Like other initially competing methods, fine-needle
aspiration and core needle biopsy have achieved not only individual but
also combined utility in the diagnosis of mass lesions. Fine-needle aspiration,
or FNA, is quick, safe, accurate, and inexpensive, and outcomes compare
well with the results of tissue biopsy when the FNA is performed and interpreted
by skilled individuals.1-5 However,
with fewer skilled individuals performing and interpreting the FNAs and
making themselves available for on-site adequacy assessment, the use of
core needle biopsy, or CNB, has increased, for not only deep-seated nonpalpable
lesions but also for palpable masses in the breast, thyroid, lymph nodes,
and soft tissue. This shift was welcomed (and in some cases encouraged)
by many pathologists, whose training in anatomic pathology and daily work
consists mainly of surgical pathology, which brings in considerably more
revenue than comparable time spent on cytopathologic activities.
CNB procedures are usually performed by radiologists,
who are also trained to perform FNAs but who will generally provide the
specimen type that the pathologists prefer, and in recent times that specimen
is often a CNB. The Catch-22 in this, so to speak, or the unanticipated
outcome, is that radiologists are not simply dropping the cores into formalin
and sending them to the pathology laboratory for processing and interpretation
the next day. As with the FNA, radiologists also want an adequacy assessment
on the CNB. Like the FNA, CNBs are time-consuming procedures (for the
radiologist, not the pathologist) that, even for palpable lesions, are
usually performed with image guidance. The CNB is also expensive and time-consuming
for patients and is uncomfortable as well. Also like the FNA, CNBs, even
with image guidance, can "miss" the lesion. Radiologists, therefore, want
to ensure that the CNB is adequate and that any specimen triage needed
(for example, for microbiologic culture or flow cytometry) is accomplished
during the single procedure. Adequacy assessment of a CNB is, therefore,
reasonable, and pathologists, despite their grumblings, are generally
complying with this new responsibility.
Unfortunately for some pathologists, assessing the
adequacy of a CNB is more challenging than assessing the adequacy of an
FNA sample. Problems are related to the nature of cell transfer from the
CNB to the glass slide, which is accomplished by (gently) making multiple
touches of the core to the slide or (gently) rolling the core over the
slide. Compared with an FNA specimen, these procedures typically transfer
significantly fewer cells and can cause cellular distortion and promote
air-drying, which challenge adequacy assessment and specimen triage. Furthermore,
the physical manipulation of the tissue core and the delay in placing
the small core into fixative sometimes lead to tissue disruption and poor
preservation that can cause difficulty in histologic interpretation.
No doubt, a well-sampled CNB specimen usually has greater
diagnostic accuracy and provides more tissue for ancillary testing compared
with the typical FNA sample,1,2,6,7
but the manipulations required to assess the adequacy of the CNB can compromise
the interpretive outcome significantly, yielding equivocal diagnoses.
After a period of struggle at my own institution, our pathologists and
radiologists collectively found a solution to this dilemma. When the pathologist
is called upon to assist a radiologist in the minimally invasive retrieval
of tissue for diagnosis, an FNA is done initially for adequacy assessment,
followed by CNB, only if (based on adequacy assessment) additional tissue
is needed. We find this to be an efficient and cost-effective approach
that also parallels a recent shift in the literature from the almost exclusive
advocation of CNB over FNA to a renewed recognition of the benefits of
FNA, including the value of FNA compared to, and combined or in tandem
with, CNB.1,3-5,7,8-18 Thus, should
you encounter problems regarding the utility of FNA versus CNB, a discussion
among pathologists and radiologists about the advantages of doing both
may be helpful. A reasonable alternative, if it is possible, is to limit
adequacy evaluations of CNBs and FNAs to pathologists in the group who
- Quinn SF, Nelson HA, Demlow TA. Thyroid biopsies:
fine-needle aspiration biopsy versus spring-activated core biopsy needle
in 102 patients. J
Vasc Interv Radiol. 1994;5:619-623.
- Ballo MS, Sneige N. Can core needle biopsy replace
fine-needle aspiration cytology in the diagnosis of palpable breast
carcinoma: A comparative study of 124 women. Cancer.
- Greif J, Marmur Y, Schwarz A, et al. Percutaneous
core cutting needle biopsy compared with fine-needle aspiration in the
diagnosis of peripheral lung malignant lesions. Cancer
- Stewart CJR, Coldewey J, Stewart IS. Comparison
of fine-needle aspiration cytology and needle core biopsy in the diagnosis
of radiologically detected abdominal lesions. J
Clin Pathol. 2002;55:93-97.
- Berner A, Davidson B, Sigstad E, et al. Fine-needle
aspiration cytology vs. core biopsy in the diagnosis of breast lesions.
Diagn Cytopathol. 2003;29:344-348.
- Yang YJ, Damron TA. Comparison of needle core biopsy
and fine-needle aspiration for diagnostic accuracy in musculoskeletal
Pathol Lab Med. 2004;128:759-764.
- Renshaw AA, Pinnar N. Comparison of thyroid fine-needle
aspiration and core needle biopsy. Am
J Clin Pathol.
- Malmstrom H. Fine-needle aspiration cytology versus
core biopsies in the evaluation of recurrent gynecologic malignancies.
- Staroselsky AN, Schwarz Y, Man A, et al. Additional
information from percutaneous cutting needle biopsy following fine-needle
aspiration in the diagnosis of chest lesions. Chest.
- Yamagami T, Iida S, Kato T, et al. Combining fine-needle
aspiration and core biopsy under CT fluoroscopy guidance: A better way
to treat patients with lung nodules? AJR.
- Chiu S, Chan LK. US-guided biopsy of breast lesions:
FNA vs. core biopsy. Biomed
Imaging Interv J. 2005;1:e6-4.
- Yun G, Sneige N, Ming G, et al. Transthoracic fine-needle
aspiration vs concurrent core needle biopsy in diagnosis of intrathoracic
lesions: A retrospective comparison of diagnostic accuracy. Am
J Clin Pathol. 2006;125:438-444.
- Singh HK, Volmar KE, Elsheikh TM, et al. The diagnostic
utility of fine-needle aspiration biopsy of soft-tissue sarcomas in
the core needle biopsy era. Pathology
Case Reviews. 2007;12:36-43.
- Silverman JF, Elsheikh TM, Singh HK. The role of
fine needle aspiration cytology of the breast in the core biopsy era.
Pathology Case Reviews. 2007;12:44-48.
- Elsheikh TM, Singh HK, Silverman JF. Fine-needle
aspiration cytology versus core needle biopsy in the evaluation of thyroid
and salivary gland lesions. Pathology
Case Reviews. 2007;12:3-9.
- Volmar KE, Singh HK, Gong JZ. The advantages and
limitations of the role of core needle and fine-needle aspiration biopsy
of lymph nodes in the modern era.
Pathology Case Reviews. 2007;12:10-26.
- Volmar KE, Singh HK, Gong JZ. Fine-needle aspiration
biopsy of lymph nodes in the modern era: reactive lymphadenopathies.
Case Reviews. 2007; 12:27-35.
- Diacon AH, Theron J, Schubert P, et al. Ultrasound-assisted
transthoracic biopsy: fine-needle aspiration or cutting-needle biopsy?
Dr. Cobb, a member of
the CAP Cytopathology Committee, is assistant director of cytopathology
and director of cytopathology fellowship, Department of Pathology, Loma
Linda (Calif.) University Medical Center.