Breast FNA

The Case for Breast Fine Needle Aspiration

The increased use of core needle biopsy (CNB) for breast lesions has led to a decrease in the use of fine needle aspiration (FNA) cytology for palpable breast lesions and those detected on mammogram.  However, as a cytopathologist with years of FNA experience, I see a definite place for FNA for the diagnosis of breast lesions.

Let me explain what I mean.

Breast lesions are detected by few different modalities. One is by mammogram. The US Preventive Services Task Force (USPSTF – try saying that three times fast!) recommends screening mammography for all women starting at age 50 every two years. Many lesions are detected in this manner. Women with dense breast tissue are recommended to have a breast ultrasound in addition to screening mammogram. Lesions can also be detected in this way. The third way is by Clinical Breast Exam (CBE – the exam done by a woman’s physician) and Breast Self Exam (BSE – the exam done by the woman herself).  All of these modalities are useful and helpful in detecting breast lesions, and, if a lesion is small and localized, it is more treatable and thus the potential for survival is much greater.

Core needle biopsy is a type of sample where multiple “cores” of tissue are removed from the lesion using ultrasound of stereotactic guidance and a large bore needle. Usually cores are about 1 inch long and 1/8 inch in diameter.  Core biopsy specimens can be taken in the radiology suite, but need to be sent out to a laboratory to be processed and made into slides for the pathologist to look at under the microscope, which can take two or three days after the sample is taken from the patient. Special studies, including immunohistochemical markers or Fluorescence In-Situ Hybridization (FISH) can be performed on the sampled tissue if it turns out to be malignant. The results of these studies have an impact on the treatment of the patient.

Fine Needle Aspiration (FNA) specimens are those specimens that are taken using a thin needle (“fine” needle), much smaller than a core needle biopsy. FNAs are cytology specimens, not tissue specimens, and are processed differently than tissue. Cytology specimens may be processed on-site, at the same time the specimen was taken, and may be evaluated by a pathologist specially trained in cytopathology.  It is a minimally invasive procedure, which costs less for the patient than a core needle biopsy or an open biopsy (surgery). The complications from an FNA are rare – minimal bleeding and in some cases a bruise may result where the needle is placed.

The question to be answered in everybody’s mind is always “cancer? or no cancer?”

FNA specimens can be evaluated on-site by a cytopathologist to help answer this question. If the answer is “cancer” or “suspicious for cancer”, a core needle biopsy can be the next step, so that further testing can be done.  The patient’s physician or oncologist can be notified immediately, and pre-treatment planning may be started even before the tissue biopsy is processed. If the answer is benign, or “no cancer”, then no further action is taken. The patient is relieved from the anxiety of waiting for biopsy results, in less time than it takes for a tissue specimen to be processed.

The take home point here is that regardless of the diagnosis of the breast lesion, cancer or no cancer, there is place for FNA. The immediate assessment of an FNA by a cytopathologist can help speed up the treatment in the cases of cancer and to help relieve patient anxiety in the cases of a benign diagnosis. It is a case where a very small needle can have a very big impact on a patient.