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.