytology (FNAC) has been extensively used for many years in the diagnosis of breast lesions, but its use has gradually been reduced in many screening programmes because of its controversial inadequate rates and suboptimal accuracy in inexperienced hands.1–3 The aim of this review is to explore current practice and confirm the continuing role of FNAC in diagnosis and management of breast lesions.

In October 2007, Cytopathology Advisory Board members and representatives of the affiliated societies were invited to participate in a round table discussion on the topic of ‘The current role of breast FNAC in clinical management’. A questionnaire was sent to all participants in advance of the meeting. The majority of participants were from European countries. The panel consisted of the following members:

G Kocjan, UK (GK), C Bourgain, Belgium (CB), A Fassina, Italy (AF), B Hagmar, Norway (BH), A Herbert, UK (AH), K Kapila, Quwait (KK), I Kardum-Skelin, Croatia (IK-S), V Kloboves-Prevodnik, Slovenia (VK-P), H Koutselini, Greece (HK), S Krishnamurthy, USA (SK), B Majak, Norway (BM), W Olszewski, Poland (WO), B Onal, Turkey (BO), Ž Pohar-Marinšek, Slovenia (ZP-M), I Shabalova, Russia (IS), J Smith, UK (JS), E Tani, Sweden (ET), P Vielh, France (PV), H Wiener, Austria (HW), U. Schenck, Germany (US) and F Schmitt, Portugal (FS).

The following is the transcript of the written answers and the discussion that followed (Figure 1).

image

Figure 1.  Members attending Advisory Board meeting of Cytopathology in Madrid, October 2007. From left to right: Dr Schenck, Dr Krishnamurthy, Dr Wiener, Prof. Olszewski, Dr Shabalova, Dr Majak, Dr Herbert, Dr Kapila, Dr Kocjan, Prof. Hagmar, Prof. Fassina, Prof. Schmitt, Dr Vielh, Dr Onal and Dr Zivko Perisic.

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Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions

  1. Top of page
  2. Abstract
  3. Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions
  4. The use of image guidance for performing breast FNAC
  5. Standard reporting system for breast FNAC. Is there a need for it?
  6. Should cancer patients be managed based on FNAC diagnosis alone, without histology?
  7. Can oestrogen receptor, HER2 be assessed on FNAC material?
  8. The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic
  9. The place of core biopsy in investigation of breast lesions
  10. Conclusions and overview of the discussion forum
  11. References

CB: In Belgium, triple assessment is a standard manner of investigating for those centres that are favouring FNAC, but not all centres have cytology. We have centres that use core biopsy (CB) in preference, as is happening everywhere. I think there are no centres that use cytology only.

SK: In MD Andersen Cancer Centre in Houston, Texas, triple assessment is the norm in my practice and the standard for investigating breast lesions. For index lesions we use only CB, for satellite lesions we use FNAC very frequently.

VK-P, ZP-M: Triple assessment is a standard practice of breast investigations in our country. FNAC is the first modality in investigating palpable lesions. We do not have organized breast screening yet.

HK, ET: The same in our countries.

KK: Triple assessment is usually performed in most patients, but if for some reason the radiology appointment is delayed for a few weeks, our clinicians insist on getting an aspirate done first. FNAC is the first modality used in symptomatic but not screening populations.

AH: In England we certainly use triple assessment, but most of the pathology assessment is provided by CB, because the Breast Screening Programme has very much moved away from FNAC. This does not apply everywhere and there are some centres with excellent FNAC services, where it is used both for cancer and non-cancer diagnosis. At the hospital where I work, which is not a screening centre, until recently we used FNAC for potentially benign disease as part of an immediate assessment, so that patients could go home the same day with a diagnosis. Clinically or radiologically malignant cases have a CB. This posed a slight problem, because cytopathologists saw less and less malignant FNAC samples except from lymph nodes. We receive FNACs for staging of lymph nodes and for satellite lesions. We also encouraged imprints of cores, partly for our own training, partly as an opportunity to provide an immediate report.

AF: Yes, we do triple assessment in Padova. We have also implemented a screening programme compensated and controlled by the Veneto Region Health Council. The first modality used is FNAC. In selected cases we also have mammotome biopsy, but the large majority is FNAC and the largest part of this is performed under ultrasound (US) guidance.

WO: We do not follow the triple assessment, especially for clinically palpable (symptomatic) lesions, only for those undergoing screening. FNAC is used as a first modality in all cases that are palpable. For screening population, CB is performed in most cases. If necessary, we use US-guided FNAC.

FS: In Portugal, we use the triple assessment. In the symptomatic palpable population FNAC is used as the first pathology modality and in the screening population, depending on the type of lesion, for example if there is a nodule that will be detectable by US we use FNAC. If it is microcalcification, we use CB. Sometimes we do not have one part of the ‘triple’ assessment, namely the ‘clinical’, as is in the case of screening. In these cases, there is only an image and cytology.

IK-S: Triple assessment (clinical, pathological, radiological) is a standard method of investigating breast lesions in Croatia. FNAC is also the first pathology modality used in symptomatic-palpable and screening populations.

BH: FNAC is often used in triple assessment, in the symptomatic population and screening population, depending on the local circumstances.

JS: Triple assessment is a standard method of investigating breast lesions in the UK. FNAC is not the first modality used in symptomatic or screening populations in my hospital.

Summary: Most countries use a ‘triple assessment’ approach, i.e. clinical, imaging and pathology, to breast diagnosis. FNAC is the first-line pathological investigation, particularly in symptomatic and some screening situations.4,5 CB is used as a first modality in some screening populations, for example, the UK. Consequently, obtaining a definitive preoperative/pretreatment diagnosis has become a sine qua non of a modern management approach to breast carcinoma. Excision biopsy of the lesion, in order to establish if it is benign or malignant, is no longer an acceptable mode of diagnosis. Triple assessment using FNAC is a cost-effective, easy to perform and time-saving approach. However, it can be applied only in those institutions where services of a cytopathologist are available and where radiologists and clinicians favour the use of the technique.

The use of image guidance for performing breast FNAC

  1. Top of page
  2. Abstract
  3. Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions
  4. The use of image guidance for performing breast FNAC
  5. Standard reporting system for breast FNAC. Is there a need for it?
  6. Should cancer patients be managed based on FNAC diagnosis alone, without histology?
  7. Can oestrogen receptor, HER2 be assessed on FNAC material?
  8. The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic
  9. The place of core biopsy in investigation of breast lesions
  10. Conclusions and overview of the discussion forum
  11. References

PV: We use image guidance for performing non-palpable breast FNAC and cytopathologists perform the aspiration in our institution: it is a ‘four hands’ procedure. We no longer use stereotactic guided FNAC and do not have the experience of performing FNAC under any other type of imaging modality.

SK: In most places in the USA, US guidance is used for FNAC of non-palpable breast lesions. Stereotactic guided FNAC is not done in our practice. For breast lesions with suspicious calcifications on mammogram, stereotactic CB alone is obtained. For initial staging of breast carcinoma, US-guided FNAC of lymph nodes is commonly used in our practice.

VK-P., ZP-M: In our institution radiologists perform the aspiration.

BM: It is the standard procedure in every hospital in Norway, not only in larger centres, but in county hospitals also.

BH, KK, ET: Yes, we use US.

GK: Is the cytopathologist present in the ultrasound or nearby, do they give any feedback to radiologists in terms of sample adequacy or do they just send the specimens to you?

BM: I think it varies between different hospitals. We are not present because the breast centre is 10 km away.

IK-S: We always use image guidance (US or stereotactic) for performing non-palpable breast FNAC. Cytologists perform the aspiration with cooperation with radiologists. If radiologists perform the aspiration alone, they should be trained in aspiration and preparation of smears.

Summary: Image guidance is used in most centres and is an important part of the modern approach to FNAC, particularly in non-palpable lesions of both symptomatic and screening populations. Stereotactic CB is performed for microcalcifications. Centres vary in who performs FNAC, radiologists or cytopathologists. One of the centres describes a combined, four-hand, approach that yields good results. The importance of the aspirator for the success of FNAC is well known, particularly in breast cytology.3 It is a common experience in large institutions, where there are many aspirators, that the quality of the material is usually inferior to those where there are fewer dedicated aspirators.6,7 Pathologists specialized in cytopathology are best qualified to collect and interpret FNAC samples. However, this is often not possible for practical reasons. One of these is the presence of a non-palpable lesion. Many European and USA centres therefore obtain FNAC samples, which are collected by radiologists under image guidance. Radiologists involved in breast imaging should ensure that they have the necessary skills to carry out FNAC under all forms of image guidance.8 The close collaboration between radiologists and cytologists, as shown by some of the participants, is the way forward to improve the quality of samples. This is particularly true of the preoperative axillary node sampling of patients with breast carcinoma, where US-guided FNAC has proven to be the most accurate and cost-effective way of management.9–13 In some cases it reduces the need for intraoperative axillary sentinel node sampling by 30%.10

Standard reporting system for breast FNAC. Is there a need for it?

  1. Top of page
  2. Abstract
  3. Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions
  4. The use of image guidance for performing breast FNAC
  5. Standard reporting system for breast FNAC. Is there a need for it?
  6. Should cancer patients be managed based on FNAC diagnosis alone, without histology?
  7. Can oestrogen receptor, HER2 be assessed on FNAC material?
  8. The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic
  9. The place of core biopsy in investigation of breast lesions
  10. Conclusions and overview of the discussion forum
  11. References

PV: We use a standard reporting system, at least in my institution. It is based on four categories, namely: insufficient for interpretation, suspicious of malignancy, malignant or benign.

US: There was an initiative some years ago to standardize the statistical groups for non-gynaecological cytology.

AH: In the UK we use a C1–C5 system: C1, inadequate; C2, benign; C3, atypical, probably benign; C4, suspicious; and C5, malignant. So that we find that the C3 and C4 categories always go to biopsy, be it CB or otherwise.5,14

AF: That applies for Italy.

ET: In Sweden, we use descriptive reporting. I do not think there is a need for a standardized European reporting system.

BH.: I think there is greater need for standardized European gynaecological nomenclature than for breast. Breast diagnoses have to be immediately understandable to the local clinicians, so they are more difficult to standardize.

SK: I think most of the institutions in the USA follow the National Cancer Insistute consensus conference recommendations belonging to the following categories: unsatisfactory, benign, atypical, suspicious and malignant.15

VK-P, ZP-M: We use the C1–C5 system proposed in the European Guidelines for quality assurance in breast cancer screening and diagnosis.16 If everybody used the same classification, it would be easier. We are happy with the system proposed in the above-mentioned Guidelines.

IK-S: According to the recommendations of the Working Group of the Croatian Society for Clinical Cytology, the breast FNAC report includes: material adequacy; microscopic description and cytological opinion. Cytological opinion includes a definitive diagnosis if available: cysts, inflammatory lesions, fibroadenoma, fibrocystic disease with/without proliferative epithelial changes (with/without atypical hyperplasia) or malignant lesions. If definitive diagnosis is not available, we follow mandatory recommendations for further management: (A) repeat FNAC [1. atypical hyperplasia, probably benign; 2. atypical hyperplasia and hormone replacement therapy (HRT)—repeat FNAC after 3-month pause in taking HRT]; (B) CB (1. repeat FNAC with atypical hyperplasia; 2. FNAC-negative, but US- and/or mammography-suspicious lesions; 3. cytologically undefined, suspicious lesions; and 4. microcalcifications if stereotactic aspiration biopsy is negative); or C) open surgical biopsy (1. CB—suspicious lesions or 2. FNAC/CB—malignant lesions).

JS: We use the UK National Health Service Breast Screening Programme (NHSBSP) guidelines, as described by Dr Herbert. I think that there should be a standardized reporting system for breast cytology, such as NHSBSP. Example.14

KK: In Kuwait, we use a modified version of the ‘The uniform approach to breast FNAC’ reporting system.15 Our reports describe the cytological findings seen in the breast aspirate followed by a concluding diagnosis, which invariably falls into one of the following categories, which are the same as the diagnostic terminology suggested in the Bethesda conference: Unsatisfactory, Benign, Atypical cytology, Suspicious for cancer, Carcinoma. Post-FNA recommendations are also included in the report.

SK: I do think that there should be a uniform standardized system of reporting. We follow a five tier system just like the NHSBSP C1–C5 and have found that this system helps us to relate to each other’s data in a more useful and meaningful way.5,14

GK: Dr Vielh, as Secretary General of the European Federation of Cytology Societies (EFCS), do you think the EFCS should encourage members to use the same classification, as exemplified in the European guidelines for breast reporting and handling breast cytology specimens?

PV: Yes, I would be happy that the EFCS would be able to at least compare data coming from different countries in Europe and unify the type of reporting, and also the conclusion that we have to give to the clinicians.

AH: As with thyroid, we have to be careful with the use of C1–C5, and clinicians should still read the report. It is very easy for cytology to be reduced to numbers only. I think that it is important to have a proper written report as well as numerical categories (C1–C5).

BM: Yes, there is a need to organize a consensus meeting, with leading breast cytopathologists making final suggestions for standardized European reporting for breast cytology.

Summary: The majority of European countries use similar reporting systems for breast FNAC (C1–C5), in keeping with European guidelines for quality assurance in breast cancer screening and diagnosis and the NHSBSP, whilst the USA uses National Institutes of Health Consensus Development Conference reporting system15–17 (Table 1). Some Scandinavian countries favour descriptive reporting since they maintain a view that breast reporting is difficult to standardize. The majority agree that a report, followed by a numerical category, means that an unequivocal cytological diagnosis of malignancy is reliable. An EFCS recommendation for use of a single reporting system would be welcomed by all European participants.

Table 1.   FNAC breast reporting categories, as listed in the European and USA guidelines
NHSBSP (UK), 20015 European Guidelines16NIH recommendations (USA)15
C1 UnsatisfactoryUnsatisfactory
C2 BenignBenign
C3 Suspicious, probably benignAtypical/indeterminate
C4 Suspicious, probably malignantSuspicious/probably malignant
C5 MalignantMalignant

Should cancer patients be managed based on FNAC diagnosis alone, without histology?

  1. Top of page
  2. Abstract
  3. Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions
  4. The use of image guidance for performing breast FNAC
  5. Standard reporting system for breast FNAC. Is there a need for it?
  6. Should cancer patients be managed based on FNAC diagnosis alone, without histology?
  7. Can oestrogen receptor, HER2 be assessed on FNAC material?
  8. The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic
  9. The place of core biopsy in investigation of breast lesions
  10. Conclusions and overview of the discussion forum
  11. References

FS: The patient may be managed on the basis of FNAC result alone, but in some hospitals they do not agree and demand a CB prior to treating patients.

VK-P: Patients may be operated based on definitive cytological diagnosis.

ET: Yes, patients may be managed based on cytology report.

KK: In our institution, advanced cases are managed on FNAC diagnosis alone. In the other cases surgery is part of management following cytological diagnosis. In cases where the cytologist has doubts about typing of the tumour and in cases ‘suspicious for a carcinoma’, a histological examination is requested.

Summary: The majority of participants agree that when triple assessment is concordant, final treatment of breast carcinoma may ensue based on FNAC alone, without CB or open biopsy. In non-concordant cases, FNAC stands as the single most important investigation. However, due to the false-negative results, other components of triple test need to be employed to enhance its efficacy and diagnostic yield.

Can oestrogen receptor, HER2 be assessed on FNAC material?

  1. Top of page
  2. Abstract
  3. Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions
  4. The use of image guidance for performing breast FNAC
  5. Standard reporting system for breast FNAC. Is there a need for it?
  6. Should cancer patients be managed based on FNAC diagnosis alone, without histology?
  7. Can oestrogen receptor, HER2 be assessed on FNAC material?
  8. The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic
  9. The place of core biopsy in investigation of breast lesions
  10. Conclusions and overview of the discussion forum
  11. References

FS: Concerning the markers, progesterone receptor (PR) and oestrogen receptor (ER) can be performed on cytology by immunocytochemistry, but HER2 should be done only by flourescence in situ hybridization (FISH) or chromogenic in situ hybridization (CISH), because there are no established protocols on how to quantify HER2 by immunocytochemistry on cytological material, even in cell blocks.

WO: I entirely agree with Professor Schmitt, that must be done. However, there is an indication that cytological material can also be used for that purpose.18

VK-P: ER, PR and HER2 are assessed on cytological material at the Institute of Oncology, but not in every hospital in Slovenia.

ET: We perform ER, PR and HER2 on FNAC smears.

SK: In the USA, ER, PR on cytology material is usually not done in the majority of places. However, in my practice ER, PR is very often performed on FNAC material including direct smears and cell blocks of loco-regional or distant metastatic lesions, and preferably not on FNAC of index lesions. I agree with Professor Schmitt and others in this regard. In very rare situations when there is a a very large mass together with a metastatic tumour and the patient does not come with paraffin blocks of the primary breast tumour from the referral centre, we may do ER, PR on cytology material to expedite the initiation of treatment, but for HER2, I agree that we do not perform immunostaining on the FNAC material, but instead perform FISH. Because it is difficult to quantify true membranous staining of HER2 on direct smears we refrain from doing any HER2 immunostaining on direct smears. However, HER2 immunostaining is performed on cell block material if available in a particular case.

GK: How do you read your ER and PR results, if they are indicated and if you perform them on the FNAC?

SK: If we perform receptors on FNAC material, we express the result as the percentage of tumour cells showing positive nuclear staining. We indicate the type of antibody that is used for the immunostaining. PR and ER are performed on cytology by immunocytochemistry at the large centres, because not all centres have immunocytochemistry, but HER2 is done only by FISH on CB or surgical biopsy.

Summary: Hormone receptor staining can be reliably performed on FNAC samples. The results are expressed as the percentage of tumour cells showing positive nuclear staining.

HER-2 protein expression on cytological preparations is insufficiently reliable for clinical use. However, there are reports of HER-2 gene amplification determined by FISH that demonstrated strong and consistent correlation with HER-2 status of formalin-fixed paraffin-embedded tissue samples.18,19

The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic

  1. Top of page
  2. Abstract
  3. Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions
  4. The use of image guidance for performing breast FNAC
  5. Standard reporting system for breast FNAC. Is there a need for it?
  6. Should cancer patients be managed based on FNAC diagnosis alone, without histology?
  7. Can oestrogen receptor, HER2 be assessed on FNAC material?
  8. The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic
  9. The place of core biopsy in investigation of breast lesions
  10. Conclusions and overview of the discussion forum
  11. References

VK-P, ZP-M: We do not have a service for benign disease in our institution (oncology centre). In Slovenia we do not have a service for on-site FNA examination and immediate diagnosis. We only evaluate sample adequacy on site when cytopathologists perform FNA.

SK: FNAC is done close to the radiology suite for non-palpable lesions and immediate assessment is performed on all cases, whether palpable or non-palpable.

US: Immediate assessment is a very useful method. The dilemma as to whether it is used in the country or not depends on the differences in the remuneration system, so that if pathologists do not get paid for doing immediate assessment, they do not do it. In our lab we cannot offer immediate assessment, despite the fact that we know that we could improve the diagnostic yield of cytology.

GK: Dr Schenk has voiced a common concern that there is often no recognition of the cytopathologist’s service spent outside the laboratory. My suggestion is for EFCS to initiate recommendations that would endorse the importance of the cytopathologist’s clinical involvement and recognize that the time spent outside the lab should be adequately resourced.

PV: Yes, it is also a very good initiative. If the radiologist is performing FNAC and the cytopathologist is interpreting the sample, this is the best method, because you can communicate with the radiologist.

AH: I think on-site evaluation and also a cytotechnologist preparing the slides is the key to success of FNAC. If we do not do that, adequacy tends to be poor. It is up to us to make sure that our colleagues know how much time we spend and how important it is to involve cytotechnologists in preparing the slides, otherwise we have to interpret poor material, and that is when we might make mistakes.

BH: Yes, we use on-site examination, but not universally.

JS: We do not use on-site examination in my hospital (Sheffield, UK).

KK: No, we do not have one-stop service. The patients are referred to the cytology clinic once a mass is detected and radiological examination done.

ET: We do not use the on-site examination system.

Summary: The majority, but not all, participants practise a degree of ‘one-stop’ diagnosis, whether it is delivering a final report or merely assessing specimen adequacy. This is in line with the European Guidelines, which state that the provision of rapid diagnostic clinics where skilled multidisciplinary advice and investigation can be provided is advantageous for women with significant breast problems in order to avoid unnecessary delay in planning clinical management or to permit immediate discharge of women with normal/benign disease. Participants agree on the importance of communication with the radiologist. A formal recognition of the importance of the time spent outside the laboratory, both for cytopathologist and for cytotechnologist, is necessary in order for this service to be available in all institutions. Lack of recognition prevents cytopathologists in some countries from practising a one-stop service. However, the majority use this highly reliable and cost-effective service where results can be obtained immediately.20–22

The place of core biopsy in investigation of breast lesions

  1. Top of page
  2. Abstract
  3. Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions
  4. The use of image guidance for performing breast FNAC
  5. Standard reporting system for breast FNAC. Is there a need for it?
  6. Should cancer patients be managed based on FNAC diagnosis alone, without histology?
  7. Can oestrogen receptor, HER2 be assessed on FNAC material?
  8. The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic
  9. The place of core biopsy in investigation of breast lesions
  10. Conclusions and overview of the discussion forum
  11. References

BM: CB is on the increase. The reason for this is that clinicians often prefer histopathology, which they consider as more informative.

BH: CB is performed only in doubtful cases. In private clinics, it is commonly practised instead of FNAC, for financial reasons. This policy certainly needs reviewing. I regret that, as in Britain, FNAC can only defend its role where there are enthusiastic and competent cytopathologists.

JS: In Sheffield, CB is the preferred modality, because of the ability to perform hormone receptors and HER2 status. I do not think this policy needs reviewing.

AF: The reason for increase of the use of CB can also be found in the different settings and attitude towards FNAC: a history of strong FNAC use; the presence of an active Cytopathology and Pathology Society; the teaching in Specialty School; the use of immunocytochemistry and molecular techniques on cytological material.

FS: The place of CB in the investigation of breast lesions is for microcalcification and in case of suspicious/inconclusive cytology. The emerging practice of most radiologists and clinicians to use CB instead of FNAC for all lesions must be reviewed and discussed with cytopathologists.

ET: CB is performed after FNAC, in a few cases, either when mammography cannot guarantee invasive carcinoma or for research purposes for tissue bank. This policy depends on the availability of trained and competent cytopathologists.

ZP-M: CB is performed on most non-palpable lesions. The reason for this is that cytological material from very small lesions is usually very poor. This policy definitely needs reviewing.

CB: Microcalcification or lesions not visible on US are investigated by CB in order to obtain sufficient material.

HK: The place of FNAC and CB is equal, CB follows FNAC. The use of different methods depends on the surgeon responsible.

SK: In my institution, CB alone is used for index lesions.

KK: CBs are not routinely done in our hospital. In a few cases it is done when the cytological diagnosis is inconclusive and the surgeon insists on a definitive diagnosis prior to surgery.

PV: Patients with palpable or non-palpable breast lesions are mainly seen in our one-stop clinic, once a week, allowing immediate assessment of slides and definitive diagnosis by the cytopathologist on duty. This is the case for nodules, as microcalcifications are usually sampled by a CB. This is only performed when FNAC is classified as suspicious for malignancy or with insufficient material for analysis.

IK-S: In Croatia, FNAC is the first pathology modality used in the investigation of breast lesions. If CB is being performed, it is after FNAC. CB instead of FNAC or simultaneously with FNAC is performed only in some centres. The National Guidelines on cytological management of breast lesions from 2003 include the indications for core biopsy: (i) FNAC-negative, but US- and/or mammography-suspicious lesions; (ii) cytologically undefined, suspicious lesions; and (iii) lesions consisting of microcalcifications if stereotactic aspiration biopsy is negative.

GK: The strength of the FNAC lies in diagnosing benign disease. Benign disease is by far the dominant finding in all institutions. Too much time is being spent on the comparisons of CB and FNAC. The methods are not mutually exclusive. FNAC is very good for benign disease, which tends to get forgotten because the women are discharged and we do not see them again. CB is the method of choice for microcalcifications and clinically/radiologically obvious malignancies as well as following inconclusive FNAC. My plea is for all institutions practising FNAC to monitor their benign/malignant diagnosis ratio and thus assess the potential saving (or cost, if CB performed in all cases) of using FNAC.

PV: I agree and I think it would be very welcome under the umbrella of EFCS. The one thing we should do individually is to try to do an annual audit of correlation between cytology and histology, because I am concerned about the false-negative results.

GK: In the setting of a triple-negative test, the negative predictive value, as reported in the literature, is 100%, reassuring the patient and clinician that clinical follow-up and not surgical intervention was sufficient for proper patient care.23

Summary: The use of CB is on the increase. The reasons for this are multifold: local policies, financial, lack of enthusiastic cytopathologists, ability to perform hormone receptors and Her2 staining, attitude towards FNAC, experience with microcalcifications in the screening programmes, inconclusive cytology results, reluctance of the radiologist to acquire inadequate FNAC samples. Some countries have developed clear guidelines as to the respective uses of FNAC and CB where the latter is used in cases of discrepant cytology/radiology, inconclusive FNAC or microcalcifications. All participants agree that microcalcifications should be investigated by CB. The importance of preserving the valuable role FNAC plays in the diagnosis of benign disease is stressed. Regular audit of the diagnostic accuracy of FNAC is recommended.

Conclusions and overview of the discussion forum

  1. Top of page
  2. Abstract
  3. Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions
  4. The use of image guidance for performing breast FNAC
  5. Standard reporting system for breast FNAC. Is there a need for it?
  6. Should cancer patients be managed based on FNAC diagnosis alone, without histology?
  7. Can oestrogen receptor, HER2 be assessed on FNAC material?
  8. The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic
  9. The place of core biopsy in investigation of breast lesions
  10. Conclusions and overview of the discussion forum
  11. References

Most participating countries have now adopted a ‘triple assessment’ approach, i.e. clinical, imaging and pathology, to breast diagnosis, with FNAC as the first-line pathological investigation in both screening and symptomatic populations, with the exception of microcalcifications. Pathologists specialized in cytopathology are best qualified to collect and interpret FNAC samples, but this is not always possible or practical. Radiologists involved in breast imaging should ensure that they have the necessary skills to carry out FNAC under all forms of image guidance. Best results are achieved by a combination of both techniques, as shown in the image-guided FNAC in the presence of the cytopathologist. The majority of European countries use similar reporting systems for breast FNAC (C1–C5), in keeping with European guidelines for quality assurance in breast cancer screening and diagnosis, although some still prefer descriptive reporting only. When triple assessment is concordant, final treatment may proceed on the basis of FNAC, without a tissue biopsy. ER and PR assessment can be done safely on FNAC material. However, not all institutions may have expertise in doing this. HER-2 protein expression on direct cytological preparations is insufficiently reliable for clinical use, although its use for FISH is possible, if expertise is available. The majority of participants practise a degree of one-stop diagnosis with a cytopathologist present in the out-patient clinic. Formal recognition of the importance of the time spent outside the laboratory, both for cytopathologist and cytotechnologist, is necessary in order to ensure appropriate resourcing. The use of CB has increased, although not always for evidence-based reasons. CB and FNAC are not mutually exclusive. FNAC should be used in diagnosis of benign, symptomatic lesions and CB in microcalcifications, suspicious FNAC findings and malignancies where radiology cannot guarantee stromal invasion.

References

  1. Top of page
  2. Abstract
  3. Triple assessment (clinical, pathology, radiology) as a standard method of investigating breast lesions and FNAC as a first pathology modality used in diagnosis of breast lesions
  4. The use of image guidance for performing breast FNAC
  5. Standard reporting system for breast FNAC. Is there a need for it?
  6. Should cancer patients be managed based on FNAC diagnosis alone, without histology?
  7. Can oestrogen receptor, HER2 be assessed on FNAC material?
  8. The use of FNAC for on-site examination and immediate (one-stop) diagnosis in a breast out-patients clinic
  9. The place of core biopsy in investigation of breast lesions
  10. Conclusions and overview of the discussion forum
  11. References