Unsuccessful preoperative biopsies, fine needle aspiration cytology or core needle biopsy, lead to increased costs in the diagnostic workup in breast cancer

Figures & data

Table I.  Characteristics of the 580 breast lesions with fine needle aspiration cytology (FNAC) or core needle biopsy (CNB).

	FNAC (n = 339)	CNB (n = 241)	p-value
Clinical feature
median patient age	59 y.	58 y.
symptomatic	60% (203)	56% (137)	0.0528
palpable	70% (237)	69% (166)	0.8549
median size on imaging	15 mm	20 mm
size < 10mm	22%	12%	0.005
range of size on imaging	3–80 mm	5–60 mm
Finding in mammogram
mass	72% (245)	70% (169)	0.5774
mass + microcalcification	5% (17)	14% (34)	0.0002
architectural distortion	6% (20)	8% (20)	0.31
microcalcification	3% (9)	4% (9)	0.47
invisible	9% (29)	2% (6)	0.0023
Finding in ultrasound (US)
only US taken	6% (19)	1% (3)	0.007
benign on US	9% (32)	8% (20)	0.6614
intermediate on US	12% (39)	8% (20)	0.2647
malignant on US	78% (266)	83% (200)	0.2034
invisible on US	0.6% (2)	0.4% (1)	1
suspicious lymph nodes	7% (24)	4% (10)	0.15
Postoperative diagnosis
benign	15% (50)	11% (27)	0.2637
DCIS	2% (8)	4% (9)	0.4545
IDC	57% (194)	51% (124)	0.1763
ILC	17% (59)	27% (65)	0.0074
other invasive cancers	8% (28)	7% (16)	0.5265

Abbreviations: DCIS = ductal carcinoma in situ, IDC = invasive ductal carcinoma, ILC = invasive lobular carcinoma.

Table II.  Prices at Helsinki University Central Hospital.

ITEM	€
Radiology
US-guided CNB	136
US-guided FNAC	95
Pathology
histology of CNB	40
cytology of FNAC	55
histology of surgical biopsy specimen	100
histology of sentinel node	365
Surgery
inpatient care per day	300
outpatient visit	75
surgical biopsy under local anaesthesia	680
surgical biopsy under general anaesthesia	1120
sentinel node biopsy	1520

Abbreviations: MG = mammogram, US = ultrasound, CNB = core needle biopsy, FNAC = fine needle aspiration cytology.

Table III.  The preoperative rate of definitely malignant diagnosis of fine needle aspiration cytology (FNAC) or core needle biopsy (CNB) in diagnosis of 503 malignant breast lesions.

	FNAC (n= 289)	CNB (n = 214)	p-value	Difference % (95 %CL)
Palpability
palpable	74% (157/213)	97 (145/149)	0.0001	24% (16.8–30.1)
non-palpable	50% (38/76)	94 (61/65)	0.0001	44% (29.9–55.4)
Size in imaging
< 10 mm	45% (24/53)	93 (26/28)	0.0001	48% (27.2–61.2)
> 10 mm	73% (171/236)	97 (180/186)	0.0001	24% (17.9–30.6)
Ultrasound
no finding	50% (1/2)	0 (0/1)	1
benign	33% (3/9)	50 (2/4)	1
indeterminate	47% (9/19)	73 (8/11)	0.2595	25% (10.6–52)
suspicious	70% (182/259)	99 (202/204)	0.0001	29% (22.9–34.6)
Mammogram
no finding	54% (15/28)	100 (4/4)	0.12	46% (5.4–64.2)
microcalcification	57% ( 4/7)	86 (6/7)	0.55	29% (17.3–62.7)
architectural distorsion	50% (8/16)	100 (20/20)	0.0004	50% (22.7–72)
mass	72% (159/222)	96 (146/152)	0.0001	24% (17.4–31)
mass + microcalcification	56% (9/16)	97 (30/31)	0.0012	41% (16.1–63.7)
Histology
DCIS	25% (2/8)	78 (7/9)	0.0567	53% (5.7–76.7)
IDC	74% (143/194)	98 (121/124)	0.0001	24% (16.6–30.7)
ILC	64% (38/59)	97 (63/65)	0.0001	33% (19.2–45.5)
other invasive cancers	43% (12/28)	94 (15/16)	0.001	51% (22.4–68)

Abbreviations: DCIS = ductal carcinoma in situ, IDC = invasive ductal carcinoma, ILC = invasive lobular carcinoma.

Table IV.  Outcomes of US-guided fine needle aspiration cytology (FNAC) (n = 177) and US-guided core needle biopsy (CNB) (n = 119) in the 296 lesions with malignant postoperative histology which appearing as spiculated masses on mammography and suspicious for malignancy on ultrasound.

Biopsy/Lesion size in imaging	FNAC 0	FNAC 1	FNAC 2	FNAC 3	FNAC 4	FNAC 5
FNAC < 10 mm (n = 25)	1 (4%)	0 (0%)	0 (0%)	4 (16%)	5 (20%)	15 (60%)
FNAC ≥ 10 mm (n = 152)	1 (1%)	3 (2%)	4 (3%)	9 (6%)	18 (12%)	117 (77%)
	CNB benign	CNB malignant
CNB < 10mm (n = 20)	1 (5%)	19 (95%)
CNB ≥ 10mm (n = 99)	1 (1%)	98 (99%)

Figure 1.  Diagnostic work-up in the 339 breast lesions with fine needle aspiration cytology (FNAC) as the initial biopsy. Abbreviations: CNB = core needle biopsy, SB = surgical biopsy, CS = cancer surgery, CA = invasive cancer, DCIS = ductal carcinoma in situ.

Figure 2.  Diagnostic work-up in the 241 breast lesions with core needle biopsy (CNB) as the initial biopsy. Abbreviations as in Figure 1.

Table V.  Time interval in days between first biopsy and definite surgical treatment for 490 women with in situ or invasive breast cancers with fine needle aspiration cytology (FNAC) or core needle biopsy (CNB).

Biopsy	median days	mean days	time interval
FNAC all (n = 283)	32	35	6–101
5 (n = 193)	31	32	6–101
0–4 (n = 90)	39	42	10–90
without add biopsies (n = 208)	31	31	6–101
with add. needle biopsy (n = 69)	42	44	13–90
with surgical biopsy (n = 6)	63	62	27–85
with add. needle and surgical biopsy (n = 4)	67	64	39–85
CNB all (n = 207)	31	32	6–77
cancer (n = 200)*	31	31	6–64
insufficient/benign/indeterminate (n = 7)	41	43	13–77
without add. biopsies (n = 202)	31	31	6–64
with add. needle biopsy (n = 1)	13	13	13
with surgical biopsy (n = 4)*	51	50	35–65

*includes one lymphoma.