Cytopathology in Focus: What breast cytology brings to rapid assessment clinics

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In a retrospective review of our experience with imprint cytology of image-detected core needle biopsy, we identified 437 cases. The cases were from both palpable and nonpalpable breast lesions with reported BIRAD ≥4. The results of imprint cytology were blinded for comparison to the histopathology diagnosis. The majority of our patients (65 percent) had benign breast lesions with high accuracy (98 percent) for imprint cytology. On the other hand, the accuracy of imprint cytology for malignant breast lesions was 95 percent. A few cases (five percent) were considered as indeterminate. These cases included papillary lesions with atypia and atypical proliferative breast disease, i.e. atypical ductal hyperplasia versus low-grade ductal carcinoma in situ. In these cases, we refrained from making a definitive diagnosis and advised the patients to wait for the final pathologic diagnosis by core needle biopsy. Overall, the results of our study with positive and negative predictive values of 91 percent and 97 percent, respectively, and 95 percent diagnostic accuracy confirmed the value of imprint cytology for the immediate interpretation of core needle biopsies.⁷

Providing an accurate diagnosis by FNAB or imprint cytology obtained from a core needle biopsy requires in-depth understanding of the complexity associated with the cytologic interpretation of the spectrum of disease entities in breast pathology. These include borderline breast disease such as atypical proliferative breast lesions, atypical ductal hyperplasia, low-grade ductal carcinoma in situ, lobular neoplasia, and flat epithelial atypia. Other lesions, such as papillary, fibroepithelial, mucinous, and sclerosing radial scar and the status of invasion, may also pose diagnostic difficulty.^16-18

There is no doubt that, compared with FNAB, core needle biopsy has now become the preferred minimally invasive sampling procedure. However, there are more similarities than differences between those two procedures, with a defined role for each of these procedures. It may be necessary to optimize the criteria for selecting the appropriate sampling procedure on an individual basis, refine protocols for follow-up management, and assess the long-term outcome of each procedure.^19,20

Cost should influence the decision on the use of FNAB versus core needle biopsy. This is particularly important in countries of limited resources where FNAB may be the only affordable procedure to sample a lesion.^21,22 This alone underscores the significance of maintaining the integrity of FNAB as a valid diagnostic procedure for palpable breast lesions. In contrast, core needle biopsy can be used in image-detected abnormalities with microcalcifications, indeterminate FNAB findings, and malignancies where breast sampling by FNAB cannot guarantee stromal invasion.

Aside from providing a diagnosis, FNAB continues to play a role in assessing the presence or absence of metastatic tumor in sentinel lymph node biopsies and in assessing the surgical margins of lumpectomy samples. In addition, the role of FNAB samples in providing the Masood cytology index as a morphologic risk factor in early breast cancer detection and prevention research has already been established.^23-25 Considering the above-stated reasons, breast cytology will remain an integral component of diagnostic cytopathology. This underscores the significance of providing sufficient training for our pathology residents and fellows so they can contribute to the effective use of breast cytology in clinical practice and breast cancer research.

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Dr. Masood is professor and chair, Department of Pathology and Laboratory Medicine, University of Florida College of Medicine–Jacksonville; medical director, UF Health Jacksonville Breast Center; and chief of Pathology and Laboratory Medicine, UF Health Jacksonville. She is a member of the CAP Cytopathology Committee.