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.

Biopsy is
‡ Excisional
± Traumatic ± Scar tissue makes subsequent evaluation difficult.

± No anesthesia or hospitalization. ± Faster ± minutes ± Anxiety alleviating? ± Most valuable when the clinical suspicion is low.

‡ Core
± May miss critical lesion ± Expensive and timeconsuming
‡ Fixation, embedding, cutting and staining«

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

‡ ‡ ‡

Intraductal carcinomas Intralobular carcinomas Malignant
± Carcinomas
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Infiltrating ductal Scirrhous Inflammatory Medullary Colloid Apocrine Tubular Papillary Spindle cell Adenoid cystic

± Trauma
‡ Fat necrosis ‡ Foreign body reaction ‡ Augmentation or reduction

± Proliferative
‡ Cysts ‡ Fibrous mastopathy ‡ Other

± ± ± ± ±

Fibroadenoma Lactating adenoma Intraductal papilloma Granular cell tumor Other

± 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
‡ 20 breast FNA¶s last year
± 1 highly suspicious ± 1 metastasis ± 2 low grade ductal proliferation ± 3 atypical
‡ 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

‡ ‡ ‡ ‡ ‡

Sensitivity: 92.5% Specificity: 99.8% PPV: 99.7% NPV: 94.2% Accuracy: 96.5%

‡ ‡ ‡

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

‡ 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.

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