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ROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN THE PREOP ASSESSMENT OF CLINICALLY SUSPICIOUS PALPABLE BREAST MASSES WITH HISTOPATHOLOGIC CORRELATION: A JRRMMC EXPERIENCE

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ROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN THE PREOP ASSESSMENT OF CLINICALLY SUSPICIOUS PALPABLE BREAST MASSES WITH HISTOPATHOLOGIC CORRELATION: A JRRMMC EXPERIENCE Powered By Docstoc
					 ROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN THE PREOP ASSESSMENT OF CLINICALLY SUSPICIOUS
     PALPABLE BREAST MASSES WITH HISTOPATHOLOGIC CORRELATION: A JRRMMC EXPERIENCE

                                          Jocelyn M. Lledo, MD

                      Department of Surgery, Jose Reyes Memorial Medical Center



Abstract

Background of the study: Fine-needle aspiration biopsy (FNAB) is one of the components of the triple
test for the investigation of breast symptoms, the other two components being clinical breast
examination and mammography. It is considered the most accurate part of the said test. This study
attempts to assess the value of the FNAB in the assessment of palpable breast masses at Jose Reyes
Memorial Medical Center over a two-year period (2006-2007).

Methods: A retrospective study of 113 patients who underwent FNAB, of which 108 had histological
verification, was performed.

Results: Out of the 57 histologically confirmed benign lesions, 43 had been classified as benign, while 3
and 11 cases were categorized as atypical and unsatisfactory, respectively. Out of the 51 histologically
confirmed malignant masses, 17 had been interpreted as malignant, while 7 cases were labeled as
suspicious and 15 cases benign. The positive predictive value was 100% with a sensitivity of 47% and
specificity of 100%. The false positive rate was zero while the false negative rate was 25.9%.

Conclusion: The high specificity, zero false positive rate and high positive predictive value of FNAB as
determined in this study justifies its use as a first-line diagnostic method in the assessment of palpable
breast masses in this institution.



Introduction

The DOH ranks breast cancer as one of the leading causes of death among Filipinos today with an
incidence of 4.4 per 100,000, second only to cancer of the trachea, bronchus and lung. The breast is
leading site of cancer among females in the country today. The DOH advocates monthly self-breast
examination (SBE) and clinical examination by a physician under the Breast Cancer Screening Program
(“Sariling Salat sa Suso”) as a campaign to detect this disease early. Currently, only 44% of Filipino
women practice SBE while a mere 5% undergo medical consultation for breast concerns.1

The triple test for the diagnostic investigation of breast symptoms consists of clinical examination,
mammography and fine-needle biopsy.2 Mammography is a diagnostic tool that is readily available only
in tertiary centers and in urbanized areas in developing countries and countries with limited resources.3
For this reason, clinical examination and FNAB remain the most practical and economical ways of
detecting breast cancer in a country such as ours.
FNAB has been established as the most precise component of the triple test for investigating palpable
breast lesions.2 This diagnostic procedure is easier, economical and relatively less traumatic as
compared to open surgical biopsy and core needle biopsy.

This research paper measures the value of FNAB in the detection of cancer in palpable breast lumps at
Jose Reyes Memorial Medical Center.



Patients and Methods

Patients with clinically palpable breast masses seen at the Surgery OPD of this institution over a 2-year
period (2006-2007) who underwent FNAB with histological confirmation afterwards were included in
the study.

The FNAB specimens were obtained by surgery residents using freehand with a 21-gauge disposable
needle attached to a 10-cc disposable plastic syringe. Aspirated substance were smeared on standard
microscope glass slides and fixed immediately in 95% alcohol. Staining with routine hematoxylin and
eosin stains were done by pathology residents.

Following cytological evaluation, smears were categorized into unsatisfactory, benign (negative),
equivocal (atypia), suspicious and malignant (positive) groups. Histologic results of the cases after
excision biopsy or mastectomy were retrieved and compared with cytology results for correlation.

Data on results of FNAB and histology were then employed to measure the sensitivity, specificity,
predictive values, true and false positive rates based on the Breast Screening Program guidelines of the
Department of Health. Sensitivity was defined as the proportion of breast cancer cases with a positive
or suspicious FNAB result while specificity was defined as the ratio of cases with benign breast masses
that had negative FNAB results. The positive predictive value was determined as the number of
histologically confirmed malignant cases with malignant or suspicious cytological results. False positive
rate is defined to be the number of patients with histologically benign masses with malignant or
suspicious cytological results while false negative rate is the number of breast cancer cases with
negative FNAB results.1-4
Results

The total number of FNAB done on palpable breast lumps during the study period was 113. The number
of histological confirmation was noted to be 108.

Table 1: Classification of 108 Fine Needle Aspirates

Cytological Diagnosis        No. (%)
Benign                      58 (53.7)
Malignant                   17 (15.7)
Suspicious                  7 (6.5)
Atypia                      8 (7.4)
Unsatisfactory              18 (16.7)
Total                       108 (100)


Table 2: Classification of 108 Histological Results of Patients with Prior FNAB

Histological Diagnosis No. (%)
Benign                 57 (53)
Malignant *            51 (47)
Total                  108 (100)
* includes those with atypia (5) and unsatisfactory (7) findings on FNAB but malignant on histologic confirmation


Table 3: Correlation of cytological and histological diagnosis of 108 fine needle aspirates

Cytological Diagnosis Histological Diagnosis
                      Malignant Benign (n = 57)
Benign                15           43
Malignant **          17           -
Suspicious **         7            -
Atypia                5            3
Unsatisfactory        7            11
Total                 51           57
** considered with cancer


Cytological Diagnosis                      Histological Diagnosis
                                           Malignant (n = 51)                          Benign (n = 57)
With Cancer (24)                           24                                          -
Without Cancer (58)                        15                                          43


Sensitivity = 24 / 51 = 47 %                                         False Positive Rate = 0 / 24 = 0 %

Specificity = 43 / 43 = 100 %                                        False Negative Rate = 15 / 58 = 25.9 %

Positive Predictive Value = 24 / 24 = 100 %
Discussion

FNAB has been established as an important diagnostic tool in the preoperative diagnosis of clinically
palpable lumps.2-6 It is vital in preparing the patient psychologically to deal with her disease prior to
surgery and promotes the discussion of treatment options available so as to proceed to a therapeutic
rather than a diagnostic procedure. It likewise prevents unwarranted surgery in benign lesions, which is
especially important in our setting where financial constraint is a common setback to seeking medical
attention.

Various studies have shown excellent correlation between FNAB and histology results. In this study
however, the sensitivity of 47% does not correspond to sensitivity of 79-99% as confirmed in different
studies. The specificity of 100% as reported in this study, however, is consistent with the 60-100%
accounted for in other studies. 4-11 The low sensitivity reported in this study may be due to relatively high
rate of unsatisfactory FNAB results (16.7%), which, in turn, may be attributed to poor aspiration
techniques or to the expertise level of the cytopathologists interpreting the results. In other studies, the
numbers of unsatisfactory smears were low since FNAB was done by pathologists who made certain that
the specimens were satisfactory during collection time. A study by Ogunniyi et al reported higher
specificity and sensitivity in centers with onsite cytopathologists as against those where clinicians were
the aspirators.12 The size of the lesion can also be a factor in the number of unsatisfactory smears, as
shown by Yeoh and Chan, who demonstrated in their study that breast lumps less than 2cm in size were
shown to be associated with a high rate of unsatisfactory smears.8

Poor FNAB specimens may necessitate multidisciplinary review of clinical and mammographic findings
so as to establish whether a repeat FNAB, core needle biopsy or excision biopsy is in order, as has been
employed in other countries in the triple test.2 In our institution where patients’ financial resources are
inadequate, mammography and ultrasound-guided biopsy may pose as hindrances to diagnosing breast
cancer early. Repeat FNAB may be a more gainful choice as a complement to clinical breast examination
in economically-restricted institutions such as ours.

The seven suspicious FNAB smears were subsequently established to be malignant histologically. This
underlines the importance of evaluating suspicious lesions further, as they usually are malignant.4,6

The positive predictive value of 100% in this study denotes that a diagnosis of malignancy by FNAB
validates definitive treatment since there are no false positive results. In addition, FNAB turns out to be
more cost-effective and, thus, more acceptable than surgical biopsy as a tool in diagnosing breast
cancer. Moreover, among financially-constrained patients with limited access or means to afford
facilities such as mammography or ultrasound, FNAB can aid in the triage of patients with clinically
palpable breast lesions so that those with malignancy can be prioritized.4

The high false negative rate reported in this study (25.9%) may be attributed to sampling errors with
benign FNAB results. Possible causes for false negative results are fibrotic lesions, failed aspiration,
mucinous carcinoma and other rare histological variants of breast cancer.12 Again, the importance of the
skill and competence of the cytopathologist interpreting the FNAB smear cannot be emphasized enough
in minimizing false negative rates in our institution. Likewise, improvements in the technical aspect of
aspiration may contribute to minimizing false negative rates. Limiting false negative rates is essential
since this may decrease false reassurances that malignancy is not present when it actually is, as well as
minimize risks of inadequate or inappropriate treatment of our patients and their disease.



Conclusion

FNAB is recommendable as a first-line diagnostic tool in patients with clinically palpable breast lumps in
resource-poor centers such as our institution, as determined by its high specificity, zero false positive
rate and high positive predictive value. Steps to improve its sensitivity as well as its false negative rate
should be taken so as to improve its accuracy as a diagnostic tool in breast cancer.



References

    1. www.doh.gov.ph. National Objective for Health, Philippines 2005-2010, DOH, Manila.
    2. Flegg KM, Rowling YJ. Staging, treatment and current investigations for breast cancer – a GP
        perspective.
    3. Vargas HI, Anderson BO, Chopra R et al. Diagnosis of breast cancer in countries with limited
        resources. Breast J 2003; 9(suppl 2): S60-S66
    4. Mohammed AZ, Edino ST, Ochicha O, Alhassan SU. Value of fine needle aspiration biopsy in
        preoperative diagnosis of palpable breast lumps in resource-poor countries: A Nigerian
        experience. Annals of African Medicine 2005; 4 (1): 19-22
    5. Erhan Y, Ozdemir N, Kapkac M, Isik S, Korkut M,Yilmaz R, Ozbal O, Ustun EE, Erhan Y. Diagnostic
        reliability of combined approach of physical examination, mammography and fine-needle
        aspiration biopsy in patients with breast cancer. Annals of Saudi Medicine 1999; 19 (3): 261-263
    6. Ariga R, Bloom K, Reddy VB et al. Fine needle aspiration of clinically suspicious palpable breast
        masses with histopathologic correlation. Am J Surg 2002; 184: 410-413
    7. Nasuti JF, Gupta PK, Baloch ZW. Diagnostic value and cost-effectiveness of on-site evaluation of
        fine needle aspiration specimens review of 5, 688 cases. Diag Cytopathol 2002; 27:1-4 Vargas
    8. Yeoh GP, Chan KW. Fine needle aspiration of breast masses: an analysis of 1533 cases in private
        practice. Hong Kong Med J 1998; 4: 283-288
    9. Mansoor I, Jamal AA. Role of fine needle aspiration in diagnosing breast lesions. Saudi Med J
        2002; 23:915-920
    10. Chaiwan B, Settakom J, Ya-In C, Wisedmongkol W, Rangdaeng S, Thorner P. Effectiveness of fine
        needle aspiration cytology of breast: analysis of 2, 375 cases from Northern Thailand. Diag
        Cytopathol 2002; 26: 201-205
    11. Panchalingham L,Atoyebi OA, Elesha SO, Atimomo CE, daRocha-Afodu JT. Cost effectives of the
        fine aspiration biopsy cytology in the management of breast lumps. Nigerian Surgical Research
        Society, 38th Scientific Meeting. 1999
    12. Ogunniyi JO, Senbanjo RO, Ogunlusi ML. Fine needle aspiration cytology in the assessment of
        breast lumps in Ibadan. Afr J Med Sci 1989; 18:151-154
  ROLE OF FINE NEEDLE ASPIRATION CYTOLOGY IN THE
PREOP ASSESSMENT OF CLINICALLY SUSPICIOUS PALPABLE
BREAST MASSES WITH HISTOPATHOLOGIC CORRELATION: A
                JRRMMC EXPERIENCE


                                   by

                          Jocelyn M. Lledo, MD

        Department of Surgery, Jose Reyes Memorial Medical Center

				
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