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• Corroborating evidence for atypical breast aspirates
  Julie Weigner, Ibrahim Zardawi
  Published on: 20 November 2017

• Published on: 20 November 2017

  Corroborating evidence for atypical breast aspirates

  • Julie Weigner, Hospital Scientist - Cytology Pathology North, Hunter, NSW, Australia
  • Other Contributors:
    • Ibrahim Zardawi, Anatomical Pathologist

  Dear Editor
  RE: Atypical aspirates of the breast: a dilemma in current cytology practice. Shuang-Ni Yu, Joshua Li, Sio-In Wong, Julia Y S Tsang, Yun-Bi Ni, Jie Chen, Gary M Tse. J Clin Pathol 2017;0:1–9. doi:10.1136/jclinpath-2016-204138
  We read with interest the findings of Shuang-Ni Yu et al regarding “Atypical aspirates of the breast: a dilemma in current cytology practice” first published on May 29 2017 in Journal of Clinical Pathology.
  Breast fine needle aspiration (FNA) utilisation has been in decline for some time and there are several reasons for the drop in the uptake of cytology in the investigation of breast diseases. Although the main sited reason is increased demand for ancillary tests, greater subjectivity of cytology when compared to histology which is generally regarded as the gold standard, and the unpreparedness of pathologists to provide unequivocal diagnoses not only in the borderline lesions but also in low grade malignancies. The need to provide a consistently high quality service to engender confidence in our speciality has never been greater.
  The probabilistic approach to reporting FNA based on the 5 tier categories (C1 unsatisfactory; C2 benign; C3 atypical/indeterminate; C4 suspicious; and C5 malignant) does provide reliable accurate diagnoses for all categories except C1 unsatisfactory and C3 atypical/indeterminate categories. The C1 category highlights a failed FNA procedure whilst a C3 result indicates some diagnostic un...

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  Dear Editor
  RE: Atypical aspirates of the breast: a dilemma in current cytology practice. Shuang-Ni Yu, Joshua Li, Sio-In Wong, Julia Y S Tsang, Yun-Bi Ni, Jie Chen, Gary M Tse. J Clin Pathol 2017;0:1–9. doi:10.1136/jclinpath-2016-204138
  We read with interest the findings of Shuang-Ni Yu et al regarding “Atypical aspirates of the breast: a dilemma in current cytology practice” first published on May 29 2017 in Journal of Clinical Pathology.
  Breast fine needle aspiration (FNA) utilisation has been in decline for some time and there are several reasons for the drop in the uptake of cytology in the investigation of breast diseases. Although the main sited reason is increased demand for ancillary tests, greater subjectivity of cytology when compared to histology which is generally regarded as the gold standard, and the unpreparedness of pathologists to provide unequivocal diagnoses not only in the borderline lesions but also in low grade malignancies. The need to provide a consistently high quality service to engender confidence in our speciality has never been greater.
  The probabilistic approach to reporting FNA based on the 5 tier categories (C1 unsatisfactory; C2 benign; C3 atypical/indeterminate; C4 suspicious; and C5 malignant) does provide reliable accurate diagnoses for all categories except C1 unsatisfactory and C3 atypical/indeterminate categories. The C1 category highlights a failed FNA procedure whilst a C3 result indicates some diagnostic uncertainty. This uncertainty is reflected in the heterogeneous mix of pathological outcomes found within C3 aspirates, ranging from benign to malignant lesions.
  Yu et al study has identified potentially helpful quantitative, cytomorphological and background features to predict the risk of malignancy within the C3 category. These findings may translate to changed clinical management decisions.
  They confirm our work and their study supports our previously published results 1-3. In our earlier study we used a comprehensive range of morphological criteria and eliminated those that did not reach statistical significance in predicting either a malignant or a benign proliferative outcome within C3. We created an algorithm to predict the probability of malignancy based on 180 consecutive C3 cases using five significant criteria (cystic background; cohesiveness; presence of myoepithelial cells or bare bipolar nuclei; papillary fragments; and tubules). This algorithm was then applied to a subsequent 182 consecutive C3 cases and the accuracy of the model was evaluated with logistic regression and receiver operating characteristic (ROC) curves. By applying this algorithm based upon the presence or absence of our key criteria we were able to stratify the risk of malignancy within C3. An upper cut-point was established, above which a case with a high probability of malignancy could be upgraded to C4.
  Our work and the current study by Yu et al support and cross validates the challenges presented by the C3 category. The similarity in the approach of both studies provides well-defined criteria with strong discriminating values and reveals the complex nature of C3. Indeed, this platform of evidence based knowledge may contribute to the review of the structured breast FNA reporting guidelines proposed by the International Academy of Cytology.
  The decline in FNA use is not evidence based but rather due to lack of expertise and confidence. With robust, objective studies delving into the grey areas of FNAs, coupled with a renewed well-defined structured reporting system, FNA of the breast may see a resurgence of popularity. FNA is a less invasive procedure when compared to core biopsy, is cost effective, amenable to rapid onsite evaluation including triaging for ancillary tests and has a quick turnaround time which benefits patients and their treating clinicians.

  Julie Weigner & Ibrahim Zardawi

  1. Weigner. J, Zardawi. I, Braye. S. The True Nature of Atypical Breast Cytology. Acta cytologica. 2013;57(5):464-472.
  2. Weigner. J, Zardawi. I, Braye. S, McElduff. P. The Microscopic Complexities of C3 in Breast Cytology. Acta cytologica. 2014;58(4):335-346.
  3. Weigner J., Zardawi I., Braye S., McElduff P. The Conundrum of Papillary Breast Lesions within the C3 Category. Acta cytologica. 2015;59(4):289-297.

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  Conflict of Interest:
  None declared.

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