Post on 15-Nov-2014
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The role of cytology in breast cancer management
March 16, 2009
The big question
• Excisional biopsy• Tissue cores• Fine needle aspirate
• Selecting optimal method:– Clinical circumstances– Radiologic findings– Skill of the operator– Confidence of physician
performing cytopathological examination
FNA is
– Least expensive • 250,000 to 750,000
savings per 1,000 FNAs in comparison with surgical biopsies.
– No anesthesia or hospitalization.
– Faster – minutes– Anxiety alleviating?
– Most valuable when the clinical suspicion is low.
• Excisional– Traumatic– Scar tissue makes
subsequent evaluation difficult.
• Core– May miss critical lesion– Expensive and time-
consuming• Fixation, embedding,
cutting and staining…
Biopsy is
Limitations
• Atypical or suspicious lesions• IF negative, nagging doubts may remain
– Triple test… If all three are negative, then reliablity approaches 100%.
• Proposed adequacy guidelines:– Minimum 10 epithelial cells– 4-6 well visualized cell groups– At least 200 well-preserved malignant cells for
unqualified diagnosis of cancer.• May impact subsequent tissue biopsies
– Hemosiderosis, hemorrhage, partial necrosis
Complications
• Minor: bleeding, local tissue injury
• Major: pneumothorax
• Limitations: cannot assess invasion and extent of disease
The triple test
• Physical examination: 70-90% accurate
• Mammography : 85-90%
• FNA biopsy: 90%
• Taken together, the diagnostic accuracy of all three tests approaches 100%
• Benign– Inflammatory lesions
• Acute and subacute mastitis• Abscess• Tuberculosis
– Trauma• Fat necrosis• Foreign body reaction• Augmentation or reduction
– Proliferative • Cysts• Fibrous mastopathy• Other
– Fibroadenoma– Lactating adenoma– Intraductal papilloma– Granular cell tumor– Other
• Intraductal carcinomas• Intralobular carcinomas• Malignant
– Carcinomas• Infiltrating ductal• Scirrhous• Inflammatory• Medullary• Colloid • Apocrine• Tubular • Papillary• Spindle cell• Adenoid cystic
– Sarcomas
• Metastatic
Never give an unequivocal diagnosis of mammary carcinoma in the presence of marked acute inflammation.
Benign cysts
• After aspiration, cyst should no longer be palpable– Residual mass
indication for reaspiration or tissue biopsy.
• Suspicious findings:– Papillary groups– Opaque or bloody fluid– Mucus
Fibrocystic changes
• Proliferation and atrophy of ducts and lobules– Hyperplasia– Papillary changes– Oncocytes
• Fibrosis– Cyst formation– Stromal nodules– Calcifications– Collagenous spherulosis
• Overall– Scanty smear with benign
components
Fibroadenoma
Mammary Carcinoma• Carcinoma of mammary ducts:
– Infiltrating ductal– Solid and gland forming– Scirrhous– Inflammatory– Medullary– Colloid or mucus– Mucocele-like lesion– Signet ring type– Apocrine– Tubular – Papillary– Intraductal carcinoma
• Solid, Comedo-, papillary• Lobular• Mixed types• Other rare types
– Spindle cell– Adenoid cystic– Metaplastic– Carcinoma mimicking Giant cell tumor of
Bone– Secretory carcinoma– Other even more rare types
• 20 breast FNA’s last year– 1 highly suspicious – 1 metastasis– 2 low grade ductal
proliferation– 3 atypical
• Sensitivity: 92.5%• Specificity: 99.8%• PPV: 99.7%• NPV: 94.2%• Accuracy: 96.5%
• Please correlate clinically and radiographically to determine if this sample is representative of the clinical lesion.
• Please be advised that a negative FNA diagnosis does not completely rule out the possibility of an underlying malignancy. Correlation with imaging and clinical information is required, if there is any discrepancy, tissue biopsy if recommended.
What is this?
fibroadenoma
What is this?
Note: Vacuole with central eosinophilic material
Infiltrating Lobular carcinoma
References:
• Koss• Breast cytology study set• Acta cytologica. The uniform approach to Breast
Fine Needle Aspiration Biopsy. • Diagnostic Cytopathology. Current Utilization of
Breast FNA in a Cytology practice.• Diagnostic Cytopathology. A Retrospective
Study of the Diagnostic Accuracy of Fine Needle Aspiration for Breast Lesions and Implications for Future Use.