The use of FNA in the diagnosis of breast and other body lesions is accepted world wide as an
effective and a relatively inexpensive tool.
In a curious fashion that is reminiscent of the mythical Sisyphius or the most mundane "Ground-Hog
Day", FNA has to return to the drawing board to prove its value. The reason for such a repetitive
rebirth is old and mostly the consequence of a lack of understanding of the principles of FNA.
Aspiration biopsy cytology is a clinical-pathological procedure that is best practiced when either the
pathologist plays the primary role in obtaining the specimen or at least when the communication between
the operator and interpreter is optimal. The three main stumbling blocks in the continuously changing
image of FNA is based on the following:
- Cytologists are uncomfortable interpreting samples in which the clinical criteria of diagnostic cytology (nuclear size, shape and texture) are only part of the morphological analysis and patterns of cell distribution of FNA biopsy smears requires familiarity with surgical pathology criteria.
- Surgical pathologists also feel uncomfortable interpreting FNA biopsies because the criteria for diagnosis are a hybrid of cytological and surgical pathology, are distinct and require to be learned anew.
- Amateurish performance of FNA by unprofessionally trained operators discourage both the interpreter and the person obtaining the specimen.
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The solution for the above problems is not abandonment but proper education and understanding the
structure needed for optimal use of FNA.
In ours and others' experience, FNA is best utilized when the pathologist performs the procedure, or
at least is on hand for an immediate evaluation and interpretation of the sample.
What is routine in radiology suites or CAT scan and ultrasound should be for all FNA related
procedures, both palpable and nonpalpable.
The Cytodiagnostic and Breast Care Center at Englewood Hospital and Medical
Center
In 1991 a multiple specialty center was opened at Englewood Hospital and Medical Center. The Center's
structure is managed according to the following chart:
The Cytodiagnosis and Breast Care Center
The medical director is a pathologist. Associated directors for Imaging, Pathology, Surgery and High
Risk are in charge of the main components of the Center, and include a radiologist, a surgeon and another
pathologist.
Within this structure, FNA of palpable breast lesions are performed by pathologists, are immediately
evaluated cytologically and correlated with the clinical and radiological findings. If no diagnostic
material is obtained or there is a discrepancy that may be due to inaccessibility of the localized
lesion, the aspiration is repeated under ultrasound guidance (but that is only 1% of the time). If the
lesion appears sclerotic and non-diagnostic cells are obtained, core biopsies are then performed by the
pathologist (less than 1% of the time).
Nonpalpable lesions are biopsied by the radiologist. Almost all nonpalpable lesions in which a mass
is identified are done under ultrasound guidance; most stereotactic biopsies are done for
microcalcifications without a mass.
The radiologist works with a technician from the pathology part of the Center. A pathologist does an
immediate evaluation of the ultrasound guided FNA. If a definite diagnosis is made, the procedure is
finished. If not, core biopsies are done (less than 1% of the time).
Because the cases selected for stereotactic biopsies are stratified for lesions with
microcalcifications and not masses, core biopsies are usually the initial procedure of choice.
MRI guided biopsies are only performed in cases in which lesions are seen only under MRI and the
procedure is similar to the ultrasound guided biopsies. An FNA with immediate evaluation is performed.
If the aspiration is not diagnostic, core biopsies are done.
