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 Biopsy is ± Least expensive Excisional 250,000 to 750,000 ± Traumatic savings per 1,000 FNAs in comparison with surgical ± Scar tissue makes biopsies. subsequent evaluation ± No anesthesia or difficult. hospitalization. ± Faster ± minutes Core ± Anxiety alleviating? ± May miss critical lesion ± Expensive and time- ± Most valuable when the consuming clinical suspicion is low. 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 Intraductal carcinomas ± Inflammatory lesions Intralobular carcinomas Acute and subacute mastitis Malignant Abscess Tuberculosis ± Carcinomas Infiltrating ductal ± Trauma Scirrhous Fat necrosis Inflammatory Foreign body reaction Medullary Augmentation or reduction Colloid ± Proliferative Apocrine Cysts Tubular Fibrous mastopathy Papillary Other Spindle cell ± Fibroadenoma Adenoid cystic ± Lactating adenoma ± Sarcomas ± Intraductal papilloma ± Granular cell tumor Metastatic ± Other 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: 20 breast FNA¶s last year ± Infiltrating ductal ± 1 highly suspicious ± Solid and gland forming ± Scirrhous ± 1 metastasis ± Inflammatory ± 2 low grade ductal ± Medullary proliferation ± Colloid or mucus ± Mucocele-like lesion ± 3 atypical ± Signet ring type ± Apocrine ± Tubular Sensitivity: 92.5% ± Papillary ± Intraductal carcinoma Specificity: 99.8% Solid, Comedo-, papillary PPV: 99.7% Lobular Mixed types NPV: 94.2% Other rare types Accuracy: 96.5% ± ± 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.