fna of breast the 6 th arab-british school of pathology
DESCRIPTION
FNA of BREAST The 6 th Arab-British School of Pathology. Nina S Shabb, M.D. American University of Beirut Medical center, Beirut Lebanon. Objectives. Overview of breast FNA AUBMC data 2003-200 CNB vs FNA of palpable and non palpable lesions. Status of breast FNA. 1930: Introduced - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/1.jpg)
![Page 2: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/2.jpg)
FNA of BREAST
The 6th Arab-British School of PathologyNina S Shabb, M.D.
American University of Beirut Medical center, Beirut Lebanon
![Page 3: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/3.jpg)
Objectives
• Overview of breast FNA
• AUBMC data 2003-200
• CNB vs FNA of palpable and non palpable lesions
![Page 4: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/4.jpg)
Status of breast FNA
• 1930: Introduced• 1980-90: ↑ ↑ ↑• Late 90’s-now: ↓• Non palpable masses: Replaced CNB• Palpable masses: CNB = FNA ? (institution
dependent)
![Page 5: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/5.jpg)
Reasons for ↓ popularity
• Lack of experienced cytopathologists– ↑ Diagnostic errors– ↑ Insufficient samples– False positives– False negatives– Medico legal issues
• Inability to distinguish In situ from invasive carcinoma
![Page 6: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/6.jpg)
Trend of FNA of breast at AUBMC
0
50
100
150
200
250
1997 1999 2001 2003 2005 2007
Number of breastFNAs
Total number: 1794
![Page 7: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/7.jpg)
AUBMC data
• All breast FNAs with corresponding surgical pathology material were reviewed over 5 years (Jan 2003 - Dec 2007)
• FNA reports were categorized C1-C5
• Palpable and non palpable masses were segregated
• Data analyzed
![Page 8: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/8.jpg)
Diagnostic categories
• C1: Unsatisfactory
• C2: Benign lesion
• C3: Atypical, probably benign
• C4: Suspicious for malignancy
• C5: Malignant
The uniform approach to breast FNA. NCI recommendations
![Page 9: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/9.jpg)
“Triple test”
• FNA results
• Clinical findings
• Radiologic findings
Combining these 3 tests improves false negative and false positive results
![Page 10: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/10.jpg)
PATHOLOGY
FNA Negative Positive Total
C1 4 5 9
C2 56 1 57
C3 9 0 9
C4 0 13 13
C5 1 92 93
Total 70 111 181
FNA/Pathology correlation, AUBMC,2003-2007
FN: 6. FP: 1. Unsatisfactory:5%
![Page 11: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/11.jpg)
Who should perform the FNA?
• The person who is going to read it! (pathologist adequately trained)– Gleans information from gross findings and
feel of the needle– Less unsatisfactory results (multiple passes
as needed)– Less interpretative errors– Highest sensitivity and specificity
![Page 12: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/12.jpg)
![Page 13: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/13.jpg)
![Page 14: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/14.jpg)
![Page 15: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/15.jpg)
![Page 16: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/16.jpg)
![Page 17: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/17.jpg)
![Page 18: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/18.jpg)
![Page 19: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/19.jpg)
![Page 20: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/20.jpg)
![Page 21: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/21.jpg)
![Page 22: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/22.jpg)
![Page 23: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/23.jpg)
![Page 24: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/24.jpg)
Complications of FNA
• Very rare– Pain– Bleeding/hematoma: Pressure– Infection: Proper cleaning– Pneumothorax: Tangential aspirate– Vasovagal reaction: Legs up– Needle tract seeding? No
![Page 25: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/25.jpg)
C1Unsatisfactory
![Page 26: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/26.jpg)
PATHOLOGY
FNA Negative Positive Total
C1 4 5 9
C2 56 1 57
C3 9 0 9
C4 0 13 13
C5 1 92 93
Total 70 111 181
FNA/Pathology correlation, AUBMC,2003-2007
C1: 5%
![Page 27: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/27.jpg)
C1 palpable vs non palpable
PATHOLOGY
FNA Palpable Negative Positive Total
C1 3 2 5
C2 35 1 36
C3 6 0 6
C4 0 12 12
C5 0 73 73
Total 44 88 132
C1: 3.5% (2.3%pos) C1: 8%
PATHOLOGY
FNA non palpable Negative Positive Total
C1 1 3 4
C2 21 0 21
C3 3 0 3
C4 0 1 1
C5 1 19 20
Total 26 23 49
![Page 28: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/28.jpg)
C1 (Unsatisfactory)
• When FNA does not explain the mass • Lesions responsible for C1
– Small– Fibrotic– Hypocellular benign and malignant
• Operator dependent • Range in literature: 0.7-47% (5%)• CNB: advantage
![Page 29: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/29.jpg)
C1
• Management: More tissue
![Page 30: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/30.jpg)
C2Benign
![Page 31: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/31.jpg)
C2 benign
• FNA: Adequate and representative material of benign disease– FCC (cysts)– Abscess– Fat necrosis– Fibroadenoma– Other
![Page 32: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/32.jpg)
PATHOLOGY
FNA Negative Positive Total
C1 4 5 9
C2 56 1 57
C3 9 0 9
C4 0 13 13
C5 1 92 93
Total 70 111 181
FNA/Pathology correlation, AUBMC,2003-2007
FN: 1
![Page 33: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/33.jpg)
FNA/pathology correlation of palpable masses
PATHOLOGY
FNA p
Negative Positive
FCC FA Other Total neg IDC ILC DCIS Other Total pos Total
C1 2 1 0 3 2 0 0 0 2 5
C2 16 18 1 PT 35 0 0 1 crib pap 0 1 36
C3 4 2 0 6 0 0 0 0 0 6
C4 0 0 0 0 7 2 2 1 tubular 12 12
C5 0 0 0 0 69 3 (2 Pleo) 1 comedo 0 73 73
Total 22 21 1 44 78 5 4 1 88 132
44 88
![Page 34: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/34.jpg)
FNA/pathology correlation of non palpable masses
PATHOLOGY
FNA np
Negative Positive
FCC FA Other Total neg IDC ILC DCIS Other Total pos Total
C1 0 1 0 1 2 0 1 0 3 4
C2 15 5 1 LN 21 0 0 0 0 0 21
C3 1 2 0 3 0 0 0 0 0 3
C4 0 0 0 0 1 0 0 0 1 1
C5 0 0 1 (ame) 1 16 1 2 0 19 20
Total 16 8 2 26 19 1 3 0 23 49
26 23
![Page 35: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/35.jpg)
C2 (benign)
• 1 False negative: (1%) DCIS Cribriform and micropapillary.
Misinterpreted on FNA as FCC
![Page 36: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/36.jpg)
![Page 37: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/37.jpg)
![Page 38: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/38.jpg)
![Page 39: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/39.jpg)
FCC
• Cyst content: Clear, few macrophages
• Hypocellular– Benign duct epithelial cells– Naked nuclei – Apocrine metaplastic cells
![Page 40: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/40.jpg)
![Page 41: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/41.jpg)
![Page 42: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/42.jpg)
Fibroadenoma
• Pigeon egg, rubbery feel
• Smears (pattern recognition)– Very cellular – 3 components
• Staghorn epithelial cohesive honeycombed duct cells
• Stromal fragments• Numerous myoepithelial cells (naked bipolar
nuclei)
![Page 43: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/43.jpg)
![Page 44: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/44.jpg)
![Page 45: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/45.jpg)
C2 (Benign)
• Negative triplet: Follow up– FNA: Benign – Clinical: Benign– Radiologic: Benign
![Page 46: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/46.jpg)
C5Malignant
![Page 47: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/47.jpg)
C5 Malignant
• Primary– IDC nos– ILC– Mucinous– Tubular– Papillary– Other
• Metastatic• Hematopoetic
![Page 48: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/48.jpg)
PATHOLOGY
FNA Negative Positive Total
C1 4 5 9
C2 56 1 57
C3 9 0 9
C4 0 13 13
C5 1 92 93
Total 70 111 181
FNA/Pathology correlation, AUBMC,2003-2007
False positive: Adenomyoepithelioma
![Page 49: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/49.jpg)
FNA/pathology correlation of palpable masses
PATHOLOGY
FNA p
Negative Positive
FCC FA Other Total neg IDC ILC DCIS Other Total pos Total
C1 2 1 0 3 2 0 0 0 2 5
C2 16 18 1 PT 35 0 0 1 crib pap 0 1 36
C3 4 2 0 6 0 0 0 0 0 6
C4 0 0 0 0 7 2 2 1 tubular 12 12
C5 0 0 0 0 69 3 (2 Pleo) 1 comedo 0 73 73
Total 22 21 1 44 78 5 4 1 88 132
44 88
![Page 50: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/50.jpg)
FNA/pathology correlation of non palpable masses
PATHOLOGY
FNA np
Negative Positive
FCC FA Other Total neg IDC ILC DCIS Other Total pos Total
C1 0 1 0 1 2 0 1 0 3 4
C2 15 5 1 LN 21 0 0 0 0 0 21
C3 1 2 0 3 0 0 0 0 0 3
C4 0 0 0 0 1 0 0 0 1 1
C5 0 0 1 (ame) 1 16 1 2 0 19 20
Total 16 8 2 26 19 1 3 0 23 49
26 23
![Page 51: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/51.jpg)
Adenomyoepithelioma
• Rare benign tumor, epithelial and ME cells• FNA.
– Scant. Scattered highly atypical epithelial cells.– Numerous foamy ME cells (histiocytes)
• CNB: Interpreted as IDC, Grade 2/3• Single false positive FNA since we started doing
FNAs of breast (>3000 cases)• AME has been reported as a cause of false + in
literature
![Page 52: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/52.jpg)
Diagnostic criteria for malignancy
1. Tumor cellularity
2. Discohesion
3. Cytologic features of malignancy.• Compare neoplastic cells to benign duct
cells• ↑ N/C ratio• Irregular nuclear contour• Hyperchromasia• Presence of nucleoli
![Page 53: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/53.jpg)
Ductal adenocarcinoma nos
• Cellular
• Necrotic background
• Monomorphic cell population
• Loss of cell cohesion
• Numerous isolated singe cells
• Anisonucleosis
• Lack of ME cells
![Page 54: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/54.jpg)
![Page 55: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/55.jpg)
![Page 56: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/56.jpg)
![Page 57: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/57.jpg)
Tumor grade
• HISTOLOGY– Glands– Nuclei– Mitosis
• CYTOLOGY– Nuclei
• Size• Membrane• Chromatin• Nucleoli
Nuclear grade 1-3Good correlation with histologic grade
![Page 58: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/58.jpg)
Special type carcinomas
![Page 59: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/59.jpg)
![Page 60: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/60.jpg)
![Page 61: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/61.jpg)
![Page 62: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/62.jpg)
Lobular carcinoma
• Low to moderate cellularity• Small chains or groups of cells, single cells• Uniform population, small to medium sized cells• Mild atypia, inconspicuous nucleoli• Occasional signet ring cells• Source of false negative• Feel of the needle in the mass while doing FNA
is most helpful
![Page 63: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/63.jpg)
![Page 64: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/64.jpg)
![Page 65: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/65.jpg)
![Page 66: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/66.jpg)
![Page 67: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/67.jpg)
Mucinous carcinoma
• Well circumscribed, soft
• Thick mucinous material
• Cell balls, minimal atypia, few signet rings
• Cannot diagnose absolutely on FNA
![Page 68: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/68.jpg)
Tubular ca
• Angular, rigid, bent tubular clusters, sharp borders
• Crowded nuclei
• Minimal tumor discohesion
• Dispersed single cells, minimal atypia
• Absence/paucity of ME cells
• Peripheral perpendicular cells
![Page 69: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/69.jpg)
Other carcinomas
• Not very good
• No clinical need
• Carcinoma and nuclear grade
![Page 70: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/70.jpg)
DCIS
• FNA cannot distinguish in situ from invasive carcinoma– Cancer cells infiltrating fibrofatty tissue,
tubular structures, cytoplasmic lumina, absence of ME cells)
• Incidence of DCIS in FNA material ranges 1-18% (palpable vs non palpable)
• CNB is more accurate but not infallible (false negative 19-66% )
![Page 71: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/71.jpg)
![Page 72: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/72.jpg)
FNA of DCIS
• DCIS Grade 3:– Pleomorphic carcinoma cells, calcium,
necrosis, macrophages – casting Calcification on mammogram
• DCIS cribriform– Low grade carcinoma – punched out holes in cell clusters
• DCIS grades 1 and 2:– No distinguishing features
![Page 73: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/73.jpg)
C5
• Management
• If the TT is positive then definitive treatment is undertaken
![Page 74: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/74.jpg)
![Page 75: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/75.jpg)
C3 & C4C3: Atypical favor benign
C4: Suspicious for malignancy
![Page 76: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/76.jpg)
C3 (atypical favor benign)
• Atypical/indeterminate/favor benign
• Lesion is probably benign
• Malignancy cannot be excluded entirely
• TT
![Page 77: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/77.jpg)
C4 (Suspicious probably malignant)
• Very high probability of malignancy but confirmation is needed prior to definitive therapy
• Others are complex lesions
• Additional material
![Page 78: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/78.jpg)
PATHOLOGY
FNA Negative Positive Total
C1 4 5 9
C2 56 1 57
C3 9 0 9
C4 0 13 13
C5 1 92 93
Total 70 111 181
FNA/Pathology correlation, AUBMC,2003-2007
C3+C4: 11.6%
![Page 79: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/79.jpg)
FNA/pathology correlation of palpable masses
PATHOLOGY
FNA p
Negative Positive
FCC FA Other Total neg IDC ILC DCIS Other Total pos Total
C1 2 1 0 3 2 0 0 0 2 5
C2 16 18 1 PT 35 0 0 1 crib pap 0 1 36
C3 4 2 0 6 0 0 0 0 0 6
C4 0 0 0 0 7 2 2 1 tubular 12 12
C5 0 0 0 0 69 3 (2 Pleo) 1 comedo 0 73 73
Total 22 21 1 44 78 5 4 1 88 132
44 88
![Page 80: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/80.jpg)
FNA/pathology correlation of non palpable masses
PATHOLOGY
FNA np
Negative Positive
FCC FA Other Total neg IDC ILC DCIS Other Total pos Total
C1 0 1 0 1 2 0 1 0 3 4
C2 15 5 1 LN 21 0 0 0 0 0 21
C3 1 2 0 3 0 0 0 0 0 3
C4 0 0 0 0 1 0 0 0 1 1
C5 0 0 1 (ame) 1 16 1 2 0 19 20
Total 16 8 2 26 19 1 3 0 23 49
26 23
![Page 81: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/81.jpg)
C3 and C4 lesions
• Nature of lesion– Proliferative breast disease with atypia– Low grade carcinoma (in–situ & invasive)– Tubular ca– Papillary lesions– Phyllodes tumor
• Technical reasons– Limited cellularity– Poor preservation of cellular features
![Page 82: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/82.jpg)
C3 and C4
• Number of dx in this category shouldn’t exceed 12% (11.6%)
• C3 in literature: 28-52% Malignant (0%)
• C4 in literature: 81-97% malignant (100%)
![Page 83: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/83.jpg)
Inconclusive FNAs of breast with adequate and representative material: A cytologic/histologic study of 18 cases.
AUBMC experience
N Shabb
F Boulous
Z Chakhachiro
![Page 84: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/84.jpg)
Patient Age Clinical presentation
FNA performed by
Dx 1 Cytologic cancer category
Dx 2 Cytologic cancer category
Final diagnosis
1 58 Hypoechoic mass
Radiologist C5 C4 Adenomyoepithelioma
2 43 6.5cm lump Clinician C3-4 C4 DCIS (crib)
3 67 lump Pathologist C2 C3 DCIS (crib, pap)
4 65 lump Clinician C4 C5 Inv crib
5 40 lump Pathologist C4 C4 Inv crib
6 46 4mm U/S Radiologist C4 C4 Tubular
7 53 3cm, gritty Pathologist C3-4 C3-4 Tubular
8 43f NA Clinician C2 C4 Tubular
9 44f lump Clinician C4 C5 Lobular
10 71f lump Clinician C4 C3-4 Inv adeno (nos) 1/3
11 50f NA Clinician C4 C4 Inv adeno (nos) 1/3
12 38f lump, preg Pathologist C4 C5 Inv adeno (nos) 2/3
13 36f 1cm Pathologist C4 C5 Inv adeno (nos) 2/3
14 50f Non palpable
Radiologist C4 C5 Inv adeno (nos) 2/3
15 73f 3cm Pathologist C4 C4 Inv adeno (nos) 2/3
16 66f 15cm hem cyst
Clinician C4 C4 ICPC
17 29f lump Radiologist C3 C3-4 FA
18 60f 2cm gritty Pathologist C4 C4 PT malignant
Inconclusive/erroneous cellular and representative FNAs/histology
![Page 85: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/85.jpg)
Papillary lesions
• FNA not reliable in distinguishing benign from malignant. Defer to histology
![Page 86: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/86.jpg)
![Page 87: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/87.jpg)
![Page 88: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/88.jpg)
False negative FNAs
• Lesions responsible for false –– Low grade ca/lobular/mucinous/tubular/DCIS– Scirrhous tumors– Hemorrhagic/cystic– Small size
• Usually sampling error (5/6)
• Can be interpretative error (1/6)
• TT
![Page 89: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/89.jpg)
False positive FNAs
• Lesions responsible for False +– Fibroadenomas– Epithelial hyperplasia– Pregnancy – Papillary lesions– Reactive atypias – Adenomyoepithelioma
• Usually interpretative errors• Poor specimen preparation• TT
![Page 90: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/90.jpg)
Post triple test recommendations
• Benign triplets– FU
• Malignant triplets– Definitive therapy
• Mixed triplets– Histologic evaluation
![Page 91: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/91.jpg)
Benefits of the triple test
• False negatives: ↓ 10 to 1%
• False positives: ↓ 1 to < 0.2%
![Page 92: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/92.jpg)
FNA diagnostic accuracy
• Literature– Sensitivity: 75-98%– Specificity: 60-100%– False positive: 0-2.5%– False negative: 2.5-
17%– Insufficient: 4-13% (P),
36% (NP)
• AUBMC– Sensitivity: 94.6%– Specificity: 98.6%– False positive: *1%– False negative: 1%
– Insufficient: 3.5% (P), 8% (NP)
![Page 93: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/93.jpg)
CNB vs FNA preoperative evaluation of breast masses
CNB FNA
Special expertise (Performing + interpretation)
No Yes
Feel effect No Yes
Safety (chest wall) No Yes
Time consuming (pathologist) No Yes
In situ/invasive +/- -
Definitive dx Better Good
Cost/TAT/pain/invasiveness Good Better
Tumor grade Better Good
Prognistic markers Yes No
Insufficient rate Better ↓ experience
False +/- Better Inevitable
Palpable Good Good
Non palpable Good No Good
![Page 94: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/94.jpg)
Current issues with FNA of breast
• False negative FNAs– High rate in inexperienced hands– Adeverse effect on patient. Delay in proper
management– Medico legal problems (10% of MLP in US)
• In situ vs invasive– Preoperative chemotherapy– LN dissection (small lesions)
![Page 95: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/95.jpg)
Conclusions
• Compared to CNB, FNA may not provide all the necessary information in modern management of some cases of breast ca. – Small lesions to determine management of
the axilla – Some larger lesions where preoperative
chemotherapy is a consideration.
![Page 96: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/96.jpg)
Conclusions
• CNB has replaced FNA in non palpable mammographically detected lesions
• FNA is highly reliable in palpable masses particularly in the hands of properly trained aspirators and interpreters
• FNA needs to be incorporated in the TT
![Page 97: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/97.jpg)
![Page 98: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/98.jpg)
Advantages of FNA
• Easy “painless” office procedure
• Quick (dx in minutes)
• Inexpensive
• Decreases hospital costs
• Helps patient plan treatment in case of carcinoma
• Helps alleviate anxiety in benign disease
![Page 99: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/99.jpg)
Advantages of FNA
• Definitive dx in inoperable ca, chest wall recurrence and LN metastases
• Useful in pregnant patients
• Diagnostic and therapeutic in benign cysts
• Helpful in triaging patients for surgery
• Decreases time in OR (eliminates need for FS)
![Page 100: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/100.jpg)
Disadvantages of FNA
• False negatives
• False positives
• Special training needed to perform and interpret FNA
• In situ vs invasive carcinoma
• Complications
![Page 101: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/101.jpg)
FNA technique
• Ljung BM: Techniques of aspiration and smear preparation
• Ljung BM: Thin needle aspiration biopsy video. Dept of Pathology UC San Francisco Ca
• Koss LG et al: Aspiration biopsy: Cytologic interpretation and Histologic Basis, 2nd ed, NY Igaku-Shoin, 1992.
![Page 102: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/102.jpg)
FNA technique
• Quick aspiration (avoid blood clot)
• Quick transfer of material on slides
• Proper smearing (avoid crush)
• Immediate fixation (avoid air dry)– Papanicoulau stain (fully frosted alcohol fixed)– Romanowsky type stain (frosted tip, air dry)– Cell block (Optional)
![Page 103: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/103.jpg)
Pointers while performing FNA
• Clinical setting (age, skin and nipple changes, axillary LN)
• Gross feel of tumor• Size of tumor. How to direct needle• FNA feel: Gritty or rubbery?• How many passes?• Rapid stain after every pass?• Naked eye inspection of cellularity
![Page 104: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/104.jpg)
FNA/pathology correlation of palpable masses
PATHOLOGY
FNA p
Negative Positive
FCC FA Other Total neg IDC ILC DCIS Other Total pos Total
C1 2 1 0 3 2 0 0 0 2 5
C2 16 18 1 PT 35 0 0 1 crib pap 0 1 36
C3 4 2 0 6 0 0 0 0 0 6
C4 0 0 0 0 7 2 2 1 tubular 12 12
C5 0 0 0 0 69 3 (2 Pleo) 1 comedo 0 73 73
Total 22 21 1 44 78 5 4 1 88 132
44 88
Sensitivity: TP/TP+FN = 88/88+1 = 98.8%
Specificity: TN/TN+FP = 44/44+0 = 100%
False negative: 1
False positive: 0
![Page 105: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/105.jpg)
FNA/pathology correlation of non palpable masses
PATHOLOGY
FNA np
Negative Positive
FCC FA Other Total neg IDC ILC DCIS Other Total pos Total
C1 0 1 0 1 2 0 1 0 3 4
C2 15 5 1 LN 21 0 0 0 0 0 21
C3 1 2 0 3 0 0 0 0 0 3
C4 0 0 0 0 1 0 0 0 1 1
C5 0 0 1 (ame) 1 16 1 2 0 19 20
Total 16 8 2 26 19 1 3 0 23 49
26 23
Sensitivity: TP/TP+FN = 23/23+0 +100%
Specificity: TN/TN+FP = 26/26+1 =96%
False negative: 0
False positive: 1
![Page 106: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/106.jpg)
Pitfalls
• Low grade carcinomas (lobular, tubular, low grade ductal)
• Apocrine metaplasia and lactational change Have large nuclei and prominent nucleoli
![Page 107: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/107.jpg)
Breast FNA report
• Precise location (laterality, O’clock, distance from nipple).
• Placement of cytologic specimen in one of 5 categories (C1-C5)
• Specimen type• Localization technique• Comment of specimen findings• Adequacy• Recommendation of correlation with clinical and
radiologic findings
![Page 108: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/108.jpg)
References:
1. Masood, S. Prognostic/predictive factors in breast cancer. 2005 Clinics in Laboratory Medicine 25 (4), pp. 809-825.
2. Chaiwun, B., Thorner, P.Fine needle aspiration for evaluation of breast
masses. 2007 Current Opinion in Obstetrics and Gynecology 19 (1), pp. 48-55.
3. Garg, S., Mohan, H., Bal, A., Attri, A.K., Kochhar, S. A comparative analysis
of core needle biopsy and fine-needle aspiration cytology in the evaluation of palpable and mammographically detected suspicious breast lesions. 2007 Diagnostic Cytopathology 35 (11), pp. 681-689.
4. Barra, A.D.A., Gobbi, H., Rezende, C.A.D.L., Gouve�a, A.P., De Lucena,
C.E�.M., Reis, J.H.P., Silva, S.Z.C. A comparision of aspiration cytology and core needle biopsy according to tumor size of suspicious breast lesions. Diagnostic Cytopathology, 2008, 36 (1), pp. 26-31.
5. How stereotactic core-needle biopsy affected breast fine-needle aspiration
utilization: An 11-year institutional review. Xie, H.B., Salhadar, A., Haara, A., Gabram, S., Selvaggi, S.M., Wojcik, E.M. 2004 Diagnostic Cytopathology 31 (2), pp. 106-110.
6. Lieske, B., Ravichandran, D., Wright, D. Role of fine-needle aspiration
cytology and core biopsy in the preoperative diagnosis of screen-detected breast carcinoma. 2006 British Journal of Cancer 95 (1), pp. 62-66.
7. Pilgrim, S., Ravichandran, D. Fine needle aspiration cytology as an adjunct to
core biopsy in the assessment of symptomatic breast carcinoma. 2005 Breast 14 (5), pp. 411-414.
8. He, Q., Fan, X., Yuan, T., Kong, L., Du, X., Zhuang, D., Fan, Z. Eleven years
of experience reveals that fine-needle aspiration cytology is still a useful method for preoperative diagnosis of breast carcinoma. 2007 Breast 16 (3), pp. 303-306
9. Oyama, T., Koibuchi, Y., McKee, G. Core needle biopsy (CNB) as a
diagnostic method for breast lesions: comparison with fine needle aspiration cytology (FNA). 2004 Breast cancer (Tokyo, Japan) 11 (4), pp. 339-342.
![Page 109: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/109.jpg)
Acknowledgments
• Dr Fuad Boulous
• Dr Zaher Chakhachiro
• Dr Alexis Bousamra
• Ms. Nisrine Hashem
![Page 110: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/110.jpg)
Benign duct epithelium
• Cohesive honeycombed sheets
• Regular round/oval evenly spaced nuclei
• Evenly distributed chromatin. No nucleoli
• Myoepithelial cells (in ductal sheets and in background)
• Apocrine cells
![Page 111: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/111.jpg)
![Page 112: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/112.jpg)
![Page 113: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/113.jpg)
Papilloma
• Cellular, bloody background
• Macrophages
• 3 dimensional papillary clusters, cell balls
• Tall columnar cells, apocrine cells and ME cells
![Page 114: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/114.jpg)
Papillary carcinoma
• Papilloma +
• Necrotic debris
• Atypical cytology High N/C ratio, hyperchromasia, nucleoli
• Absence of apocrine cells and ME cells
![Page 115: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/115.jpg)
FNA palpable masses
• 73% FNAs• 67% malignant• C1: 3.5%• C2: FCC (16), FA(18),
PT (1), – DCIS crib +micropapa
(1) FN
• C4: IDC (7), ILC (2), DCIS (2), Tubular (1)
PATHOLOGY
FNA Palpable Negative Positive Total
C1 3 2 5
C2 35 1 36
C3 6 0 6
C4 0 12 12
C5 0 73 73
Total 44 88 132
![Page 116: FNA of BREAST The 6 th Arab-British School of Pathology](https://reader033.vdocuments.net/reader033/viewer/2022051517/5681580f550346895dc57d29/html5/thumbnails/116.jpg)
FNA of non palpable masses
• 27% FNAs• 47% malignant• C1: 8%• C5: 1 FP.
Adenomyoepithilioma• The only FP in our 17
year experience (>2500 cases)
PATHOLOGY
FNA non palpable Negative Positive Total
C1 1 3 4
C2 21 0 21
C3 3 0 3
C4 0 1 1
C5 1 19 20
Total 26 23 49