Pathologists like a bit on the slide

• needle core biopsy
• fine needle aspiration cytology
• breast lesions

I read with interest the article on the role and histological classification of needle core biopsy (NCB) in conjunction with fine needle aspiration cytology (FNAC) in the preoperative assessment of impalpable breast lesions by Ibrahim et al.¹ The authors state that FNAC had an inadequacy rate of 58.7%, a complete sensitivity of 34.5%, and a specificity of 47.6%.

These findings are at variance with the published literature. My own research on FNAC of impalpable breast lesions demonstrated non-diagnostic (no epithelial cells) in 14% of samples. When this was combined with imaging (ultrasound), all of the non-diagnostic cases were resolved, with 70% showing no change on follow up, 17% producing benign histology, and 13% yielding a malignant outcome.² The inadequacy rate, sensitivity, and positive predictive value for the symptomatic lesions were 4%, 95.2%, and 100%, respectively.³

In a further study, I compared FNAC cytology with NCB at several anatomical sites, including the breast. NCB was only marginally better, occasionally offering additional information. This slight advantage resulted from the availability of tissue from the first and often the only pass for assessment of architecture and performance of ancillary tests.⁴

The main reasons for abandonment of FNAC in favour of NCB in the preoperative management of patients with breast lesions are failure of the aspirator to produce diagnostic material and unfamiliarity of the interpreter with the subtleties of breast FNAC.

I believe by taking an active role with on site assessment of the FNAC material and discussion with radiological colleagues, the cytopathologist could offer an FNAC service comparable to surgical pathology in sensitivity and very similar to frozen section in specificity.²

FNAC is cost effective, with consistent results in experienced hands; sensitive, with relatively few false negative results; and highly specific.³