| Abstract|| |
Context: Core-needle biopsy (CNB) is a minimally invasive screening and diagnostic tool which provides intact tissue fragments for histopathological examination.
Aims: This study was conducted to review the current practices of handling and reporting CNBs performed for core-needle biopsies from four organ systems which are frequently encountered in our institution. These include breast, prostate, soft tissues, and lymph nodes. Settings and Design: This was a retrospective study conducted at a tertiary care hospital. Materials and Methods: CNB reports of breast, prostate, soft tissue, and lymph nodes were accessed and categorized based on the site of biopsy, number, and average length of the cores. The CNB reports were categorized into diagnostic or nondiagnostic. In case of diagnosis of malignancy, reports were recorded as structured or nonstructured reports. Statistical Analysis Used: Fisher's exact test and Chi-square tests were applied to check the significance of the results obtained on comparing the number of cores and size of cores with the outcome of report. Results: Out of 16,300 surgical pathology specimens received, 400 were CNBs comprising breast (n = 211), prostate (n = 108), soft tissue (n = 50), and lymph node (n = 31). Majority of the CNBs had 2–5 cores and the size of the core was ≥0.5 cm, which accounted for most of the reports which were diagnostic. There was a lack of clinical and radiological detail in many of the cases. Out of the malignant cases diagnosed, structured reports were given in 30% of breast, 79.3% of prostate, 41.7% soft tissue, and 60% of lymph node needle biopsies. Conclusions: The audit helped to identify areas of improvement in CNB services.
Keywords: Breast, core needle biopsy, lymph node, prostate, soft tissue, survey
|How to cite this article:|
Garg P, Pathak P, Goyal R, Arora VK, Singh N. Current practice in handling and reporting needle biopsies: A hospital-based survey. Indian J Pathol Microbiol 2018;61:197-200
|How to cite this URL:|
Garg P, Pathak P, Goyal R, Arora VK, Singh N. Current practice in handling and reporting needle biopsies: A hospital-based survey. Indian J Pathol Microbiol [serial online] 2018 [cited 2020 Jun 6];61:197-200. Available from: http://www.ijpmonline.org/text.asp?2018/61/2/197/230569
| Introduction|| |
Core needle biopsy (CNB) is a minimally invasive, cost-effective screening, and diagnostic tool where a core of tissue is obtained for histopathological examination. The diagnostic yield of CNB depends on multiple factors such as operator skills, number and size of cores sampled, and extent of sampling. Relevant clinical and radiological details, skill of the pathologist, and use of synoptic reporting (SR) also influence the diagnostic rate., Usefulness of CNB in early detection of breast and prostatic malignancies is well established.,,,,,,,, In palpable breast lesions, CNB can reliably differentiate between an in situ versus an invasive lesion and is a preferred technique for hormone receptor analysis by immunohistochemistry., Transrectal ultrasound-guided systematic biopsy method has been accepted as the “gold” standard technique for prostate biopsies. The number and length of cores are determining factors for the accuracy of prostatic malignancy detection. For soft-tissue lesions, evaluation of the preoperative biopsy helps to guide operative planning as well as consideration for neoadjuvant chemotherapy/radiotherapy.,,, In pathology of the lymph nodes, excisional biopsy is the preferred method; however, CNB is now advocated as the first-line investigation by some studies.,,, In our current clinical setup, CNBs for surgical disorders from four organ systems – breast, prostate, soft tissue, and lymph nodes are commonly performed. This survey was conducted to review the current practices of handling and reporting CNBs performed for these sites.
| Materials and Methods|| |
This was an audit of CNB done between October 2012 and April 2014. Clearance was obtained from the Ethical Committee. Core needle biopsies of breast, prostate, soft tissues, and lymph nodes were accessed, and the details regarding the site of biopsy, number, and average length of the cores were collected from the requisition forms. All the CNBs, irrespective of site, were recorded as either <0.5 cm or >0.5 cm in length, and the number of cores was documented as 1, 2–5, and >5 cores as measured on gross examination. The reports were categorized into diagnostic or nondiagnostic. In case of diagnosis of malignancy, reports were recorded as structured or nonstructured. The percentage of diagnostic and nondiagnostic reports and structured and nonstructured reports was calculated. The proportions of diagnostic and nondiagnostic reports in biopsies with relation to varying sizes and number of cores were calculated using Fisher's exact test and Chi-square test. Data are represented as numbers and percentages.
| Results|| |
During the audit period, 16,300 surgical pathology specimens were received, of which 400 were needle biopsies comprising breast (n = 211, 53%), prostate (n = 108, 27%), soft tissue (n = 50, 12.5%), and lymph node (n = 31, 7.5%). Eighty percent (319/400) of the CNBs were from breast and prostate. Majority of the needle biopsy cores submitted for histopathological examination from the four sites had 2–5 cores [Table 1]. Furthermore, the size of the core was ≥0.5 cm in most of the submitted CNBs [Table 2]. Clinical details were not documented by the submitting clinician in the requisition forms in breast (n = 52/211, 24.6%), prostate (n = 23/108, 21.3%), soft tissue (n = 20/50, 40%), and lymph node (n = 11/31, 35.5%).
|Table 1: Distribution of cases according to number of cores submitted and its correlation with outcome of the report|
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|Table 2: Distribution of cases according to size of the cores submitted and its correlation with outcome of the report|
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Relevant radiological details were not documented in breast (n = 173/211, 82%), prostate (n = 85/108, 78.7%), soft tissue (n = 33/50, 66%), and lymph node (n = 27/31, 87.1%). After processing and microscopic examination of the tissue, diagnostic reports were given in 182/211 (86.2%) of breast, 88/108 (81.5%) of prostate, 34/50 (68%) of soft tissue, and 15/31 (48.4%) of lymph CNBs. Proportion of diagnostic reports in relation to number and size of cores are shown in [Table 1] and [Table 2], respectively. There was a positive correlation of the number and of the cores with the outcome of the report in breast with P = 0.001. Malignancy was diagnosed in 143/211 (67.8%) of breast, 29/108 (26.8%) of prostate, 24/50 (48%) of soft tissue, and 15/31 (48.4%) of lymph node CNBs. Out of the malignant cases diagnosed, structured reports were given in 30% of breast, 79.3% of prostate, 41.7% of soft tissue, and 60% of lymph node needle biopsies.
| Discussion|| |
CNB serves as an interface between an invasive excisional biopsy and fine-needle aspiration cytology, by providing intact tissue fragments while being minimally invasive. As a diagnostic and screening tool, role of CNB in breast and prostate is well established.,,,,,,,, This explains the larger proportion of needle biopsies from these organs in our study. In case of soft-tissue tumors, CNB is performed for deep-seated and large lesions, while an excisional biopsy is the preferred approach for superficial and small-sized lesions; hence, the number of CNBs do not account for the total number of soft-tissue lesions which come to our laboratory. Role of CNB in lymph node pathology is controversial as the World Health Organization system for lymphoma classification relies on histologic findings from excisional biopsies.
Breast CNBs have a high reported adequacy rate, and the number and size of the cores have shown to improve their diagnostic rates., In our study, increased number of submitted cores from breast tissue and larger core size was associated with the larger proportion of diagnostic cases while, majority of the cases with a non-diagnostic report had only one core submitted and/or had core length of <0.5 cm, emphasizing the importance of adequate number and length of cores in CNBs.
The importance of number and length of CNBs is most well studied in prostate cancer.,,, A 10–12 core extended sampling protocol increases cancer detection, while the number of cores in proportion with the volume of prostate has also shown to have similar efficacy.,, The proportion of needle biopsies with ≥6 cores is less in our study (16%) reiterating that a uniform sampling protocol has to be followed for prostatic CNBs. Another important morphometric parameter of prostate is needle core length, which is an alternative way to inspect more tissue. As the length of prostatic cores varied significantly in our study and were largely <10 mm long, they were divided into two groups with 5 mm as the division. The proportion of diagnostic reports was higher with prostatic biopsy length of >0.5 mm (85.7%), favoring the view that needle core length is an important parameter influencing the rate of cancer detection.
In soft-tissue lesions, accuracy of CNBs varies from 68% to 100%,,, and can differentiate soft-tissue sarcomas from benign soft-tissue tumors with high accuracy. However, accuracy of diagnosis depends on sampling of tumor and thus number and size of cores are important. In our study, no significant difference was seen in diagnostic rate with respect to number and size of cores which might be misleading owing to the small sample.
In lymph node pathology, excisional biopsy has been the standard method of tissue sampling, providing ample tissue for assessment, but it is less preferred due to invasive nature of the procedure and greater patient morbidity. With careful use of tissue coupled with advances in immunohistochemical and molecular investigative techniques, core biopsy has been advocated as possible alternative to traditional fine-needle aspiration and excisional biopsy.,,, In our study, only 48% of lymph node CNBs were diagnostic, which is much lower than previously reported., The sample size of lymph node CNBs in our study may be a limiting factor; however, it does appear to be an area for directing our attention for improvement.
Clinical data and radiological information play a very important role in the interpretation of a needle biopsy specimen. Triple diagnosis of breast lesions is based on clinical presentation, radiologic examination, and type of surgery performed. Similarly, in prostatic CNBs, information regarding prostate-specific antigen, the clinical context, and the type of specimen should be provided in the request form. This along with information about prior biopsies or resections, or prior treatment, helps in the interpretation of the microscopic findings within the appropriate clinical context.,,,,, In the present study, majority of CNBs had no relevant details mentioned in the requisition form. This tends to increase the turn-around time of reporting as additional time is required for getting the clinical history. This is also important in lesions of soft tissue where site and depth of the lesion are the two most important factors which are essential for making a diagnosis. In lymph node enlargements, site, presence of organomegaly, and relevant hematological are important factors in making a diagnosis.,, Lack of communication between the clinicians and a pathologist still persists in our current system and needs to be addressed.
The communication from the part of a pathologist is also important, and thus the use of SR is being increasingly advocated since narrative reporting can cause misinterpretation due to lack of information and structure.,,,,,, In our study, highest use of a structured report was seen with prostatic malignancies. While reporting protocols are also available for breast, soft-tissue tumors, and lymphoma, these are not frequently utilized in our setup. To increase the overall completeness of pathology reports, these issues have to be addressed.
| Conclusions|| |
The current practices of obtaining and reporting of CNBs in our institute are not in accordance with the prescribed international guidelines. If appropriate measures are taken, there may be an improvement in the outcome of core needle biopsies, especially in those obtained from soft tissues and lymph nodes. Use of structured reports may improve the clarity of communication between the pathologists and clinicians.
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Conflicts of interest
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[Table 1], [Table 2]