Comparison between Fine Needle Aspiration Cytology (FNAC) and Core
Needle Biopsy (CNB) in The Diagnosis of Breast Lesions
*Rahman MZ,1 Das NC,2 Siddiqui SR,3 Sultana N,4 Hossain I,5Jahan I 6
[Journal of Histopathology and Cytopathology, 2019 Jan; 3 (1):38-44]
Keywords: Breast, lump, diagnosis, fine needle aspiration cytology, core needle biopsy, histopathology
- *Professor Mohammad Zillur Rahman, Professor of Pathology, Chattogram Medical College, Chattogram. firstname.lastname@example.org
- Narayan Chandra Das, Consultant Pathologist, Chattogram Port Hospital, Chattogram.
- Syeda Rumman Aktar Siddiqui, Assistant Professor of Biochemistry, Cumilla Medical College, Cumilla.
- Nasrin Sultana Assistant Professor of Pathology, Chattogram International Medical College, Chattogram.
- Ismail Hossain Lecturer, Department of Pathology, Chattogram Medical College, Chattogram.
- Ishrat Jahan, Consultant Pathologist. Power Development Board (PDB), Chattogram.
A lump in the breast whether benign or malignant results anxiety for the patient and her family and the surgeon. Histological tissue diagnosis is a universally accepted means of definitive diagnosis.1 FNAC has become widely accepted tool for diagnosis of breast lesions as it is safe and simple method with high diagnostic accuracy. The main aim of FNAC is to separate malignant lesions that require more radical therapy from benign ones that may be conservatively managed.2
It has been shown that FNAC has reduced the number of open biopsies because of its high diagnostic sensitivity and specificity.3 However, FNAC reports still have lack important information about the histopathological type, grade, receptors, and intrinsic behavior of the tumor. All of this information is of great importance for correct preoperative evaluation by both surgeon and oncologist.4
The tru-cut biopsy of palpable breast lesions based on histological study of tissue
specimens can provide all the reliable information to guide the surgeon and the oncologist for ideal modern therapeutic strategy in surgical decision making. It permits the eventual use of new adjuvant therapy.4
There is controversy in literature about the role of FNAC and tru-cut biopsy in assessment of breast lesions. Some studies favor FNAC over tru-cut as less expensive, faster and more sensitive. Others criticize the use of FNAC as the only diagnostic test. Some authors recommended combining the two techniques.5
The purpose of the present study was to determine the value of fine needle aspiration cytology in the diagnosis of breast lumps and to compare the result of FNAC with tru-cut biopsy diagnosis to assess its accuracy.
The study was a one-year retrospective study done in care lab, Chittagong Bangladesh from 1/1/2016 to 20/12/2016. Fifty eight female patients, irrespective of their age, presented with breast lumps diagnosed clinically were included in this study.
FNAC was performed with 22 gauge needle that was attached to a 10 cc syringe.
The palpable lesion was immobilized and the needle was inserted into the lesion. Multidirectional sampling was done by moving the needle back and forth. Negative pressure was applied during this time and released prior to removing the needle. The sample obtained was ejaculated onto a glass slide and smeared. At least 4 slides were fixed with 95% alcohol. The smears were stained rapidly with Papanicolaou stain
Tru-cut or Core needle biopsies (CNB) were carried out with a 14 gauge needle with a 23 mm throw that is mounted on an automatic spring loaded gun (Magnum). Lignocaine 1% was used as local anesthesia to reduce discomfort. A small skin nick was made with size 12 scalpels and needle introduced through the wound. At least 2 good strips of tissue were taken. The needle was inserted and as soon as the lump was reached, the needle was advanced. Once the inner needle was inside the mass the outer needle was pushed and the whole tru cut was withdrawn. The material inside the stillet was taken and sent for histopathological examination.
58 fine needle aspiration cytology and core biopsy specimens of patients presenting with a suspicious breast lesion were included in this study. The age range of total 58 patients was 15-75 years with mean age of 37.41 years. Out of these 58 patients 34 patients had benign lesions and 24 had malignant tumors. The highest frequency of benign breast lumps were mostly in the age range of 21-30 years and the highest frequency of malignant breast lumps were found in the age group of 31-40 years (Table I). Statistical analysis by Chi-square test was not significant Chi-square (P = 0.121)
Table I: Age distribution of the subjects (n = 58)
|≤ 20 Years||2 (5.7)||0 (0.0)||2 (3.4)|
|21 – 30 Years||13 (38.2)||5 (20.8)||18 (31.0)|
|31 – 40 Years||10(29.4)||10 (41.6)||21 (36.2)|
|41 – 50 Years||6 (18.1)||4 (16.8)||10 (15.7)|
|51 – 60 Years||1 (2.9)||5 (20.8)||6 (10.3)|
|>60 Years||2 (5.7)||0 (0.0)||2 (3.4)|
Chi-square t-test significance: P = 0.121; Not Significant
Right breasts were involved in 31 (53.4%) patients and rest of 27 (46.6%) patients had their lesion in left breast. Left breast involvement was slightly higher than the right (53.4% vs. 46.6%) for benign lesion. But regarding breast carcinoma; right breast lesion is higher than left the right (62.5% vs. 37.5%) (Table II)
Table II: Side distribution of breast lesion (n = 58)
|Malignant (DCC + DCIS)
|Right||16 (47.0)||15 (62.5)||31 (53.4)|
|Left||18 (53.0)||9(37.5)||27 (46.6)|
Chi-square t-test significance: P = 0.145; Not Significant
Table III: Distribution of breast lesions (n = 58)
|Benign||Granuloma||14 (24.1)||14 (24.1)||14 (24.1)|
|Non-diagnostic||8 (13.8)||7 (12.1)||0 (0.0)|
|FCC||5 (8.6)||4 (6.9)||11 (19.1)|
|FA||4 (6.9)||4 (6.9)||4 (6.9)|
|Suspicious Cell||3 (5.2)||3 (5.2)||0 (0.0)|
|FA + FCC||1 (1.7)||1 (1.7)||1 (1.7)|
|Chr. Mastitis||1 (1.7)||1 (1.7)||2 (3.4)|
|Abscess||1 (1.7)||1 (1.7)||1 (1.7)|
|ADH||0 (0.0)||1 (1.7)||2 (3.4)|
|Malignant||DCIS||0 (0.0)||1 (1.7)||1 (1.7)|
|DCC||21 (36.3)||21 (36.3)||23 (38.0)|
In FNAC out of 58 cases, majority of the cases were diagnosed as DCC 21(36.3%). 14 (24.1%) were reported granuloma, 5 cases fibroadenoma, 4 diagnosed as a fibrocystic changes, one case was of fibroadenoma with fibrocystic changes, one chronic mastitis, and one case was breast abscess. No ADH and DCIS were found in FNAC.
In Tru-cut, Out of 58 cases majority of the cases were diagnosed as DCC (36.3%), which is same as FNAC. 14 (24.1%) were reported granuloma which is also same as FNAC. One case was of ADH and one case was DCIS was diagnosed which were confirmed by histopathology
On FNAC 37 (63.7) patients were reported as benign and 21(36.3) patients were labeled to have malignancy. Comparison of fine needle aspiration cytology and final diagnosis made on excision biopsy showed that three cases were erroneously diagnosed as benign on fine needle aspiration cytology whereas it was found to be malignant on excision biopsy (Table IV). Chi-square t-test was done and was highly Significant (P = 0.000).
.Table IV: Association between final diagnosis and FNAC (n = 58)
|Benign||37 (63.7)||34 (100)||3 (12.5)|
|Malignant||21(36.3)||0 (0.0)||21 (87.5)|
Chi-square t-test significance: P = 0.000; Highly Significant
On Tru-cut biopsy, 36 (62.0) patients were called benign and 55 (68.8%) patients were diagnosed to have malignancy. Comparison of Tru-cut biopsy and final diagnosis made on excision biopsy showed that two cases were erroneously diagnosed as benign on Tru-cut whereas it was found to be malignant on excision biopsy (table-.5). Chi-square t-test was done and was highly significant (P = 0.000)
Table V: Association between final diagnosis and Tru-cut (Core Needle) Biopsy (n = 58)
|Benign (36)||36 (62.0)||34 (100)||2 (8.4))|
|Malignant (22)||22(38.0)||0 (0.0)||22 (91.6)|
Chi-square t-test significance: P = 0.000; highly significant
The validity of screening test was calculated by sensitivity, specificity and accuracy. The sensitivity of FNAC was 88.88 %. The specificity of FNAC was 1000% and the accuracy rate was 95.08%. The sensitivity of core biopsy was 92.30%, specificity was 100% and accuracy rate was 96.66% (Table V).
Table V: Validity of FNAC and Tru-cut biopsy in respect to final diagnosis
|Sensitivity||88.88 %||92.30 %|
|Specificity||100 %||100 %|
|Positive Predictive Value (PPV)||100 %||100 %|
|Negative Predictive Value (NPV)||91.89 %||94.44 %|
|Diagnostic Accuracy||95.08 %||96.66 %|
In our study, total 58 patients were included. Age range was 15-75 years. Mean age was 37.41 years (SD = 12.41) which is almost similar to Homesh et al6 (33.77 years).6 Hatada et al7 reported a mean age of 52 years, Yong et al8 reported a mean age of 57 years and mean age of 60 years was reported by Agarwal et al.9 Carcinoma was most commonly diagnosed in the age group of 31-40 years which is similar to Saha et al10 Study by Khemka et al,11 expressed that the peak incidence of breast carcinoma was between 40-44 years
In the 1980s and early 1990s the surgical biopsy of palpable breast lumps was considered the gold standard for the diagnosis of breast lumps. FNAC has been used as a diagnostic modality and is currently used as one of the modalities of assessment for breast lesions. FNAC of the breast is an excellent, safe and cost-effective diagnostic procedure. The cost of FNAC is minimal, equipment is inexpensive and the technique is simple. Breast aspiration can be done anywhere, at the patient bed, at physician office or at clinic. The most significant advantage of FNAC is the high degree of accuracy, rapid results, and a less invasive procedure than a tissue biopsy. FNAC of the breast can reduce the number of open breast biopsies.
FNAC and CNB represent the most widely used methods for pathological diagnosis of breast nodules, both with their specific advantages and limitations. In our experience, comparable results for FNAC and CNB were obtained in terms of sensitivity (88.88% vs 92.30%), specificity (100% vs 100%), diagnostic accuracy (95.08% vs 96.66%) and NPV (91.89 vs 94.44). As for any diagnostic procedure, a higher NPV is important to minimize under-treatment and it was achieved by CNB.
In most cases, CNB has both higher sensitivity and specificity than FNAC in diagnosing benign and malignant lesions. However, as reported by Willems et al,12 the studies which reported high sensitivity (97.1%), specificity (99.1%), PPV (99.3%) and NPV (96.2%) included only definitive benign and malignant lesions.
Studies carried out by Homesh et al6, Usami et al13, to compare CNB & FNAC have reported very high sensitivity (91-99%), specificity (96-100%), positive predictive value (100%), and negative predictive value (100%) for CNB which are better than results for FNAC for both palpable and non-palpable lesions. In our study sensitivity, Diagnostic Accuracy and NPP were higher in case of CNB; specificity and PPP were same for both the procedures.
FNAC and core biopsy are complementary procedures. In this study we found out that fine needle aspiration cytology from predominant number of patients had similar results as compared to core biopsy and then results were comparable to the final diagnosis on excision biopsy
FNAC and CNB provide almost similar values of diagnostic accuracy. So if FNAC gives diagnosis one can go and proceed with surgery. But, if FNAC is negative then plan for CNB.
- Kumar V, Abbas AK, Aster JC. Basic Pathology 10th
- Velu ARK, Srinivasamurthy BC, Rani J. Cytological evaluation of benign breast lesions with histopathological correlation. Indian Journal of Pathology and Oncology, January – March 2016;3(1):7-10.
- Khan A, Jamali R, Jan M, Tasneem M. 2014. Correlation of Fine Needle Aspiration Cytology and Histopathology Diagnosis in the Evaluation of Breast Lumps. International journal of medical student. pp. 40-43.
- Bodur M, Hourani S, Mefleh W, Shabatat A, Karadsheh S, Nawaiseh O, Ebous A. Comparison Between Fine Needle Aspiration Cytology And Tru-cut Biopsy In The Diagnosis of Breast Cancer. Journal of Surgery Pakistan (International),2008; 13(1):19-21.
- Ghorori RMH, Ewais MK. Fine needle aspiration cytology vs core needle biopsy in diagnosis of benign breast lesions. AAMJ, 2004;2(2):127-142.
- Homesh NA, Mohamed A, Hamod A, Sofiani E. The diagnostic accuracy of fine needle aspiration cytology versus core needle biopsy for palpable breast lump(S). Saudi Med J, 2005; 26 (1):42-46.
- Hatada T, Ishii H, Ishii S, Okada K, Fujiwara Y, Yamamura T. Diagnostic value of Ultrasound-Guided Fine-needle Aspiration Biopsy, Core-Needle Biopsy, and evaluation of
combined use in the diagnosis of Breast lesions. J Am Coll Surg 2000; 190:299-303.
- Yong WS, Chia KH, Poh WT, Wong CY. A comparison of Trucut Biopsy with fine needle aspiration cytology in the diagnosis of breast cancer. Singapore Med J 1999; 40: 587-590.
- Agarwal T, Patel B, Rajan P, Cunningham DA, Darzi A, Hadjimina S. Core biopsy versus FNAC for palpable breast cancers. Is image guidance necessary? Eur J Cancer 2003; 39: 52-56.
- Saha A, Mukhopadhyay M, Das C, Sarkar K, Shaha AK, Sarkar DK. FNAC versus Core Needle Biopsy: A Comparative Study in Evaluation of Palpable Breast Lump. Journal of Clinical and Diagnostic Research. 2016;10(2):5-8.
- Khemka A, Chakrabarti A, Shah S, Patel V. Palpable breast lumps; Fine Needle Aspiration Cytology versus histopathology: A Correlation Of Diagnostic Accuracy. The Internet Journal of Surgery. 2009;18:1-13.
- Willems SM, van Deurzen CH, van Diest PJ. Diagnosis of breast lesions: fine-needle aspiration cytology or core needle biopsy? A review. J Clin Pathol. 2012; 65(4):287-92.
- Usami S et al. Pathological aspects of core needle biopsy for non-palpable breast lesions. Breast Cancer. 2005; 12(4):272–78.