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reviews
Adv Clin Exp Med 2013, 22, 6, 887–892
ISSN 1899–5276
© Copyright by Wroclaw Medical University
Marta WesołaA–D, Michał JeleńE, F
The Diagnostic Efficiency of Fine Needle Aspiration
Biopsy in Breast Cancers – Review
Wydolność diagnostyczna biopsji cienkoigłowej w rakach gruczołu
piersiowego – przegląd piśmiennictwa
Department of Pathomorphology and Oncological Cytology, Wroclaw Medical University, Poland
A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation;
D – writing the article; E – critical revision of the article; F – final approval of article; G – other
Abstract
The introduction of fine needle aspiration biopsy (FNAB) into diagnostics set new standards for less invasive morphological diagnostics research. This diagnostic method is better in many ways than core biopsy. In some researchers’ view, FNAB is not an infallible method for assessing breast lesions, because it requires highly trained radiologists and cytologists in order to correlate the cytological findings with a radiological examination. Some researchers
argue that FNAB is characterized by high diagnostic sensitivity and specificity; others that it has a greater advantage
when it comes to costs in relation to conventional lymph node biopsy. Using ultrasound to guide FNAB decreases
the number of false negative results and increases the sensitivity and specificity of FNAB. Fine needle aspiration
biopsy plays an important role in the initial determination of the staging of breast lesions and of the character of
the lesions (benign or malignant) (Adv Clin Exp Med 2013, 22, 6, 887–892).
Key words: fine needle biopsy, fine-needle aspiration, diagnostic techniques and procedures, breast neoplasms,
breast cancer.
Streszczenie
Wprowadzenie do diagnostyki biopsji aspiracyjnej cienkoigłowej (BAC) zapoczątkowało nowe standardy w zmniejszeniu inwazyjności morfologicznych badań diagnostycznych. Ta metoda diagnostyczna jest lepsza od biopsji gruboigłowej pod wieloma względami. Przez niektórych badaczy BAC nie jest uważana za niezawodną metodę oceny
zmian w piersiach, ponieważ wymaga wysoko wykwalifikowanych radiologów i cytologów, aby korelować ustalenia
cytologiczne z badaniem radiologicznym. Z jednej strony szacuje się, że BAC charakteryzuje się dużą czułością
diagnostyczną i specyficznością. Z drugiej strony, według innych autorów, BAC charakteryzuje się akceptowalną
czułością, a jest bardziej korzystna, jeśli chodzi o koszty w stosunku do konwencjonalnej biopsji węzłów chłonnych.
Stosowanie BAC pod kontrolą USG zmniejsza liczbę fałszywie ujemnych wyników, zwiększa czułość diagnostyczną
i swoistość BAC. Biopsja aspiracyjna cienkoigłowa odgrywa ważną rolę we wstępnym określaniu stopnia zaawansowania zmian w piersi oraz określeniu charakteru zmiany (łagodna lub złośliwa) (Adv Clin Exp Med 2013, 22,
6, 887–892).
Słowa kluczowe: biopsja cienkoigłowa, biopsja aspiracyjna cienkoigłowa, techniki i procedury diagnostyczne,
nowotwory piersi, rak piersi.
The introduction of fine needle aspiration biopsy (FNAB) into diagnostics set new standards
for less invasive morphological diagnostics research. FNAB, as a routine procedure in pathomorphological diagnostics, is used for tumors
that are accessible by the needle, such as thyroid
tumors, breast tumors or peripheral adenopathies.
In breast tumors, FNAB can be performed on all
that are palpable [1]; for nonpalpable breast lesions ultrasound-guided FNAB is used [2]. FNAB
is not only a diagnostic method, but, first of all,
it provides prognostic information, facilitating the
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M. Wesoła et al.
choice of a treatment option. This method not only
reduces health care costs but also the psychological
costs to the patients [3].
The results of FNAB examinations have been
categorized into 4 classes: benign, atypical/indeterminate, suspicious/probably malignant and, finally, malignant – a classification which has been
approved by the National Cancer Institute. A malignant result is a signal to plan therapy; an indeterminate result states presence of atypia with a risk
of malignancy; a benign result means that there is
a good probability of a benign diagnosis in clinical findings [2].
In connection with the different opinions of
pathomorphologists on which diagnostic method
(core biopsy or FNAB) is better, the obvious question that comes to mind is whether the diagnostic
efficiency of the FNAB method is sufficiently satisfactory. FNAB is not only less invasive and simpler than the once-dominant drill biopsy, which
laid the foundation for contemporary core biopsy,
but (even more importantly) it has replaced surgical biopsies almost completely [4–6]. It is also
faster and costs less to perform [4, 7]. In comparison to core biopsy, FNAB is simpler and safer in
lesions close to the chest wall or abdominal cavity [7]. This type of biopsy has become fundamental to breast cancer diagnostics.
FNAB in the Staging
of Mammary Gland Lesions
Cytopathology plays a big role in the changing trends in the diagnostics of breast cancers.
This contribution includes the implementation of
FNAB, the analysis of the results and the optimization of new technologies for small-sized samples
so as to provide the necessary information, both
prognostic and predictive. Many studies have confirmed the fact that cytomorphology constitutes an
integral part of breast cancer research and prevention [8, 9]. Dennison et al. carried out prospective
study involving 143 people with palpable nodule
with a diameter of more than 2 cm [10]. The research showed that 95 out of 105 patients with malignant lesions were confirmed by FNAB, which
means the sensitivity of this method is 90.4%. In
comparison, utilizing core biopsy confirmed 100
cases, which gives an accuracy level of 95.2%; this
degree of sensitivity, was obtained only after drawing sample materials from 4 spots [10]. Similar results were obtained in a study by Sun et al., aimed
at comparing FNAB and core biopsy [11]. The diagnostic sensitivity of FNAB was 93.8%, whereas for core biopsy it was 90.1%, so the researchers concluded that both FNAB and core biopsy
are sensitive and efficient methods of breast cancer detection [11]. According to Horgan et al.,
the sensitivity of FNAB varies from 52% to 93%,
which is a very wide range. False positive results
from FNAB have been assessed as infrequent,
ranging from 0.3% to 1.1% [12, 13]. False negative results range from 6% to 11% [14, 15]. In other studies, the sensitivity of FNAB guided by ultrasound ranged from 25% to 95% and its specificity
was 97% to 100% [16–18]. False positive results
vary from 1.4% to 1.6% [19–21]. Factors such as
the specialist’s experience and/or the size and type
of tumor may have a major impact on the sensitivity of the tests [12, 22]. A study conducted by Kurita et al. involving 182 patients found that the absolute sensitivity of the FNAB method was 93%,
while the absolute sensitivity of core biopsy was
86% in a study involving 56 patients; however, it is
difficult to compare these 2 values due to the large
difference in the number of test subjects [23]. Chinese researchers He et al. decided that it was necessary to evaluate the importance of FNAB in preoperative diagnostics of breast cancer once again by
conducting long-term clinical studies. Engaging in
this over the course of 11 years, the team conducted 1238 fine needle aspiration biopsies; in 1071
of these patients, breast cancer was discovered in
postoperative examination. The diagnostic sensitivity of FNAB was 87.72%, the specificity of the
method was 99.4%, and its overall precision was
97.74%. False negative results were 2.28% and false
positives 0.6%. He et al. believe those results suggest that FNAB is still a useful and reliable method
for preoperative diagnosis of breast cancer [24].
The sensitivity of FNAB was 77.22% in a study
by Farshid and Rush, who concluded that when experienced cytopathologists are available, fine FNAB
can be a very accurate, fast and cost-efficient method in the diagnosis of breast cancer [25]. From 1991
to 2010, Keen et al. conducted a study aimed at
evaluating the quality of FNAB. They claimed that
within those 2 decades the quality of the method
improved; but because of the method of selecting
patients, FNAB is often used as a back-up test of lesions that are not clinically suspicious [26].
The efficiency of the FNAB can be evaluated by comparing it with other methods, such as
core biopsy. Hukkinen et al. stress the necessity
of proper preoperative diagnosis of breast lesions,
and in their study they compare the efficiency of
FNAB with the efficiency of core biopsy on the basis of the two methods’ ability to identify a malignant lesion. Out of 289 post-surgically identified
cases of malignant lesions, 194 had been recognized preoperatively as malignant through the use
of FNAB, while core biopsy showed 206 malignant lesions out of a total number of 214 identified
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Fine Needle Aspiration Biopsy in Breast Cancers
post-surgically. In terms of percentages, those accuracy rates are 67% for FNAB and 96% for core
biopsy. The research showed that among the patients who underwent FNAB, 93 additional biopsies were conducted, whereas for patients who had
core biopsy only 2 additional biopsies were performed. The authors suggest that the costs of using FNAB are higher and recommend using core
biopsy [27].
A study by Nagar et al. showed that the diagnostic sensitivity and specificity of FNAB (89% and
98% respectively) were similar to those of core biopsy (100% and 90% respectively), but that FNAB
is a more cost-efficient method [28]. Al-Sindi
et al. conducted a study of the diagnostic efficiency of FNAB involving 303 people; the diagnostic
sensitivity of FNAB was 96.5% and the specificity was 98.3% [29]. In this study very high scores
were obtained, demonstrating the usefulness of
FNAB in the diagnosis of lesions in the mammary gland. Other studies, however, have indicated
much lower efficiency for this method. One such
study was conducted by Swinson et al., involving
369 patients. The sensitivity of FNAB guided by
ultrasound was 33%, whereas the real number of
lesions in patients with symptoms of breast cancer was 44% [30]. Kooistra et al. concluded that
FNAB has limited use in the routine determination of breast lesions. In order to avoid unnecessary cuts, it can be applied in the case of major
breast lesions with a low degree of radiological
and clinical suspicion of malignancy. In more suspicious lesions it can be applied in order to obtain
rapid confirmation of cancer when accompanied
by core biopsy [31]. According to Brancato et al.,
FNAB gives good results, but due to the relatively
high degree of inaccuracy, it is less sensitive than
core biopsy; at the same time, core biopsy has lower specificity in comparison to FNAB [32]. Their
study indicated that core biopsy is a more reliable
method of diagnosis of lesions visible in ultrasound. However, the diagnostic strategy of using
FNAB as the 1st test is justified provided the core
biopsy is integrated as a 2nd test in order to eliminate any doubts regarding inconclusive FNAB results [32]. Kooistra et al. did an overview in which
they compared 2 methods for the preoperative diagnosis of breast lesions, namely FNAB and core
biopsy [33]. They concluded that the method that
most often proves decisive is core biopsy. FNAB,
as mentioned before, is a faster method and it entails less anxiety for the patient; core biopsy allows
quite reliable assessment of the histological type,
the stage of advancement and/or the expression of
the receptors [33].
Table 1. Study results for FNAB sensitivity and specificity
Researchers
FNAB
sensitivity
%
FNAB
specificity
%
Dennison et al.
90.4
–
Sun et al.
93.8
–
Horgan et al.
52–93
–
Krishnamurthy
25–95
97–100
He et al.
87.7
99.4
Farshid and Rush
77.2
–
Al-Sindi et al.
96.5
98.3
Table 2. Comparisons of FNAB and core biopsy
Researchers
FNAB
sensitivity
%
CORE
BIOPSY
sensitivity
%
FNAB
specificity
%
CORE
BIOPSY
specificity
%
Dennison
et al.
90.4
95.2
–
–
Sun et al.
93.8
90.1
–
–
Kurita et
al.
93
86
–
–
Hukkinen
et al.
67
96
–
–
Nagar et
al.
89
100
98
90
FNAB in the Diagnosis
of Lymph Nodes
Masood stated that FNAB can be used in determining the severity of changes in axillary lymph
nodes before surgery. On this basis the presence
of metastases can be established prior to surgery,
and the unnecessary excision of all lymph nodes
can be avoided [34]. Tan has a similar opinion on
this matter, noting that the use of FNAB with ultrasound prior to surgery is an important component of preoperative assessments of the stage of
a lesion. In patients with impalpable nodes that are
detectable by means of imaging methods, the use
of ultrasound-guided FNAB can reduce the risk of
mapping failure [35].
The accuracy of ultrasound-guided FNAB in
detecting metastatic disease before the procedure
in patients with breast cancer varies depending
on the number of lymph nodes with metastatic lesions. In the case of a single lymph node (a sentinel
lymph node), the accuracy level is 40–50%; in cases where 4 or more nodes are involved, accuracy
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M. Wesoła et al.
increases to 90% [36]. This result is quite good in
comparison to other methods: the sensitivity of
the intraoperative examination of lymph node is
75%, reprint cytology about 63%, and the results
of the molecular research related to the histological research are 90% [36]. Swinson et al. conducted a study in which 369 patients were tested [30].
They reported that the level of detection in ultrasound-guided FNAB was 33%, whereas the real
number of lesions in patients with symptoms of
breast cancer was 44%. Based on this study, authors concluded that the detection rate allowed
a reduction in the number of sentinel node biopsies in favor of one-step and less-invasive surgery
in the armpits [30].
Determining the
Progesterone, Estrogen and
HER2 Receptors with FNAB
Overexpression of HER2, progesterone and estrogen has been shown in breast cancers, and amplification of these receptors is useful in diagnosing
breast cancers. Inverse correlations have been shown
between HER2 and estrogen expression and between HER2 and progesterone expression [37–39].
Some authors [40, 41] believe that because of the
recently introduced molecular classification of
breast cancer, which requires immunohistochemical assessment of the expression of progesterone
receptors, estrogen receptors and HER2 receptors,
as well as an evaluation of predictive factors evaluation, FNAB has become less important than core
biopsy. In their opinion, in order to carry out the
immunohistochemical assessment of the expression of membrane proteins and evaluate predictive
factors, it is crucial to collect histological material,
which is possible only in case of core biopsy [40, 41].
However, nuclear protein staining can be performed on the material obtained in a cervical smear
test. The expression of progesterone and estrogen
receptors has a nuclear location, so it is possible
to measure their amplification level using material
from an FNAB [36, 38, 39]. As for HER2 receptors,
Wojnar et al. showed in their study that its expression can be measured not only by the immunohistochemical method, but also by the fluorescence
in situ hybridization (FISH) method [37].
Summary
FNAB is an essential element of the diagnosis of
lesions in the mammary gland, and despite the wide
range of results regarding the diagnostic sensitivity
of this method; it has great importance as a method for initial evaluations of the clinical situation, as
well as allowing the planning of surgical treatment.
Some researchers do not consider FNAB a reliable
method for assessing breast lesions, because it requires highly trained radiologists and cytologists
in order to correlate the cytological findings with
the radiological examination [42]. It has been estimated that FNAB is characterized by 68% diagnostic sensitivity and as much as 100% specificity [43].
Others argue that FNAB has acceptable sensitivity
and is more cost-efficient than conventional lymph
node biopsies [35]. Using ultrasound-guided FNAB
decreases the number of false negative results and
increases the sensitivity and specificity of FNAB [16, 44]. FNAB, especially USG-guided FNAB plays
an important role in the initial determination of the
staging of breast lesions [16]. The decision regarding the choice of a diagnostic method still depends
on the doctor, his or her experience and diagnostic knowledge. Guidelines regarding the section of
breast material prepared by oncological specialists can be helpful. The recommendations for using FNAB are: palpable breast lesions, like enlarged
lymph nodes or nodular changes; and changes that
can be detected only by imaging methods, for example changes which may be malignant. The recommendations for using core biopsy are: palpable nipple lesions, nipple changes without any symptoms,
detectable only by imaging methods, and changes
suspected in clinical tests where the FNAB results
were negative [45].
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Address for correspondence:
Marta Wesoła
Department of Pathomorphology and Oncological Cytology
Wroclaw Medical University
Borowska 213
50-556 Wroclaw
Poland
Tel: +48 79 71 17 461
E-mail: [email protected]
Conflict of interest: None declared
Received: 15.03.2013
Revised: 29.08.2013
Accepted: 26.11.2013
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