成人高血压的评估与治疗(澳大利亚)

BACKGROUND

For decades, small samples of tissue have been obtained using a needle to diagnose lesions in many anatomical locations.2 Breast lesions were identified as particularly suitable for the technique due to their accessibility.2 The use of smears obtained by aspiration for diagnostic purposes was reported as early as 1933, when Stewart’s series of 2,500 specimens included almost 500 breastlesions.3 The publication of cytology results for a series of 2,111 fine needle aspiration (FNA) samples by Franzen and Zajicek in 1968 established the technique as a vital part of the assessment of breast lesions.4

FNA cytology and core biopsy were originally used to diagnose palpable breast lesions. Both methods have a high degree of sensitivity and specificity. FNA cytology is an excellent method for diagnosing palpable lesions; its sensitivity has been reported to be between 89% and 98%5 and its specificity between 98% and 100%.6

Following the introduction of mammographic screening, FNA cytology and core biopsy are now also used to diagnose impalpable breast lesions.The sensitivity and specificity of stereotactic FNA cytology with impalpable lesions have been reported to be 77–100% and 91–100% respectively.6 The use of core biopsy has increased, especially in the evaluation of lesions that are associated with high inadequacy rates with FNA cytology – such as mammographically detected lesions that are very small, suspected radial scars or microcalcifications.6 Both the sensitivity and specificity of core biopsy for the diagnosis of impalpable lesions are usually reported to be at least 90%.2 In a multidisciplinary breast setting it has been shown that ultrasound-guided core biopsy has a sensitivity of 82% and a specificity and a positive predictive value (PPV) for malignancy of 100%.7 In general, core biopsy has been shown to be superior for the confirmation of benign lesions, as the rate of samples reported as unsatisfactory is less than for FNA cytology (12.5% versus 34.2%).5

Unlike studies about FNA cytology where the procedure has been used in large series of palpable and image-detected lesions, most studies about core biopsy include selected cases. Rosen (1999)8 reports that core biopsy is accurate for thediagnosis of most breast lesions, but fails to identify 6–12% of mammographically detected microcalcifications and under-diagnoses ductal carcinoma in situ (DCIS). Rosen also states that most follow-up studies of the results of core biopsies are inadequate at present.7

In the United Kingdom, 62% of cancers detected in 1996–1997 in the National Health Service Breast Screening Programme were diagnosed preoperatively by FNA cytology or core biopsy.9 Even though this is still short of the National Health Service Breast Screening Programme target of 70%, Britton and McCann (1999)9 argue that it represents an improvement over previous years, and an improvement that is likely to continue as a result of improved technological expertise by the radiographers, radiologists and pathologists involved.

When the UK National Health Service Breast Screening Programme was established, FNA cytology was the method of choice in the assessment of imagedetected lesions. However, in recent years there has been an increase in the use of core biopsies to facilitate a preoperative diagnosis.9 There are two principal explanations for this trend. One is the increased rate of inadequate specimens in impalpable lesions, sampled by FNA cytology.The other is the lack of expertise among pathologists in the interpretation of fine needle aspirates.The first explanation may be due to lack of technical skill or the nature of the lesion.The experience and skill of the operators and pathologists and the nature of the lesion will affect the choice of biopsy technique.

FNA cytology and core biopsy are complementary procedures.6,10 Pinder and associates (1996)10 and Masood (1996)6 have stated there is insufficient evidence to decide if one method is better than another.These authors recommend the use of the appropriate combination of FNA cytology and/or core biopsy as the best approach for the diagnosis of breast lesionsat different settings.6,10

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