Journal of Cytology

ORIGINAL ARTICLE
Year
: 2011  |  Volume : 28  |  Issue : 3  |  Page : 111--113

The clinical effectiveness of fine needle aspiration biopsy in patients with palpable breast lesions seen at the University College Hospital, Ibadan, Nigeria: A 10-year retrospective study


Cornelius O Ukah, Olayiwola A Oluwasola 
 Department of Pathology, University College Hospital, Ibadan, Oyo State, Nigeria

Correspondence Address:
Cornelius O Ukah
Department of Histopathology, Nnamdi Azikiwe University, P.M.B. 5025 Awka, Anambra State
Nigeria

Abstract

Background: Although open surgical biopsy is the «SQ»gold standard«SQ» for diagnosis of palpable breast lesions, in recent years two types of minimally invasive breast biopsy techniques, core needle biopsy and fine needle aspiration biopsy (FNAB), have become established for the diagnostic evaluation of palpable breast lesions. Aims: This study was undertaken to evaluate the clinical effectiveness of FNAB as a first line diagnostic procedure in the management of patients with breast lumps in University College Hospital (UCH), Ibadan, using the suggested thresholds for cytology performance as recommended by the United Kingdom National Health Services Breast Screening Programme (NHSBSP). Settings and Design: A 10-year retrospective cohort study carried out in the Pathology Department of UCH. Materials and Methods: All FNAB and histologically diagnosed cases of breast lesions in the pathology department between January 1996 and December 2005 were reviewed. The cytological diagnoses were then categorized into one of five diagnostic categories in accordance with the recommendations of the NHSBSP. Results: The positive predictive value for malignancy was 99.3% with a complete sensitivity of 97.7% and specificity (full) of 94.2%. Conclusions: The high quality assurance measures obtained in this study affirms FNAB as a clinically effective diagnostic procedure for breast lesions.



How to cite this article:
Ukah CO, Oluwasola OA. The clinical effectiveness of fine needle aspiration biopsy in patients with palpable breast lesions seen at the University College Hospital, Ibadan, Nigeria: A 10-year retrospective study.J Cytol 2011;28:111-113


How to cite this URL:
Ukah CO, Oluwasola OA. The clinical effectiveness of fine needle aspiration biopsy in patients with palpable breast lesions seen at the University College Hospital, Ibadan, Nigeria: A 10-year retrospective study. J Cytol [serial online] 2011 [cited 2021 Feb 27 ];28:111-113
Available from: https://www.jcytol.org/text.asp?2011/28/3/111/83467


Full Text

 Introduction



Although an open surgical biopsy is the 'gold standard' for diagnosis of palpable breast lesions, in recent years two types of minimally invasive breast biopsy techniques, core needle biopsy and fine needle aspiration biopsy (FNAB), have become established for the diagnostic evaluation of palpable breast lesions. [1],[2]

FNAB is utilized as a first line diagnostic procedure in the management of patients with breast lesions in UCH, Ibadan, based on previous studies showing high diagnostic accuracy, but the evaluation of the clinical effectiveness of this diagnostic procedure has not been assessed in this centre. Thus, the need for this study.

 Materials and Methods



All FNAB and histological diagnosed cases of breast lesions in the pathology department between January 1996 and December 2005 were reviewed. The cytological diagnoses were then categorized into one of five diagnostic categories in accordance with the recommendations of the United Kingdom National Health Services Breast Screening Programme (NHSBSP). [3]

All the histological slides were reviewed in order to confirm the original diagnosis.

Cases whose cytological or histological diagnoses could not be verified because of inadequate records or unavailability of the original slides or tissue blocks were excluded from further analysis.

The final histological diagnosis of each case was then compared with its cytological diagnosis. This comparative analysis was done using performance indicators of quality assurance as recommended by NHSBSP. [3]

Ethical approval was obtained from the ethical committee of University of Ibadan/University College Hospital, Ibadan.

 Results



A total of 1401 FNAB of palpable breast lesions were evaluated over the period of study. This constituted 12.0% of all cytology (both gynecological and non-gynecological) specimens seen during the study period. Out of this 1401 FNAB of palpable breast lesions, 38 (2.7%) were categorized as unsatisfactory (C1), 803 (57.3%) were categorized as benign (C2), 6 (0.4%) were categorized as atypia; probably benign (C3), 107 (7.6%) were categorized as suspicious for malignancy (C4), and 447 (31.9%) were categorized as malignant (C5).

Out of the 1401 aspirates, 1359 (97.0%) were obtained from females, 39 (2.8%) were from males and in 3 (0.2%) sex was not specified.

The overall age range was from 7 to 91 years with a mean age of 39.5 years. 43(3.1%) of the cases age was not mentioned in the records. The peak age of presentation of patient with breast lesions was in the fourth decade of life.

Histological report was documented for 250 of the 1401 breast aspirates giving an overall biopsy rate of 17.8%, histological report was documented for 123 of the 803 C2 categories with a biopsy rate of 15.3%, histological report was documented for 96 of the 447 C5 categories with a biopsy rate of 21.5%, histological report was documented for 5 of the 38 C1 categories with a biopsy rate of 13.2%, histological report was documented for one of the six C3 categories with a biopsy rate of 16.7%, and histological report was documented for 25 of the 107 C4 categories with a biopsy rate of 23.4%.

The cytological diagnoses were correlated with histological results and a comprehensive table of these data was constructed [Table 1] from which quality performance criteria were calculated as specified in the United Kingdom National Health Services Breast Cancer Screening Programme guidebook. [4] The absolute and complete sensitivity of FNAB in this study were 93.5% and 97.7% respectively with a false negative rate of 1.7% . The positive predictive value for malignancy was 99.3%. The specificity (full) and specificity (biopsy cases only) were 94.2% and 91.3% respectively with a false positive rate of 0.6%. The negative predictive value was 99.5%. [Table 2] shows a comparative analysis of the results of this present study when compared with the minimum and preferred suggested thresholds and also with the current median threshold as shown in the guidelines for non-operative diagnostic procedures and reporting in breast cancer screening of the United Kingdom NHSBSP. [2]{Table 1}{Table 2}

 Discussion



International studies have demonstrated good correlation between FNAB and histology results. [5]

The absolute and complete sensitivity of 93.1% and 97.4% respectively obtained in this study are significantly above the lower limits of preferred standards for quality assurance suggested by the NHSBSP (which are >80% and >90% respectively) as well as the current median values (which are 57.1% and 81.5% respectively). [3] The reasons for this is likely to be due to non-inclusion of non-palpable breast lesions in this study and also due to the fact that most of our patients present with advanced tumors thereby minimizing sampling error as evidenced by an inadequate rate of 2.7% obtained in this current study as against the suggested minimum and current median rates of <25% and 23.4%, respectively. [3] The positive predictive value for malignancy of 99.3% obtained in this current study is above the suggested minimum value of >98%. [3]

False positivity is one of the most worrying aspects of breast FNAB as mastectomy could be done for a benign lesion with serious clinical and medico-legal implications. [4] The current false positive rate of 0.6% obtained in this current study is well within the recommended <1%. [3]

It has been shown that false positive fine needle smears often occur with peculiar types of breast lesions such as intraductal papilloma, fat necrosis, tubular adenomas, pregnancy- or radiation- related changes and granulomas. [6] In this current study, the three false positive aspirates were intraductal papilloma, fibrocystic changes and fibrocystic changes with moderate epithelial hyperplasia, respectively.

False negative diagnosis is another area of concern. Even in the most experienced centers, 10% of cancers have a false negative cytology. [7] This is reflected in the current median false negative rate of 6.3%. [3] It is said to be more commonly encountered in fibrotic lesions, radiation-associated changes and tumor desmoplastic reaction as in invasive lobular carcinoma. [8] The false negative rate of 1.7% obtained in this study is well within the recommended minimum threshold of <6% [3] and is likely due to the fact that most of our patients with malignancy present with advanced tumors thereby minimizing sampling error. [9],[10]

There is a significant reduction in the proportion of unsatisfactory smears (4.3%) in this series when compared with 26.8% [11] obtained in this centre 22 years ago. This significant reduction in the inadequacy rate was partly due to pathologists becoming the aspirators instead of the surgeons as was the case before the establishment of FNAB clinic in the pathology department and partly due to the relatively long practice of FNAB in UCH, Ibadan, that has progressively enhanced the expertise of the pathologists. [5],[12] This difference is reflected in the significantly lower diagnostic accuracy (which was 79%) [11] in that series when compared with the current series (which was 97.4%). However, the current inadequacy rate is still high when compared with the 1.9% [5] and 0.7% [13] inadequacy rates obtained in Kano and USA, respectively.

It is likely that with reduction in the number of aspirators and care with the aspiration, the number of unsatisfactory smears will reduce further and the degree of accuracy of diagnosis will increased further.

In conclusion, this study shows that FNAB of palpable breast masses in UCH, Ibadan, is clinically effective.

In order to further reduce the inadequacy rate, to increase further the accuracy of FNAB in UCH and to improve the diagnostic importance of breast FNAB, we recommend the setting up of a core team of aspirators, who will perform and interpret all breast needling procedures; and also the establishment of an ancillary laboratory for breast FNAB.

References

1Litherland JC, Evans AJ, Wilson AR, Kollias J, Pinder SE, Elston CW, et al. The impact of core-biopsy on pre-operative diagnostic rate of screen detected breast cancers. Clin Radiol 1996;51:562-5.
2Ariga R, Bloom K, Reddy VB, Kluskens L, Francescatti D, DowlatK, et al. Fine-needle aspiration of clinically suspicious palpable breast masses with histopathologic correlation. Am J Surg 2002;184:410-3.
3Robin L, Diana B, Liz A, Tom A, Ruth A, Tony R. Guidelines for cytology procedures and reporting in breast cancer screening. Cytology subgroup of the national co-coordinating committee for breast screening pathology. Sheffield: NHS Cancer Screening Programme;2001.
4Kline TS, Joshi LP, Neal HS. Fine needle aspiration of the breast: Diagnosis and pitfalls. A review of 3545 cases.Cancer 1979;44:1458-64.
5Mohammed 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. Ann Afr Med 2005;4:19-22.
6Orell SR. Radial scar/complex sclerosing lesion-A problem in the diagnostic work-up of screen-detected breast lesions. Cytopathology 1999;10:250-8.
7Smallwood J, Herbert A, Guyer P, Taylor I. Accuracy of aspiration cytology in the diagnosis of breast disease. Br J Surg 1985;72:841-3.
8Dey P, Luthra UK. False negative cytologic diagnosis of breast carcinoma. Acta Cytol 1999;43:801-5.
9Hassan AW. Breast cancer. NigerJ Surg Sci 1992;2:36-8.
10Hassan I, Muhammed I, Attah MM, Mabogunje O. Breast cancer during pregnancy and lactation in Zaria, Nigeria. East Afr Med J 1995;72:280-2.
11Ogunniyi JO, Senbanjo RO, Ogunlusi ML. Fine needle aspiration cytology in the assessment of breast lumps in Ibadan. Afr J Med Med Sci 1989;18:151-4.
12Nerurkar A, Osin P. The diagnosis and management of pre-invasive breast disease: The role of new diagnostic techniques. Breast Cancer Res 2003;5:305-8.
13O'Neil S, Castelli M, Gattuso P, Kluskens L, Madsen K, Aranha G. Fine-needle aspiration 697 palpable breast lesions with histopathologic correlation. Surgery 1997;122:824-8.