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No useful role for fine needle aspiration as a marker for familial breast cancer
The Breast (2000) 9, 218–219 © 2000 Harcourt Publishers Ltd doi:10.1054/brst.1999.0157, available online at http://www.idealibrary.com on
SHORT REPORT
No useful role for fine needle aspiration as a marker for familial breast cancer H. El Teraifi,2 D. G. R. Evans,1 Z. Mohammad2 and A. Howell3 1 Department of Medical Genetics; 2Department of Cytology; 3Department of Medical Oncology, Christie Hospital, Manchester, UK S U M M A R Y. A study of a single fine needle aspiration taken from the upper outer quadrant of 228 asymptomatic women attending a family history clinic has been performed. No abnormalities were detected. This is not a useful screening tool in asymptomatic women at risk of breast cancer. © 2000 Harcourt Publishers Ltd
228 asymptomatic women out of 757 gave informed consent. FNA was performed with a 1.5 inch, 21 gauge needle and a 10 ml syringe attached to a Cameco syringe pistol. Sampling of each breast 1 cm superolateral to the areolar complex with multiple passes under constant negative pressure (to ensure a good sample) was performed. The aspirated material was then smeared onto a slide and stained with Papanicolaou stain. The slide was examined under a microscope for signs of PBD or other breast abnormalities. Samples from 30 high-risk women were re-read by an independent pathologist.
INTRODUCTION It has previously been reported that fine needle aspiration (FNA) of four quadrants of both breasts is useful in detecting occult proliferative breast disease (PBD) in women at increased genetic risk of breast cancer.1 This, if repeatable, could make a useful approach alongside screening mammography in premenopausal women at high genetic risk. Previous studies have also shown that PBD in the presence of a family history is associated with an up to 9-fold increase in risk of malignant disease over 10 years2 and may predict genetic status.3 Women identified with proliferative lesions in the context of a strong family history may consider prophylactic mastectomy in view of the recent 90% reduction in breast cancer risk reported from the Mayo clinic.4 In view of the invasiveness of a four quadrant approach we have undertaken a study to assess the value of one quadrant FNA per breast in a breast cancer family history clinic.
RESULTS Women were divided into high-risk (> 25% lifetime of breast cancer), moderate risk (16–25%) and low risk (< 16%) groups according to the Claus tables.5 Ages ranged from 24–65 years with the majority, 126 aged 36–49 and a further 67 aged < 36 years. There were 93 high-risk women, 106 at moderate risk and 29 at low risk. All women had normal breast examinations and mammograms at the time of their FNA. No evidence of PBD was found on 451 samples, or on review in 60 high risk samples. However, five women (3 high risk, 2 moderate) halted testing after one sample due to discomfort and many further women have subsequently commented that they would not want the procedure repeating as a screening test. Two high-risk women have subsequently developed invasive breast cancer. A BRCA2 mutation carrier developed bilateral Grade II ductal carcinoma in the lower quadrants 72 months after FNA. A further woman had invasive lobular with widespread LCIS in the upper quadrant 28 months after a normal FNA. Another
PATIENTS AND METHODS All women attending the Nightingale Centre Family History Clinic in South Manchester, UK over an 20 month period (January 1992–August 1993) were aksed (with local ethical approval) if they would consent to an FNA of the upper outer quadrant of both breasts. Women are referred on the basis of an apparently significant family history by their breast surgeons or GPs. Over that time period some Address correspondence to: D. G. R. Evans, Department of Medical Genetics, Christie Hospital, Manchester M20 9BX, UK
218
No useful role for FNA as a marker for familial breast cancer 219 two high-risk women developed DCIS 71 months and atypical lobular hyperplasia 38 months (upper outer quadrant) after normal FNA. Five women including two BRCA1 mutation carriers have had prophylactic mastectomies with normal pathology. Thus 4/93 high-risk women developed significant breast pathology within 6 years of assessment.
screening FNA in the context of a family history of lobular carcinoma, this did not pick up our high-risk women including three who developed pathology in the appropriate quadrant. We do not consider FNA as a screening tool in an asymptomatic high/moderate risk population.
Acknowledgement DISCUSSION While FNA is, in general, a well tolerated procedure we are doubtful that women would tolerate four quadrant FNA on each screening visit, even in a high-risk group. The absence of any PBD in this large sample does not suggest that this will be a useful adjunct to breast examination and mammography in the high or moderate risk groups. As PBD and DCIS is not a feature of BRCA1 related breast pathology6 there is even less indication to perform FNA as a screening test in the context of a breast/ovarian family history. Nonetheless, the presence of incidental findings of PBD on breast biopsy should still alert the clinician to a high level of risk which could be associated with genes yet to be discovered (e.g. BRCA3).6 We have recently undertaken prophylactic bilateral mastectomies on four women with mammographically detected LCIS who had at least three affected relatives with breast cancer and two of these had an occult invasive lobular carcinoma in the contralateral breast. While it could be interpreted that there was a role for
We are grateful to Ms Jean Edney for help in collating the patient statistics and Dr Ian Ellis for reviewing FNA samples.
References 1. Marshall C J, Schumann G B, Ward J H, Riding J M, CannonAlbright L, Skolnick M. Cytological identification of clinically occult proliferative breast disease in women with a family history of breast cancer. Am J Clin Pathol 1991; 95: 157–165. 2. Page D L, Dupont W D. Anatomic markers of human premalignancy and risk of breast cancer. Cancer 1990; 66: 1326–1335. 3. Skolnick M H, Cannon-Albright L A, Goldgar D E et al. Inheritance of proliferative breast disease in breast cancer kindreds. Science 1990; 250: 1715–1720. 4. Hartmann L C, Schaid D J, Woods J E et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 1999; 340: 77–84. 5. Claus E B, Risch N, Thompson W D. Autosomal dominant inheritance of early onset breast cancer: implications for risk prediction. Cancer 1994; 24: 412–419. 6. Breast Cancer Linkage Consortium. Pathology of familial breast cancer: differences between breast cancers in carriers of BRCA1 and BRCA2 mutations and sporadic cases. Lancet 1997; 349: 1505–1510.
SHORT REPORT
No useful role for fine needle aspiration as a marker for familial breast cancer H. El Teraifi,2 D. G. R. Evans,1 Z. Mohammad2 and A. Howell3 1 Department of Medical Genetics; 2Department of Cytology; 3Department of Medical Oncology, Christie Hospital, Manchester, UK S U M M A R Y. A study of a single fine needle aspiration taken from the upper outer quadrant of 228 asymptomatic women attending a family history clinic has been performed. No abnormalities were detected. This is not a useful screening tool in asymptomatic women at risk of breast cancer. © 2000 Harcourt Publishers Ltd
228 asymptomatic women out of 757 gave informed consent. FNA was performed with a 1.5 inch, 21 gauge needle and a 10 ml syringe attached to a Cameco syringe pistol. Sampling of each breast 1 cm superolateral to the areolar complex with multiple passes under constant negative pressure (to ensure a good sample) was performed. The aspirated material was then smeared onto a slide and stained with Papanicolaou stain. The slide was examined under a microscope for signs of PBD or other breast abnormalities. Samples from 30 high-risk women were re-read by an independent pathologist.
INTRODUCTION It has previously been reported that fine needle aspiration (FNA) of four quadrants of both breasts is useful in detecting occult proliferative breast disease (PBD) in women at increased genetic risk of breast cancer.1 This, if repeatable, could make a useful approach alongside screening mammography in premenopausal women at high genetic risk. Previous studies have also shown that PBD in the presence of a family history is associated with an up to 9-fold increase in risk of malignant disease over 10 years2 and may predict genetic status.3 Women identified with proliferative lesions in the context of a strong family history may consider prophylactic mastectomy in view of the recent 90% reduction in breast cancer risk reported from the Mayo clinic.4 In view of the invasiveness of a four quadrant approach we have undertaken a study to assess the value of one quadrant FNA per breast in a breast cancer family history clinic.
RESULTS Women were divided into high-risk (> 25% lifetime of breast cancer), moderate risk (16–25%) and low risk (< 16%) groups according to the Claus tables.5 Ages ranged from 24–65 years with the majority, 126 aged 36–49 and a further 67 aged < 36 years. There were 93 high-risk women, 106 at moderate risk and 29 at low risk. All women had normal breast examinations and mammograms at the time of their FNA. No evidence of PBD was found on 451 samples, or on review in 60 high risk samples. However, five women (3 high risk, 2 moderate) halted testing after one sample due to discomfort and many further women have subsequently commented that they would not want the procedure repeating as a screening test. Two high-risk women have subsequently developed invasive breast cancer. A BRCA2 mutation carrier developed bilateral Grade II ductal carcinoma in the lower quadrants 72 months after FNA. A further woman had invasive lobular with widespread LCIS in the upper quadrant 28 months after a normal FNA. Another
PATIENTS AND METHODS All women attending the Nightingale Centre Family History Clinic in South Manchester, UK over an 20 month period (January 1992–August 1993) were aksed (with local ethical approval) if they would consent to an FNA of the upper outer quadrant of both breasts. Women are referred on the basis of an apparently significant family history by their breast surgeons or GPs. Over that time period some Address correspondence to: D. G. R. Evans, Department of Medical Genetics, Christie Hospital, Manchester M20 9BX, UK
218
No useful role for FNA as a marker for familial breast cancer 219 two high-risk women developed DCIS 71 months and atypical lobular hyperplasia 38 months (upper outer quadrant) after normal FNA. Five women including two BRCA1 mutation carriers have had prophylactic mastectomies with normal pathology. Thus 4/93 high-risk women developed significant breast pathology within 6 years of assessment.
screening FNA in the context of a family history of lobular carcinoma, this did not pick up our high-risk women including three who developed pathology in the appropriate quadrant. We do not consider FNA as a screening tool in an asymptomatic high/moderate risk population.
Acknowledgement DISCUSSION While FNA is, in general, a well tolerated procedure we are doubtful that women would tolerate four quadrant FNA on each screening visit, even in a high-risk group. The absence of any PBD in this large sample does not suggest that this will be a useful adjunct to breast examination and mammography in the high or moderate risk groups. As PBD and DCIS is not a feature of BRCA1 related breast pathology6 there is even less indication to perform FNA as a screening test in the context of a breast/ovarian family history. Nonetheless, the presence of incidental findings of PBD on breast biopsy should still alert the clinician to a high level of risk which could be associated with genes yet to be discovered (e.g. BRCA3).6 We have recently undertaken prophylactic bilateral mastectomies on four women with mammographically detected LCIS who had at least three affected relatives with breast cancer and two of these had an occult invasive lobular carcinoma in the contralateral breast. While it could be interpreted that there was a role for
We are grateful to Ms Jean Edney for help in collating the patient statistics and Dr Ian Ellis for reviewing FNA samples.
References 1. Marshall C J, Schumann G B, Ward J H, Riding J M, CannonAlbright L, Skolnick M. Cytological identification of clinically occult proliferative breast disease in women with a family history of breast cancer. Am J Clin Pathol 1991; 95: 157–165. 2. Page D L, Dupont W D. Anatomic markers of human premalignancy and risk of breast cancer. Cancer 1990; 66: 1326–1335. 3. Skolnick M H, Cannon-Albright L A, Goldgar D E et al. Inheritance of proliferative breast disease in breast cancer kindreds. Science 1990; 250: 1715–1720. 4. Hartmann L C, Schaid D J, Woods J E et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 1999; 340: 77–84. 5. Claus E B, Risch N, Thompson W D. Autosomal dominant inheritance of early onset breast cancer: implications for risk prediction. Cancer 1994; 24: 412–419. 6. Breast Cancer Linkage Consortium. Pathology of familial breast cancer: differences between breast cancers in carriers of BRCA1 and BRCA2 mutations and sporadic cases. Lancet 1997; 349: 1505–1510.