Indian Medical Gazette

54

FEBRUARY 2013

Original Study

Breast Fine Needle Aspiration Cytology Reporting :

A Study of Application of Probabilistic Approach
Amrish N. Pandya, Professor & Head, IHBT Department,
Neelam P. Shah, Resident, Pathology Department
Government Medical College, Surat.

Abstract
Background: This study is based on application of
probabilistic approach in reporting of breast fine needle
aspiration cytology, its accuracy and correlation with
likelihood of carcinoma in histology. Material and Method:
Breast cytology was reported according to 1 of 6 categories,
positive, suspicious, atypical, proliferative without atypia,
unremarkable and unsatisfactory. Histologic correlation was
done whenever possible. Results: Out of total 515 cases,
138 were correlated in histology. There were no false
positive cases. The probability of finding carcinoma on
histology, for suspicious and atypical categories was 94.11%
and 75% respectively. All lesions from proliferative without
atypia and unremarkable categories were benign on
histology. Conclusion: The probabilistic approach is
uniform, accurate method and easy to apply in reporting of
breast FNAs. Suspicious and atypical categories were
associated with increased incidence of carcinoma in
histology and therefore such cases should be further
evaluated for histology.

The trend has now been shifting to a less invasive

procedure in its diagnosis. The sensitivity of FNA in
diagnosis of breast lesion is 90-95 %1.
Some cytologic lesions may have features mimicking
to those of low grade or sparsely cellular carcinoma. Many
authorities recognized this limitation of breast cytology and
advised use of categorical or probabilistic approach in
reporting of breast FNA to limit false positive or false
negative results2, 3, 4, 5, 6.
The aim of scheme proposed by Wang and Ducatman
is to categorize a lesion according to likelihood of being a
carcinoma on basis of FNA finding rather than to predict
precise histologic diagnosis3.
In this study we divide3,4 breast FNAC in one out of six
categories- positive, suspicious, atypical, proliferative
without atypia, unremarkable and unsatisfactory; and
correlate it with surgical specimen in aspects to predicting
likelihood of carcinoma.

Keywords

Material and Method

breast carcinoma, fine needle aspiration cytology

(FNAC), probabilistic approach

This study was ethically approved by appropriate

authority. This was a cross sectional study of 482 patients
with palpable breast lump. Out of these 33 patients had
bilateral breast lumps. So, total 515 FNAC cases from 482
patients. Both females and males were included in this study.
Metastasis in breast, cyst, abscess and fat necrosis were
excluded. Out of 515 FNAC cases, 138 were correlated in
histology. Remaining was not correlated in histology

Introduction
A palpable breast lump, whether benign or malignant, is
a cause of anxiety to patient. Therefore accurate pathological
diagnosis is crucial for further treatment and estimation of
an outcome.

Address for correspondence: Dr Neelam P Shah, 4th year Resident Pathologist, Pathology Department, Government Medical College,
Surat 395 001. E-mail : neelampshah84@gmail.com

Indian Medical Gazette

55

FEBRUARY 2013

because they lost to follow-up for further management.

Each patient was subjected to FNAC of breast lump
under aseptic precautions after explaining the procedure
and taking written consent. FNA was performed by using
a 10 ml disposable syringe and 22/23-gauge needle. No
local anesthesia was given during the procedure. FNA
smears were stained with H & E, Pap & MGG stains. Tissue
sections, obtained from mastectomy/lumpectomy
specimens were stained with H and E stains.

c)

One cell population refers to one population of

atypical epithelial cells, as opposed to mix population
of atypical and benign appearing epithelial cells or
atypical epithelial cells and stromal cells.

d)

Hyper cellularity refers to atypical cell population

only, rather than increased cellularity due to another
component such as inflammatory or stromal cells.

2)

Suspicious for carcinoma (see Fig. 2)

When any three of the above features for malignancy
are present, a suspicious diagnosis is given.

In cytology, lesions were divided according to following

criteria3, 4.
1)

Positive for carcinoma (see Fig. 1) - all four of the

following criteria must be met.

Fig. 2

Fig. 1
Smear shows positive cytology having hyper cellular smear,
showing many single, loosely cohesive groups of large,
pleomorphic duct cells with irregular nuclear margin & coarse
chromatin and prominent nucleoli. The histologic diagnosis
was infiltrating ductal carcinoma (Pap stain 1000 x)

a)

Cellular dyshesion refers to presence of abundant

single epithelial cells or loosely cohesive groups of
epithelial cells (this excludes singly bare bipolar cells
and stromal cells).

b)

Cytologic atypia may be variable but should at least

include high nuclear: cytoplasmic ratio and
markedly eccentrically located nuclei. Other useful
feature which may or may not be present depending
on the level of pleomorphism, include nuclear
membrane irregularity, coarse and clumped
chromatin, multiple and irregular nucleoli.

Smear shows suspicious cytology, with scattered single

atypical cells with eccentric nuclei. But lesion lacks hyper
cellularity. The histologic diagnosis was infiltrating ductal
carcinoma (H & E 1000 x)

3)

Epithelial proliferative lesion with atypia (see

Fig. 3)
This diagnosis is made when specimen is cellular
with many epithelial cells and when epithelial cells
present in groups show significant crowding and
overlapping and/or specimen show one other
feature of malignancy (cellular dyshesion, one cell
population, cellular atypia )

4)

Epithelial proliferative lesion without atypia

(see Fig. 4)
This category is used when a specimen is cellular
with many epithelial cells and epithelial cells in group
show no or mild crowding and overlapping with,
obvious myoepithelial cells present. Most
fibroadenoma tends to fall in this category.

Indian Medical Gazette

56

FEBRUARY 2013

Cytologic diagnosis was correlated with surgical

specimen whenever possible. Surgical specimens were
classified into invasive carcinoma, ductal carcinoma in situ
and benign lesion. Probability of carcinoma in histology
for each category was calculated in percentages.
Observations

Fig. 3
Cytology smear shows proliferative breast lesion with atypia.
There is cohesive groups of cells with marked crowding,
overlapping and mild to moderate atypia. The histologic
diagnosis was infiltrating ductal carcinoma. (MGG 400x)

Table 1 shows distribution of 515 cases on aspiration

cytology and histologic follow- up examination in each
category. Table 2 shows correlation of cytologic and
histologic diagnosis of breast FNAC along with probability
of being carcinoma in histology for each category in this
study. There was no false positive diagnosis on cytology.
Approximately 94.11% of cases from suspicious category
had carcinoma. Approximately 75% from atypical category
shows carcinoma. None of the lesions from proliferative
breast disease without atypia or unremarkable category
shows carcinoma.

Fig. 4
Cytology smear shows Proliferative breast lesion without
atypia, cohesive group of cells with myoepithelial cells.
There is no significant atypia or crowding/overlapping. The
histologic diagnosis was fibro adenoma. (MGG 400 x)

5)

Unremarkable
When none of the four features of carcinoma was
present, such lesions were described as
unremarkable.

6)

Non diagnostic/unsatisfactory
If specimen is acellular or extremely hypo cellular
and when it does not yield an explanation of lesion
based on information provided by clinician, it was
reported as unsatisfactory.

Discussion
Breast cancer is the commonest cancer of urban Indian
women and the second commonest in the rural women
next to cervical cancer. Owing to the lack of awareness of
this disease and in absence of a breast cancer screening
program, the majority of breast cancers are diagnosed at a
relatively advanced stage7.

Indian Medical Gazette

FEBRUARY 2013

The rising incidence of breast cancer continues to

concern. There are three main objectives for investigations
in breast carcinoma, to establish correct diagnosis and
staging the disease, to detect breast cancer in very early
stage & to predict the prognosis.
Triple diagnosis is combination of clinical examination,
mammography and FNB. If all three investigations are in
agreement that the lesion is either benign or malignant
diagnostic accuracy is over 99%.Now, the trend has been
shifting to a less invasive procedure in its diagnosis. The
sensitivity of FNAC in diagnosis of breast lesion is 90-95
%. Definitive treatment is often based on cytological
diagnosis without histological confirmation, unless there is
disagreement between cytology and clinical and/or
mammographic assessment1.
Therefore a uniform reporting system with high
reproducibility should be used in reporting breast FNAC.
National Cancer Institute sponsored consensus
conference on breast FNA biopsy in 1996, recommended
the classification of breast FNAs into one out of the following
5 categories; benign, atypical, suspicious, malignant, or
unsatisfactory8.
A proposal for uniform terminology and reporting of
breast fine needle aspirate has provided a practical scheme

57

for classifying breast fine needle aspiration results for

reporting and management3.
The criteria proposed by Wang and Ducatman are
reproducible, reduces subjectivity and offered a good frame
for the implementation of quality control procedure9.
The aim of this scheme is to categorize a lesion according
to likelihood of being a carcinoma on basis of FNA findings.
The positive for carcinoma category has high specificity
and least false positive rate. The suspicious and atypical
categories serve maximum sensitivity and indicate
uncertainty about diagnosis and required further diagnostic
procedure. Proliferative without atypia and unremarkable
categories indicate benign lesion. However if aspirate is
hypo cellular it must be mentioned in report3.
A gray zone in breast cytology has long been
recognized. It is in which an unequivocal diagnosis cannot
be reached with fine needle aspiration cytology findings. It
is due to overlapping features of benign epithelial proliferative
lesion, mostly fibro adenoma, and a well differentiated
carcinoma as well as borderline lesions of breast4, 10. The
gray zone in breast fine needle aspiration cytology is a broad
spectrum that changes from proliferative fibrocystic disease
to sclerosing adenosis to malignancy.
Diagnosing gray zone pathology as atypical in fine needle

58

Indian Medical Gazette

FEBRUARY 2013

aspiration cytology causes no delay in treatment as excision

biopsy is recommended for all equivocal cases10.

management of any of these categories should base on the

result of triple test.

The presence of nuclear pleomorphism, high nuclear:

cytoplasmic ratio, epithelial cell atypia, low number of bipolar
nuclei and necrosis are useful parameters to predict
malignancy in atypical FNAC of breast11.

There is no false positive lesion in this study. All lesions

from positive category are malignant in histology. All lesions
from proliferative without atypia and unremarkable category
are benign in histology. Out of 12 unsatisfactory cases, 5
cases were correlated in histology. Out of 5, one was fibro
adenoma, one was atypical ductal hyperplasia and 3 were
infiltrating ductal carcinoma not otherwise specified. So,
unsatisfactory smears should be evaluated in conjunction
with clinical and imaging appearance.

In this study, 94.11%, 75% lesions are malignant in

histology from cytologic suspicious and atypical lesion
respectively. Percentages of malignancy in histology from
cytological suspicious and atypical lesion in various studies
were shown in Table 3.

Thus, this probabilistic approach in FNAC provides

information about possibility of carcinoma in histology and
also provides standardized guideline for breast aspiration
reporting. This scheme of reporting is also applicable on
male breast lesions2.
There is also interobserver agreement of this scheme
of reporting on a set of breast FNAs prepared on thin prep
slides14.
Summary
Probabilistic approach proposed by Wang and Ducatman
has definite cytologic criteria for each category. It is
associated with likelihood of histologic finding of carcinoma,
also accurate, easy to apply and provides a uniform
approach in reporting of breast aspiration.
References
Percentage of malignancy in atypical category is higher
compared to other studies. This is because only clinically
suspicious lesion in atypical category is evaluated further
by histology and remaining was only followed up.
Thus like other studies this study also showed that it
was essential to
have two less definitive
categories(suspicious and atypical) and there was a definite
difference between them. Possibility of carcinoma on
histology for suspicious category is more than atypical
cytologic category. Therefore it is worthwhile to keep these
two categories separate.
This study, like other studies3, 4, 10, 12, and 13 also suggests
that diagnosis of atypia is clinically significant because it is
associated with increased likelihood of malignancy and such
cases should be evaluated for histology. But, ultimate

1.

Karin Lindholm-Breast. Orell S.R., Sterrett G.F.,

Whitaker D. Fine needle aspiration cytology. 4th
edition. Reed Elsevier India Private Limited, New Delhi:
Chapter7, pg.167; 2005.

2.

MacIntosh R.F., Merrimen J.L., Barnes P.J.

Application of the probabilistic approach to reporting
Breast fine needle aspiration in males. Acta Cytol. 52:
530-534, 2008.

3.

Wang H.H., Ducatman B.S: Fine needle aspiration

of the breast: a probabilistic approach to diagnosis of
carcinoma. Acta Cytol. 42(2): 285-289, 1998.

4.

Ayata G., Abu-Jawdeh G.M., Fraser J.L., Garcia L.W.,

Upton M.P., Wang H.H. Accuracy and consistency
in application of a probabilistic approach to reporting

Indian Medical Gazette

FEBRUARY 2013

59

breast fine needle aspiration. Acta cytol. 47(6): 973978, 2003.

zone in breast fine needle aspiration cytology. How to

report on it? Acta Cytol. 46(3):513-518, 2002.

5.

David L. Page, Joyce E. Johnson, William D. DuPont.

Probabilistic approach to the reporting of fineneedle aspiration cytology of the breast. Cancer
Cytopathology. 81(1): 6-9, 1997.

11. Phuong Viet The Tran, Philip C. W. Lui, Alex M. C.

Yu, Pham The Vinh, Helen H. L. Chau, Tony K. F.
Ma, Puay-Hoon Tan, Gary M. Tse. Atypia in fine
needle aspirates of breast lesions. J Clin Pathol.
63:585-591, 2010.

6.

Logrono R., Kurtycz. D.F., Inhorn S.L Criteria

for reporting fine needle aspiration on palpable and
non palpable masses of the breast. Acta cytol. 41(3):
623-627, 1997.

7.

Agarwal G., Ramakant P. Breast Cancer Care in

India: The Current Scenario and the Challenges for
the Future. Breast Care. 3(1): 21-27, 2008.

8.

[No authors listed]. The uniform approach to breast

fine-needle aspiration biopsy. National Cancer Institute
Fine-Needle Aspiration of Breast Workshop Sub
committees. Diagn Cytopathol. 16 (4): 295-311, 1997.

9.

Francesco Feoli, Marianne Paesmans, Pascal Van

Eeckhout. Fine needle aspiration cytology of breast:
impact of experience on accuracy, using standardized
cytologic criteria. Acta cytol. 52: 145-151, 2008.

10. Ozkara S.K., Ustun M.O., Paksoy N. The gray

12. Chengquan Zhao, Anwar Raza, Sue E. Martin,

Jiangqiu Pan, Timothy S. Greaves, Camilla J. Cobb.
Breast fine-needle aspiration samples reported as
proliferative breast lesion: Clinical utility of the
subcategory proliferative breast lesion with atypia
Cancer Cytopathol. 117(2):137-147, 2009.
13. Jennifer C. Lim, Hytham Al-Masri, Alia Salhadar, H.
Bill Xie, Sheryl Gabram and Eva M. Wojcik. The
significance of the diagnosis of aypia in breast fine
needle aspiratiom. Diagn. Cytopathol. 31(5):285-288,
2004.
14. Bradley Gornstein, Timothy Jacobs, Yvan Bdard,
Charles Biscotti, Barbara Ducatman, Lester Layfield,
Grace McKee, Nour Sneige and Helen Wang.
Interobserver agreement of a probabilistic approach
to reporting breast fine-needle aspirations on Thin
Prep. Diagn Cytopathol. 30:389-395, 2004.