What is the role of fine needle aspiration (FNA) in the workup of breast lesions?

Updated: Aug 09, 2018
  • Author: Hemant Singhal, MD, MBBS, MBA, FRCS, FRCS(Edin), FRCSC; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Although fine-needle aspiration (FNA) is no longer the criterion standard for initial evaluation of all palpable breast masses, it is particularly useful in the evaluation of cystic lesions detected by ultrasonography. [23]

FNA results are reported as benign, suggestive of malignancy, or nondiagnostic. Aspiration of a benign cystic lesion should result in collapse of the cavity. Documentation of complete collapse by follow-up ultrasonography may be helpful in decreasing the incidence of recurrence. Persistence of a palpable mass and recurrence following aspiration are general indications for further workup.

The use of FNA does confer a couple of advantages: it is inexpensive and quick to perform. The results can be made available rapidly, enabling a one-stop diagnostic and results clinic. Excellent results with FNA and triple assessment are reported in the literature. This approach has an accuracy of over 90% for palpable breast lesions when all 3 components are concordant for benign or malignant disease. However, in as many as 40% of cases, the findings are not concordant. [2]

Moreover, FNA is an operator-dependent technique, and the reporting of breast cytologic results is more demanding than histologic analysis. The degree of expertise required is not always available. Findings from cellular samples are limited in that the reviewer may not be able to determine the grade or invasiveness of the tumor. It is also difficult to diagnose lobular carcinoma on the basis of cytologic results [12] ; however, there is evidence to indicate that ultrasound and FNA biopsy are similarly useful for the axillary staging of patients with invasive lobular and invasive ductal carcinoma. [24]

The technique of FNA is determined largely by individual surgeon preference, which may, in part, reflect hand size and strength. It is typically used for identifying the presence of metastatid disease in abnormal lymph nodes. [14]  A 21-gauge (green) needle is used most commonly, although in expert hands, a 23-gauge (blue) needle can yield as much information, with less discomfort and bruising. Some clinicians opt for a hand-held 10-mL syringe, whereas others prefer a 20-mL syringe used with a syringe holder. Syringe holders allow a vacuum to be maintained easily but can make control of the needle tip less precise.

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