THE ROLE OF CYTOLOGY IN BREAST CANCER MANAGEMENT

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THE ROLE OF CYTOLOGY IN BREAST CANCER MANAGEMENT Powered By Docstoc
					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.

				
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