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Fnac for csso 2012 myles smith

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CSSO presentation 2012, Utility of FNAC in a symptomatic breast population

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Fnac for csso 2012 myles smith

  1. 1. Myles Smith, Cynthia Heffron, Barbara Loftus, Michael Jeffers, Jane Rothwell, James Geraghty Departments of Surgery and Histopathology, AMNCH, Dublin, Ireland
  2. 2.  There is controversy surrounding the optimal tissue biopsy methodology in the diagnosis of symptomatic breast cancer and the identification of benign disease  Kocjan et al concluded that the use of core biopsy (CB) has increased for various reasons  However, it has been suggested that fine needle aspiration cytology (FNAC) should be used in the diagnosis of symptomatic, and benign lesions
  3. 3.  Advantages: ◦ Highly accurate in experienced hand ◦ Cost effective ◦ May be used for small lesions not amenable to CB ◦ Complementary to core biopsy practice ◦ Complete sensitivity 93% CB vs 82% FNAC...but for FNAC+CB 98% ◦ Benign disease: early discharge and reassurance
  4. 4.  Potential disadvantages: ◦ ER and PR receptor status ◦ Tumour grade ◦ LVI  Jayaram G et al Acta Cytol 2005  Future potential: ◦ FNAC + gene expression technology: ◦ Improve diagnostic accuracy and classification ◦ ?obviate the need for CB  Uzan C et al Cancer Cytopathol 2009  Raza M et a; Bioinformation 2006
  5. 5.  Younger ◦ 27% triaged as low risk were, <35 ◦ No increase in cancer diagnosis 10:1 17:1 Benign:malignant ratio Patient referrals to Cancer Centres (HIQA) 2006 2009
  6. 6.  Media priority  Screening centres GP General Surgeon, +/-SI in Breast Breast Cancer Specialist GP General Surgeon Breast Specialist Patient
  7. 7.  “One-stop” triple assessment Rapid Assessment Breast Clinic (RABC) potentially allows: ◦ Reduction in time to diagnosis and treatment of breast cancer ◦ Immediate reassurance and discharge of those with benign disease ◦ Developed also as a response to high volumes….
  8. 8.  We aimed to assess the utility of fine needle aspiration cytology (FNAC) in the context of a “one-stop” symptomatic breast triple assessment clinic (RABC)  We specifically wished to assess: ◦ The diagnostic accuracy of FNAC in breast cancer ◦ Identify the proportion of patients who were diagnosed with benign disease and hence discharged
  9. 9.  We analysed prospective data collected at our RABC, over a 4 year period ◦ 2004-2007 (inclusive)  RABC commenced in 2002  We chose the years 2004-2007 to avoid any variability in data ◦ Learning curve  Clinical system  Computerisation
  10. 10. •FNAC only Palpable Lump<35 •Mammogram •FNAC Palpable Lump>35 Results <4 hours Benign Malignant Discordant/ Inadequate/ Atypical FNAC  FNAC findings were classified in accordance with the British National Co-ordinating Committee for Breast Cancer Screening
  11. 11. Concordant Benign (C2) High Risk: FRAC Genetic risk/profiling (10%) Fibroadenoma >3cm excised (Phyllodes) Malignant (C4/C5) Surgery as appropriate Low Risk: Reassured and discharged LABC Neoadjuvant Rx 1° Endocrine
  12. 12. DiagnosisAssessmentStainingFixationSampling Pathologist Air dried MGG Definitive Staining Inadequate: Repeat FNAC ETOH Papanicolau Residual Saline/Hank‟s Adequate
  13. 13.  C5: Malignant ◦ High nuclear to cytoplasmic ratio  Variable shape  C4: Suspicious for malignancy  Atypical cells with a high nuclear to cytoplasmic ratio and moderate pleomorphism  benign groups and bipolar bare nuclei in the background  C3: Atypical ◦ Mild anisonucleosis and nuclear crowding may represent hyperplastic change  differential includes an atypical ductal or low grade in situ lesion  C2: Benign ◦ Benign group of ductal epithelial cells  C1: Inadequate ◦ Low cellularity specimen with blood and fragments of adipose tissue  At least 6 epithelial cell groups are required for C2 classification
  14. 14. Clinical Examination Mammography Pathology E1 Normal R1 Normal C1 Inadequate for analysis E2 Nodularity R2 Probably Benign C2 Benign E3 Benign R3 Indeterminate C3 Atypia probably benign E4 Suspicious R4 Probably Malignant C4 Atypia probably malignant E5 Malignant R5 Malignant C5 Malignant Key Extra, a module of Order Communications (Healthcare Management Systems, Tennessee, USA)
  15. 15.  RABC throughput ◦ 2004-2007 inclusive  Total Attendances=4487  Mean 22.4 new/week 1572 (35%) 2916 (65%) FNAC no FNAC
  16. 16. Positive Predictive Values % PPV (C5) 100 PPV (C4) 95.6 PPV (C3) 18.6  Positive predictive value of (C5) diagnosis: ◦ The number of correctly identified cancers expressed as a percentage of the total number of cancers after core biopsy or histology post resection False negative/positive and inadequate % False negative rate (excludes C1) 3.85 False positive rate 0.00 Inadequate rate 17.31 Inadequate rate from cancers 2.99 The figures are calculated as per the NHSBP guidelines 1/1572
  17. 17. Sensitivity and Specificity % Absolute Sensitivity 80.77 Complete Sensitivity 94.02 Specificity (full) 77.36 The figures are calculated as per the NHSBP guidelines  Absolute sensitivity:  The number of carcinomas diagnosed (C5) expressed as a percentage of the total number of carcinomas sampled  Complete sensitivity:  The number of carcinomas that were not falsely negative or inadequate on FNAC expressed as a percentage of the total number of carcinomas  Specificity (full):  The number of correctly identified benign lesions (the number of C2 results minus the number of false negatives) expressed as a percentage of the total number of benign lesions aspirated
  18. 18. Invasive 98% DCIS 1% Total benign 0% No further histology 1% Final Histology  Total number C5:  192  12.2% total FNAC  Comment:  No False Positives  1 DCIS diagnosed post mastectomy  2 Primary endocrine  Hence no further histology IDC 73 ILC 11 Other 5
  19. 19.  Total number C4: ◦ 24  1.5% Total FNAC  Comment: ◦ DCIS 4 ◦ Phyllodes 2  1 False positive ◦ Discordant; clinical nodularity and normal mammogram ◦ CBx2, then excision ◦ Dx: Duct ectasia, apocrine metaplasia Invasive 79% DCIS 17% Total benign 4% No further histology 0% Final Histology IDC 10 ILC 6 Pap 1
  20. 20. Invasive 1% DCIS 0% Total benign 12% No further histology 87% Final Histology  Total C2:  1041  66.2% Total FNAC  Comment  Discordant triple assessment 137  Invasive 9 (6.6% of disc TA)  IDC 6  ILC 2  Metaplastic 1  Benign 128 (93.4%)  Fibrocystic 84  Fibroadenoma 35  Other 9
  21. 21. Invasive 19% DCIS 0% Total benign 74% No further histology 7% Final Histology  Total C3:  43  2.7% Total FNAC  Comment  3 re-examined and reclassified as C2  40 USS and core biopsy  Invasive 6  IDC 4  ILC 2  Benign 34
  22. 22. C1, Inadequate Invasive 2% DCIS 0% Total benign 37% No further histology 61% Final Histology  Total C1:  272  17.3% Total FNAC  Outcome: • USS 165 • No further histology • Reassured and discharged/FRAC • Lipoma • USS+Core biopsy 100 • (if lesion visualised) • Invasive 7 (2.6% of total ) • IDC 4 • ILC 2 • Primary osteogenic sarcoma 1
  23. 23. 5.8 (85%) 1 FNAC Benign Malignant 18.3 (95%) 1 RABC Attendance Benign Malignant
  24. 24.  FNAC had a high diagnostic accuracy ◦ Prospectively acquired cohort of 4487, with 1572 FNAC  Symptomatic disease triple assessment RABC  We found the complete sensitivity of FNAC to be 94% ◦ PPV of 100% for a C5 ◦ PPV of 95.65% for a C4  The specificity was 77% - correct identification of benign disease
  25. 25. False negative rateFalse positive rate  Small: ◦ 3.85%  Negligible: ◦ Only one case being classified as suspicious (C4) with a discordant triple assessment and final diagnosis of benign disease, ◦ 5 cases of C4/C5 being DCIS
  26. 26.  Small proportion of indeterminate (C3) cases (n=43, 2.7%), which had a poor PPV for cancer (18.6%) ◦ The majority of these were ultimately diagnosed with benign disease (75%) ◦ Much lower than reported in the literature 18.6 vs 55%  Bulgaresi P et al Breast Cancer Res Treat 2006  There were 165 cases with an insufficient (C1) report who had no further histology ◦ Ultrasound did not reveal a suspicious target ◦ Lipomas were historically inappropriately referred for FNAC
  27. 27.  The majority (80%) of patients were immediately and definitively diagnosed: ◦ Benign disease: 66%  Reassured ◦ Malignant disease: 13.75%  Therapeutic surgery  Excluding those who required further diagnostic tests ◦ Core biopsy ◦ Discordant triple assessment
  28. 28.  We found FNAC to be highly accurate in diagnosing breast cancer in this population, with the benefit of rapid diagnosis and discharge of those with benign disease  We found the complete sensitivity of FNAC to be 94% ◦ PPV of 100% for a C5 ◦ PPV of 95.65% for a C4  Benign disease was accurately identified, with the specificity being 77%
  29. 29.  On the basis of our results, we believe that FNAC remains an important diagnostic modality especially in the „„one stop‟‟ triple assessment of symptomatic breast patients  It may be particularly suited to settings in which high volumes of benign disease are seen, where same day diagnosis reassures the patient and obviates the need for a second visit
  30. 30.  AMNCH ◦ Mrs. Terry Hannan ◦ Mr. Eddie O‟Connor  University of Toronto ◦ Dr. Mark Corrigan
  31. 31. FNAC Classification C5 C4 C3 C2 C1 Total Histology Malignant 190 23 8 9 7 232 Invasive 189 19 8 9 7 229 Non-invasive 1 4 0 0 0 5 Total benign 0 1 32 128 100 261 No Histology 2 0 3 904 165 1079 Total FNAC results 192 (12.2%) 24 (1.5%) 43 (2.7%) 1041 (66.2%) 272 (17.3%) 1572
  32. 32. The Health Information and Quality Authority HIQA The role of the Authority: - Setting standards - quality and safety, data and information - Monitoring compliance with standards - Investigating serious concerns about the health and welfare of service users - Registration and inspection of residential homes for children and older people - Advising on the collection and sharing of information - Evaluating the clinical and cost effectiveness of health technologies and provide advice to the Minister and HSE The role of the Authority: “is to promote safety and quality in the provision of health, and personal social services for the benefit of the health and welfare of the public” (Section 7 of the Health Act 2007).
  33. 33.  Relatively pure symptomatic population  Prospective, real-time capture of robust data in our rapid breast clinic  Performance of FNAC in our clinic by 2 pathologists with a special interest in FNAC  Standardised, audited and quality assured data  Data management
  34. 34.  Indications: ◦ FNAC report of:  “inadequate” (C1)  “atypia probably benign” (C3)  “suspicious” (C4) ◦ Discordant triple assessment ◦ Locally advanced  ER/PR/HER2 ◦ Elderly/Infirm  primary endocrine therapy  Technique: ◦ USS: Toshiba Aplio 80 ◦ 1% lignocaine/lidocaine ◦ 14 gauge core biopsy with an automated disposable Bard Max Core
  35. 35.  Weekly multidisciplinary meeting ◦ Tumour Board  Standardised reporting  Data manager to ensure integrity of data and database  Audit and quality assurance ◦ Yearly  British National Health Service Breast Screening standards  Irish HIQA (Health Information and Quality Authority) standards

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