Recommendations from the European Breast Cancer Guidelines

Should needle core biopsy vs. fine needle aspiration cytology be used to diagnose breast cancer in women with suspicious breast lesions in mammography?

Recommendation

In individuals with suspicious breast lesions (including mass lesions, asymmetric breast density, calcifications and/or architectural distortions) in mammography, the ECIBC's Guidelines Development Group recommends needle core biopsy over fine needle aspiration cytology to diagnose breast cancer (strong recommendation, moderate certainty in the evidence).

Recommendation strength

  •   Strong recommendation against the intervention
  •   Conditional recommendation against the intervention
  •   Conditional recommendation for either the intervention or the comparison
  •   Conditional recommendation for the intervention
  • Strong recommendation for the intervention

A recommendation can be strong or conditional.

When a recommendation is strong, most women will want to follow it. When a recommendation is conditional, the majority of women want to follow it but may need more discussion with their healthcare professional first.

Subgroup

Initially, the GDG had divided this question in three according to different types of subpopulations (i. mass lesions and/or asymmetric density, ii. architectural distortions and iii. calcifications) but as the literature search did not find studies giving information for the relevant outcomes separately for the two subpopulations, it was merged.

Justification

Overall justification

The GDG agreed that NCB is recommended over FNAC for the following reasons:

 

Detailed justification

Desirable Effects:
The GDG judged that there are large desirable effects of the intervention (NCB) due to the increased number of true positives and true negatives and less false positives and false negatives.

 

Undesirable Effects:
The GDG judged that the undesirable effects of the intervention, including bleeding and pain, are trivial.

 

Balance of effects:
The GDG judged that the balance of effects favours NCB because the desirable health effects considerably outweigh the undesirable ones.

 

Resources required:
The GDG judged that the additional resources required for NCB are negligible in view of its increased effectiveness.

 

Equity:
The GDG judged that the strong recommendation for the use of NCB would result in increased equity within countries that currently do not routinely use NCB in all healthcare centres.

Considerations

Implementation

The GDG noted that FNAC may have utility in other medical conditions or contexts (e.g. FNAC of axilla lymph nodes) and as such reinforces that this recommendation applies only to the population addressed in this question; the GDG did not consider other populations.
 
The GDG noted that there may be resistance to implementation in certain settings where providers are using FNAC over NCB. The concomitant issue is that if we are monitoring the move to NCB you should also monitor other histopathology tests that are implemented in parallel to NCB. nitor other histopathology tests that are implemented in parallel to NCB .

Monitoring and Evaluation

The GDG notes that the Quality Assurance Development Group should be alerted to this recommendation and consider monitoring and evaluation issues for this question. Monitoring the positive predictive value of the intervention may be helpful for quality assurance.

The GDG notes that centres currently performing FNAC instead of NCB (for the population in this question) should be monitored for the implementation of this intervention.


Research Priorities

Research on how to communicate more effectively with women so they can make an informed choice, in this assessment stage of breast cancer, for NCB vs FNAC, based on this recommendation. This is particularly important in settings where FNAC is still used.

Evidence

Download the evidence profile

Assessment

Background

In the assessment of women who have a screening mammography showing suspicious findings, the aim is to minimise the need for surgical removal of non-clinically relevant lesions and, at the same time, to minimise the risk of missing a clinically relevant lesion. The only way to significantly reduce both risks is to perform pre-surgical cytology or histopathology assessment of suspicious lesions. Currently, there are two non-operative methods to obtain samples of a breast lesion: fine needle aspiration cytology involves the removal of cells which does not conserve the architectural structure of the lesion and needle core biopsy which removes tissue from the lesion. Depending on the type of lesion the needle core biopsy may be carried out under ultrasound or stereotactic guidance, utilising needles of varying calibre and vacuum assisted technology where indicated.

Mass lesions and asymmetric densities represent about 30-40% of the suspicious breast lesions that are sampled for cytological/histological assessment in the mammographic screening population and about 70% of the sampled lesions in symptomatic women (Venkatesan 2009). Sampling of these lesions is usually less challenging than that of other radiological findings such as calcifications (microcalcifications in previous BIRADS) because these changes are usually visible on ultrasound.

Architectural distortions comprise about 7% of the lesions undergoing cytological/histological sampling in screening. In this population, sampling may be more challenging than in mass lesions, because the limits of the lesions are not clearly defined and the changes may not be visible on ultrasound.

Calcifications constitute about 30% of the lesions undergoing cytological/histological sampling in screening. Representative sampling tends to be more difficult and more expensive because calcifications are impalpable and are rarely visible on ultrasound. Despite this calcification may be associated with in situ and invasive carcinoma. The overall risk for each diagnosis in a woman with calcifications is approximately 6%.

Fine needle aspiration cytology (FNAC) is a minimally invasive diagnostic method performed with a 20-25 gauge needle. This procedure can provide rapid diagnosis (less than 30 minutes) and reduce biopsy related pain due to the use of a smaller needle size. Factors such as tumour size (small lesions), the type of suspicious mammographic lesion (in particular in case of calcifications) and the use of freehand method without any radiological guidance have been documented to affect the rate of inconclusive results (Perry, 2006). Since the architectural pattern of a lesion is not preserved in FNAC, it is not possible to accurately distinguish in situ from invasive carcinoma. In view of this, FNAC samples are not suitable for assessment of histological tumour type, grade and biomarker profile. It is important to have access to this information pre-operatively to make decisions regarding type of surgery and in the consideration of recommendations regarding neoadjuvant chemotherapy for the treatment of invasive breast cancer.

Needle core biopsy (NCB) involves sampling of the suspicious lesion with a needle ranging in size from 8G to 11G for the vacuum assisted systems and 12G to 18G for other types of needle core biopsy (50). At the time of writing, NCB is considered a standard procedure for the evaluation of most breast lesions. In some countries, FNAC is still used as the first line of sampling due to ease of access and lower cost. The pathological analysis of the tissue sample taken by NCB or vacuum assisted NCB (VANCB) permits evaluation of cellular and architectural features of a lesion. This enables distinction of in situ from invasive carcinoma and determination of prognostic and predictive biological information including histological type, grade and biomarker receptor status. This greatly improves the pre-surgical decision-making and management process. The use of tissue biopsy has been related to mildly increased pain, risk of haematoma due to larger needle size and, on rare occasions, an increased risk of infection compared with FNAC.

Although the role of FNAC is questionable due to rates of inadequacy and limitations in characterising and profiling a tumour as outlined above, it may be useful in the assessment of some types of abnormality. In deciding to utilise FNAC or NCB it is important to consider the clinical and imaging characteristics of the lesion and ability or not to visualise the lesion on ultrasound.

Open biopsy is a surgical procedure that is diagnostic and frequently therapeutic at the same time. It is the most invasive method to obtain a diagnosis and is performed only when it has not been possible to reach a diagnosis using the non-invasive techniques described above.

Some authors have hypothesised that cell or tissue sampling may increase the risk of metastases due to displacement of cancer cells. Although there is a large consensus regarding the benefits of cytological and/or histological assessment prior to surgery, this issue has been addressed in the systematic review with evaluation of any indirect evidence or related research.

Management of Conflicts of Interest (CoI): CoIs for all Guidelines Development Group (GDG) members were assessed and managed by the Joint Research Centre (JRC) following an established procedure in line with European Commission rules. GDG member participation in the development of the recommendations was restricted, according to CoI disclosure. Consequently, for this particular question, the following GDG members were recused from voting: Roberto d'Amico, Jan Danes and Miranda Langendam. Lydia Mouzaka was restricted from voting, as a preventive measure, as the CoI information was not provided, but after its provision it was assessed and no CoI were found. For more information please visit http://ecibc.jrc.ec.europa.eu/gdg-documents

Is the problem a priority?
Yes *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
In the assessment of women who have a screening mammography showing suspicious findings, the aim is to minimise the risk of surgery for non-clinically relevant lesions and, at the same time, minimise the risk of missing a clinically relevant lesion. The only way to significantly reduce both risks is to have a pre-surgical cytology or histopathology assessment of suspicious lesion.
Additional Considerations

The GDG prioritised this question for the ECIBC.

How accurate is the test?
Accurate *
* Possible answers: ( Very inaccurate , Inaccurate , Accurate , Very accurate , Varies , Don't know )
Research Evidence
From a total of 9 studies directly comparing the accuracy of NCB to FNAC in a population 1498 women with suspicious lesions in mammography, the pooled estimates were:

Test accuracy

- Fine needle aspiration cytology
Sensitivity: 0.83 (95% CI: 0.71 to 0.91) Specificity: 0.96 (95% CI: 0.92 to 0.98)

- Needle core biopsy
Sensitivity: 0.92 (95% CI: 0.87 to 0.95) Specificity: 0.99 (95% CI: 0.66 to 1.00)



Additional Considerations

The GDG discussed the surprisingly high specificity for FNAC; the variation observed may be due to the reference standard that was used in these studies.

The GDG notes that the data involved for the decision is primarily test accuracy outcomes as no evidence was found for patient-important outcomes and there is no direct evidence as to how test accuracy relates to the effect on health outcomes.

Wang et al in January 2017 published a similar review that compares the sensitivity and specificity of NCB and FNAC in women with suspicious lesions. Authors estimated that the pooled sensitivity of NCB was 87% (95% CI = 84- 88) versus 74% for FNAC (95% CI = 72%-77%, and the pooled specificity of NCB was 98% (95% CI= 96-99) versus 96% for FNAC (95% CI= 94-98).

The GDG expressed their concern with the reference standard used in the systematic review of Wang 2017. In fact, they used as gold standard: 1) Final pathological results by open surgical biopsy or frozen Section 2) A definitive diagnosis reported on core biopsy specimens was considered as gold standard if it correlated with the radiological findings. 3) For patients with lesions with a benign result after the biopsy and not undergoing operations, Wang 2017 used long-term follow-up information as an indirect assessment of the presence of breast cancer. The second criterion has a strong rationale, since the NCB may have ablated all the malignancy, but makes it difficult to have a fair comparison between FNAC and NCB specificity.

How substantial are the desirable anticipated effects?
Large *
* Possible answers: ( Trivial , Small , Moderate , Large , Varies , Don't know )
Research Evidence
OutcomeStudy designTest accuracy QoEEffect per 1000 patients/year for pre-test probability of 34%Effect per 1000 patients/year for pre-test probability of 50%Importance
core needle biopsyfine needle aspiration cytologycore needle biopsyfine needle aspiration cytology
True positivescross-sectional (cohort type accuracy study)
HIGH
a,b
313 (296 to 323)282 (241 to 309)460 (435 to 475)415 (355 to 455)
TP absolute difference31 more TP in core needle biopsy45 more TP in core needle biopsy
False negatives27 (17 to 44)58 (31 to 99)40 (25 to 65)85 (45 to 145)
FN absolute difference31 fewer FN in core needle biopsy45 fewer FN in core needle biopsy
True negativescross-sectional (cohort type accuracy study)
HIGH
a,b
653 (436 to 660)634 (607 to 647)495 (330 to 500)480 (460 to 490)
TN absolute difference19 more TN in core needle biopsy15 more TN in core needle biopsy
False positives7 (0 to 224)26 (13 to 53)5 (0 to 170)20 (10 to 40)
FP absolute difference19 fewer FP in core needle biopsy15 fewer FP in core needle biopsy
  1. Most studies do not clearly report details on patients selection, index test or intervention. The panel considers that this unclear risk of bias does not affect the overall confidence in the accuracy estimates
  2. Most studies include an heterogeneous population with suspicious lesions in the mammography, being mass lesions the most frequent . This directly applies to the question whether biopsy or cytology should be used.

Baseline prevalence assumptions: The prevalence of malignant disease from a systematic review of indirect comparisons between NCB and FNAC was 34% (median estimation; range from 1% to 94%) (Dahabreh 2009). The prevalence of malignant disease from direct comparisons between NCB and FNAC also varied. In those studies which included patients with suspicious mass lesions, the prevalence of malignancy ranged from 56% to 83%. In those studies which included heterogeneous lesions, the prevalence of malignancy ranged from 13% to 29%.

Rate of inconclusive results was higher for FNAC compared to NCB in all studies except in one (Tikku 2015). Inconclusive results using FNAC ranged from 2.8% to 51% whereas inconclusive results using NCB ranges from 2% to 14%.

Local recurrence: four retrospective studies in a total of 1885 women found no significant difference with respect to the local recurrence rate between patients who had undergone a preoperative diagnostic needle core biopsy (863 women) or an excisional biopsy (1022 women). The local recurrence rates varied between 1.1 and 3.7% for the needle core biopsy group and between 2.1 and 10.3% for the excisional biopsy group.

Adverse events: the most frequent adverse event is pain although pain leading to test discontinuation is occasional. The absolute incidence of adverse events such as bleeding or infection is low and the incidence of severe complications is less than 1%.
Additional Considerations

Overall, the GDG judged that the greater number of true positives and negatives as well as the lower number of false positives and negatives with NCB, compared to FNAC, were large desirable anticipated effects.

The GDG agreed by voting that the desirable effects were ‘large’ with 18 members voting; no other options were voted.

How substantial are the undesirable anticipated effects?
Trivial *
* Possible answers: ( Large , Moderate , Small , Trivial , Varies , Don't know )
Research Evidence
OutcomeStudy designTest accuracy QoEEffect per 1000 patients/year for pre-test probability of 34%Effect per 1000 patients/year for pre-test probability of 50%Importance
core needle biopsyfine needle aspiration cytologycore needle biopsyfine needle aspiration cytology
True positivescross-sectional (cohort type accuracy study)
HIGH
a,b
313 (296 to 323)282 (241 to 309)460 (435 to 475)415 (355 to 455)
TP absolute difference31 more TP in core needle biopsy45 more TP in core needle biopsy
False negatives27 (17 to 44)58 (31 to 99)40 (25 to 65)85 (45 to 145)
FN absolute difference31 fewer FN in core needle biopsy45 fewer FN in core needle biopsy
True negativescross-sectional (cohort type accuracy study)
HIGH
a,b
653 (436 to 660)634 (607 to 647)495 (330 to 500)480 (460 to 490)
TN absolute difference19 more TN in core needle biopsy15 more TN in core needle biopsy
False positives7 (0 to 224)26 (13 to 53)5 (0 to 170)20 (10 to 40)
FP absolute difference19 fewer FP in core needle biopsy15 fewer FP in core needle biopsy
  1. Most studies do not clearly report details on patients selection, index test or intervention. The panel considers that this unclear risk of bias does not affect the overall confidence in the accuracy estimates
  2. Most studies include an heterogeneous population with suspicious lesions in the mammography, being mass lesions the most frequent . This directly applies to the question whether biopsy or cytology should be used.

Baseline prevalence assumptions: The prevalence of malignant disease from a systematic review of indirect comparisons between NCB and FNAC was 34% (median estimation; range from 1% to 94%) (Dahabreh 2009). The prevalence of malignant disease from direct comparisons between NCB and FNAC also varied. In those studies which included patients with suspicious mass lesions, the prevalence of malignancy ranged from 56% to 83%. In those studies which included heterogeneous lesions, the prevalence of malignancy ranged from 13% to 29%.

Rate of inconclusive results was higher for FNAC compared to NCB in all studies except in one (Tikku 2015). Inconclusive results using FNAC ranged from 2.8% to 51% whereas inconclusive results using NCB ranges from 2% to 14%.

Local recurrence: four retrospective studies in a total of 1885 women found no significant difference with respect to the local recurrence rate between patients who had undergone a preoperative diagnostic needle core biopsy (863 women) or an excisional biopsy (1022 women). The local recurrence rates varied between 1.1 and 3.7% for the needle core biopsy group and between 2.1 and 10.3% for the excisional biopsy group.

Adverse events: the most frequent adverse event is pain although pain leading to test discontinuation is occasional. The absolute incidence of adverse events such as bleeding or infection is low and the incidence of severe complications is less than 1%.
Additional Considerations

Inconclusive results were lower in NCB than in FNAC. Risk of local recurrence was similar between NCB and excisional biopsy.

The main direct adverse effects and complications of both FNAC and NCB is pain during the biopsy procedure. It seems obvious that larger needles would cause more biopsy-related pain. Haematoma formation can be expected after any needle biopsy, but haematomas requiring intervention are uncommon.

Overall, the GDG considered these undesirable anticipated effects as trivial.

What is the overall certainty of the evidence of test accuracy?
High *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Additional Considerations

The overall certainty of the evidence of test accuracy was considered high. Although most of the included studies underreported some items of QUADAS II tool, consistency was seen across studies with very similar sensitivity and specificity. Only one small study had a high risk of bias but it did not appear to affect the results. Therefore, the GDG did not lower for risk of bias and considered that this limitation did not affect the overall certainty of the results.

The GDG considered that, although the studies did not have a homogeneous population (they included a mixture of findings in mammography: mass lesions, calcifications, etc.) there was no reason to suspect that the already good accuracy results would improve if there was a high proportion of calcification lesions in the study population. Therefore, they did not lower the certainty of the evidence due to indirectness.

What is the overall certainty of the evidence for any critical or important direct benefits, adverse effects or burden of the test?
Moderate *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Additional Considerations

Observational accuracy type studies with a proper design provided information about the rate of inconclusive results for NCB and FNAC. A large number of observational accuracy type studies with indirect comparisons between NCB and FNAC provided information about adverse effects (see table of the included studies).

To estimate the risk of local and distant recurrence, presumably due to displacement of tumour cells, an observational study compared the local recurrence up to 5 years after diagnosis in women who had biopsy and in women who had only surgical assessment, adjusting for all the known prognostic factors (Taxin 1997). Despite the inherent design limitation of retrospective studies, the risk was similar in women who received either of the two types of biopsy.

What is the overall certainty of the evidence of effects of the management that is guided by the test results?
Moderate *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Additional Considerations

The GDG considered the certainty of the information for health outcomes as being moderate due to some uncertainty regarding the management for some lesions of intermediate malignancy potential.

How certain is the link between test results and management decisions?
Moderate *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Additional Considerations

The GDG considered the impact of false negatives. The GDG noted the uncertainty concerning cases that are false negatives on biopsy. What happens to a person who is false negative is very variable. It is possible that in multidisciplinary conferences false negatives may have additional biopsies but in other cases they may go undetected for an unknown amount of time. The impact will vary depending on the biology of the tumour that has not been diagnosed.

The GDG acknowledges that there is less uncertainty in what happens to persons who are false positive due to a clearer pathway for their management, as all positive biopsies undergo surgery.

What is the overall certainty of the evidence of effects of the test?
Moderate *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Additional Considerations

The GDG acknowledged that results from test accuracy studies provide indirect estimations of effects (downstream consequences) of the tests on health outcomes.

The GDGs final judgement on the certainty of the evidence was based on the assumption that there will always be more desirable health effects than undesirable ones based on better typification of breast lesions with NCB.

Is there important uncertainty about or variability in how much people value the main outcomes?
Probably no important uncertainty or variability *
* Possible answers: ( Important uncertainty or variability , Possibly important uncertainty or variability , Probably no important uncertainty or variability , No important uncertainty or variability , No known undesirable outcomes )
Research Evidence
No systematic review was conducted.
Additional Considerations

A few people may prefer surgical/ excisional biopsy instead of either of the tests proposed, due to anxiety towards pain as an adverse effect or because they can choose to remove completely the lesion as soon as possible. The GDG felt that once a person has made the decision to have a biopsy, they would place great value on the accuracy of the test and there would not be much variability. The GDG noted this judgement on value may not apply to people who do not choose to have a biopsy. The GDG, therefore, judged that there is probably no important uncertainty in the value women place on the main outcomes once they have chosen to have a biopsy.

Does the balance between desirable and undesirable effects favor the intervention or the comparison?
Favors the intervention *
* Possible answers: ( Favors the comparison , Probably favors the comparison , Does not favor either the intervention or the comparison , Probably favors the intervention , Favors the intervention , Varies , Don't know )
Additional Considerations

The GDG judged that it favours the intervention for the reasons discussed (more desirable than undesirable effects on health)

How large are the resource requirements (costs)?
Negligible costs and savings *
* Possible answers: ( Large costs , Moderate costs , Negligible costs and savings , Moderate savings , Large savings , Varies , Don't know )
Research Evidence


Additional Considerations

The GDG judged that the cost of the intervention is negligible.

The GDG noted that with inconclusive results a repeat biopsy is required. Therefore, the average cost per case in FNAC, that has a greater number of inconclusive results, would be higher.

Indirect evidence: Two studies conducted in the USA (Masood2015 and Nagar2012) reported that biopsy with NCB was more expensive than FNAC. However, due to the greater number of inconclusive results with FNAC, the initial biopsy with FNAC may require additional biopsies, and surgeries, thus raising the costs per case as compared to cost per case in NCB.

What is the certainty of the evidence of resource requirements (costs)?
Low *
* Possible answers: ( Very low , Low , Moderate , High , No included studies )
Additional Considerations

Low certainty due to indirectness. Both studies were conducted in Finland and were 10 years old. Costs and resources used may not be applicable to other European settings.

Does the cost-effectiveness of the intervention favor the intervention or the comparison?
Favors the intervention *
* Possible answers: ( Favors the comparison , Probably favors the comparison , Does not favor either the intervention or the comparison , Probably favors the intervention , Favors the intervention , Varies , No included studies )
Research Evidence



Additional Considerations

The GDG notes that NCB is more costly but there would be 29% more non-operative malignant diagnosis prior to surgery with NCB compared to FNAC which would be advantageous as less additional biopsies due to inconclusive results are needed and surgical planning is improved. No intraoperative frozen sections are needed to clarify if the lesion is benign or malignant; less re-excisions are required to achieve complete removal of the tumour. As the increased costs are negligible, compared with the increased benefits, the GDG judged that the cost-effectiveness favours the intervention.

What would be the impact on health equity?
Varies *
* Possible answers: ( Reduced , Probably reduced , Probably no impact , Probably increased , Increased , Varies , Don't know )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG agreed that the impact on health equity would vary. On the one hand the GDG noted that a recommendation for the use of NCB would result in increased equity within countries that currently do not routinely use NCB in all healthcare centres.
On the other hand, in some countries FNAC is still used, so in those countries it may result in inequity.

Is the intervention acceptable to key stakeholders?
Yes *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG noted that FNAC requires less time and inconvenience for the woman; as such they may find NCB less acceptable. However, the GDG judged that acceptability overall will likely be greater because there is more reliable diagnostic information provided with NCB than FNAC.
The GDG noted that individual clinicians in healthcare centres where they are currently using FNAC may not find NCB so acceptable.

Is the intervention feasible to implement?
Yes *
* Possible answers: ( No , Probably no , Probably yes , Yes , Varies , Don't know )
Research Evidence
No systematic review was conducted.
Additional Considerations

The GDG judged that this intervention would be feasible to implement.

The GDG agreed that clinicians performing FNAC should be able to perform NCB without significant additional human resources or training.

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  • Symmans, W. F., Weg, N., Gross, J., Cangiarella, J. F., Tata, M., Mazzo, J. A., & Waisman, J. (1999). A prospective comparison of stereotaxic fine-needle aspiration versus stereotaxic core needle biopsy for the diagnosis of mammographic abnormalities. Cancer, 85(5), 1119-1132.
  • Tikku, G., & Umap, P. (2015). Comparative Study of Core Needle Biopsy and Fine Needle Aspiration Cytology in Palpable Breast Lumps: Scenario in Developing Nations. Turk Patoloji Derg, 32(1), 1-7. doi:10.5146/tjpath.2015.01335
  • Usman, K., Nisar, B., & Sajid, M. (2015). Diagnostic accuracy of fine needle aspiration cytology in a breast lump using histopathology as gold standard. Saudi Med J, 9(1), 191-193.
  • Westenend, P. J., Sever, A. R., Beekman-De Volder, H. J., & Liem, S. J. (2001). A comparison of aspiration cytology and core needle biopsy in the evaluation of breast lesions. Cancer, 93(2), 146-150.
  • Yu, Y. H., Wei, W., & Liu, J. L. (2012). Diagnostic value of fine-needle aspiration biopsy for breast mass: a systematic review and meta-analysis. BMC Cancer, 12, 41. doi:10.1186/1471-2407-12-41
  • Zhou, J. Y., Tang, J., Wang, Z. L., Lv, F. Q., Luo, Y. K., Qin, H. Z., & Liu, M. (2014). Accuracy of 16/18G core needle biopsy for ultrasound-visible breast lesions. World J Surg Oncol, 12, 7. doi:10.1186/1477-7819-12-7
ECONOMIC EVIDENCE
  • Hukkinen, K., Kivisaari, L., Heikkila, P. S., Von Smitten, K., & Leidenius, M. (2008). Unsuccessful preoperative biopsies, fine needle aspiration cytology or core needle biopsy, lead to increased costs in the diagnostic workup in breast cancer. Acta Oncol, 47(6), 1037-1045. doi:10.1080/02841860802001442
  • Vimpeli, S. M., Saarenmaa, I., Huhtala, H., & Soimakallio, S. (2008). Large-core needle biopsy versus fine-needle aspiration biopsy in solid breast lesions: comparison of costs and diagnostic value. Acta Radiol, 49(8), 863-869. doi:10.1080/02841850802235751