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FNA of BREAST The 6 th Arab-British School of Pathology Nina S Shabb, M.D. American University of Beirut Medical center, Beirut Lebanon.

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Presentation on theme: "FNA of BREAST The 6 th Arab-British School of Pathology Nina S Shabb, M.D. American University of Beirut Medical center, Beirut Lebanon."— Presentation transcript:

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2 FNA of BREAST The 6 th Arab-British School of Pathology Nina S Shabb, M.D. American University of Beirut Medical center, Beirut Lebanon

3 Objectives Overview of breast FNA AUBMC data CNB vs FNA of palpable and non palpable lesions

4 Status of breast FNA 1930: Introduced : ↑ ↑ ↑ Late 90’s-now: ↓ Non palpable masses: Replaced CNB Palpable masses: CNB = FNA ? (institution dependent)

5 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

6 Trend of FNA of breast at AUBMC Total number: 1794

7 AUBMC data All breast FNAs with corresponding surgical pathology material were reviewed over 5 years (Jan Dec 2007) FNA reports were categorized C1-C5 Palpable and non palpable masses were segregated Data analyzed

8 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

9 “Triple test” FNA results Clinical findings Radiologic findings Combining these 3 tests improves false negative and false positive results

10 PATHOLOGY FNANegativePositiveTotal C1459 C C3909 C4013 C Total FNA/Pathology correlation, AUBMC, FN: 6. FP: 1. Unsatisfactory:5%

11 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

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24 Complications of FNA Very rare –Pain –Bleeding/hematoma: Pressure –Infection: Proper cleaning –Pneumothorax: Tangential aspirate –Vasovagal reaction: Legs up –Needle tract seeding? No

25 C1 Unsatisfactory

26 PATHOLOGY FNANegativePositiveTotal C1459 C C3909 C4013 C Total FNA/Pathology correlation, AUBMC, C1: 5%

27 C1 palpable vs non palpable PATHOLOGY FNA Palpable NegativePositiveTotal C1325 C C3606 C4012 C5073 Total C1: 3.5% (2.3%pos)C1: 8% PATHOLOGY FNA non palpable NegativePositiveTotal C1134 C2210 C3303 C4011 C Total262349

28 C1 (Unsatisfactory) When FNA does not explain the mass Lesions responsible for C1 –Small –Fibrotic –Hypocellular benign and malignant Operator dependent Range in literature: % (5%) CNB: advantage

29 C1 Management: More tissue

30 C2 Benign

31 C2 benign FNA: Adequate and representative material of benign disease –FCC (cysts) –Abscess –Fat necrosis –Fibroadenoma –Other

32 PATHOLOGY FNANegativePositiveTotal C1459 C C3909 C4013 C Total FNA/Pathology correlation, AUBMC, FN: 1

33 FNA/pathology correlation of palpable masses PATHOLOGY FNA p Negative Positive FCCFAOtherTotal negIDCILCDCISOtherTotal posTotal C C PT35001 crib pap0136 C C tubular12 C (2 Pleo)1 comedo073 Total

34 FNA/pathology correlation of non palpable masses PATHOLOGY FNA n p Negative Positive FCCFAOtherTotal negIDCILCDCISOtherTotal posTotal C C21551 LN C C C5001 (ame) Total

35 C2 (benign) 1 False negative: (1%) DCIS Cribriform and micropapillary. Misinterpreted on FNA as FCC

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39 FCC Cyst content: Clear, few macrophages Hypocellular –Benign duct epithelial cells –Naked nuclei –Apocrine metaplastic cells

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42 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)

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45 C2 (Benign) Negative triplet: Follow up –FNA: Benign –Clinical: Benign –Radiologic: Benign

46 C5 Malignant

47 C5 Malignant Primary –IDC nos –ILC –Mucinous –Tubular –Papillary –Other Metastatic Hematopoetic

48 PATHOLOGY FNANegativePositiveTotal C1459 C C3909 C4013 C Total FNA/Pathology correlation, AUBMC, False positive: Adenomyoepithelioma

49 FNA/pathology correlation of palpable masses PATHOLOGY FNA p Negative Positive FCCFAOtherTotal negIDCILCDCISOtherTotal posTotal C C PT35001 crib pap0136 C C tubular12 C (2 Pleo)1 comedo073 Total

50 FNA/pathology correlation of non palpable masses PATHOLOGY FNA n p Negative Positive FCCFAOtherTotal negIDCILCDCISOtherTotal posTotal C C21551 LN C C C5001 (ame) Total

51 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

52 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

53 Ductal adenocarcinoma nos Cellular Necrotic background Monomorphic cell population Loss of cell cohesion Numerous isolated singe cells Anisonucleosis Lack of ME cells

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57 Tumor grade HISTOLOGY –Glands –Nuclei –Mitosis CYTOLOGY –Nuclei Size Membrane Chromatin Nucleoli Nuclear grade 1-3 Good correlation with histologic grade

58 Special type carcinomas

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62 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

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67 Mucinous carcinoma Well circumscribed, soft Thick mucinous material Cell balls, minimal atypia, few signet rings Cannot diagnose absolutely on FNA

68 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

69 Other carcinomas Not very good No clinical need Carcinoma and nuclear grade

70 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% )

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72 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

73 C5 Management If the TT is positive then definitive treatment is undertaken

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75 C3 & C4 C3: Atypical favor benign C4: Suspicious for malignancy

76 C3 (atypical favor benign) Atypical/indeterminate/favor benign Lesion is probably benign Malignancy cannot be excluded entirely TT

77 C4 (Suspicious probably malignant) Very high probability of malignancy but confirmation is needed prior to definitive therapy Others are complex lesions Additional material

78 PATHOLOGY FNANegativePositiveTotal C1459 C C3909 C4013 C Total FNA/Pathology correlation, AUBMC, C3+C4: 11.6%

79 FNA/pathology correlation of palpable masses PATHOLOGY FNA p Negative Positive FCCFAOtherTotal negIDCILCDCISOtherTotal posTotal C C PT35001 crib pap0136 C C tubular12 C (2 Pleo)1 comedo073 Total

80 FNA/pathology correlation of non palpable masses PATHOLOGY FNA n p Negative Positive FCCFAOtherTotal negIDCILCDCISOtherTotal posTotal C C21551 LN C C C5001 (ame) Total

81 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

82 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%)

83 Inconclusive FNAs of breast with adequate and representative material: A cytologic/histologic study of 18 cases. AUBMC experience N Shabb F Boulous Z Chakhachiro

84 PatientAgeClinical presentation FNA performed by Dx 1 Cytologic cancer category Dx 2 Cytologic cancer category Final diagnosis 158Hypoechoic mass RadiologistC5C4Adenomyoepithelioma cm lumpClinicianC3-4C4DCIS (crib) 367lumpPathologistC2C3DCIS (crib, pap) 465lumpClinicianC4C5Inv crib 540lumpPathologistC4 Inv crib 6464mm U/SRadiologistC4 Tubular 7533cm, grittyPathologistC3-4 Tubular 843fNAClinicianC2C4Tubular 944flumpClinicianC4C5Lobular 1071flumpClinicianC4C3-4Inv adeno (nos) 1/3 1150fNAClinicianC4 Inv adeno (nos) 1/3 1238flump, pregPathologistC4C5Inv adeno (nos) 2/3 1336f1cmPathologistC4C5Inv adeno (nos) 2/3 1450fNon palpable RadiologistC4C5Inv adeno (nos) 2/3 1573f3cmPathologistC4 Inv adeno (nos) 2/3 1666f15cm hem cyst ClinicianC4 ICPC 1729flumpRadiologistC3C3-4FA 1860f2cm grittyPathologistC4 PT malignant Inconclusive/erroneous cellular and representative FNAs/histology

85 Papillary lesions FNA not reliable in distinguishing benign from malignant. Defer to histology

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88 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

89 False positive FNAs Lesions responsible for False + –Fibroadenomas –Epithelial hyperplasia –Pregnancy –Papillary lesions –Reactive atypias –Adenomyoepithelioma Usually interpretative errors Poor specimen preparation TT

90 Post triple test recommendations Benign triplets –FU Malignant triplets –Definitive therapy Mixed triplets –Histologic evaluation

91 Benefits of the triple test False negatives: ↓ 10 to 1% False positives: ↓ 1 to < 0.2%

92 FNA diagnostic accuracy Literature –Sensitivity: 75-98% –Specificity: % –False positive: 0-2.5% –False negative: % –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)

93 CNB vs FNA preoperative evaluation of breast masses CNBFNA Special expertise (Performing + interpretation) NoYes Feel effectNoYes Safety (chest wall)NoYes Time consuming (pathologist)NoYes In situ/invasive+/-- Definitive dxBetterGood Cost/TAT/pain/invasivenessGoodBetter Tumor gradeBetterGood Prognistic markersYesNo Insufficient rateBetter↓ experience False +/-BetterInevitable PalpableGood Non palpableGoodNo Good

94 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)

95 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.

96 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

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98 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

99 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)

100 Disadvantages of FNA False negatives False positives Special training needed to perform and interpret FNA In situ vs invasive carcinoma Complications

101 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, 2 nd ed, NY Igaku-Shoin, 1992.

102 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)

103 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

104 FNA/pathology correlation of palpable masses PATHOLOGY FNA p Negative Positive FCCFAOtherTotal negIDCILCDCISOtherTotal posTotal C C PT35001 crib pap0136 C C tubular12 C (2 Pleo)1 comedo073 Total Sensitivity: TP/TP+FN = 88/88+1 = 98.8% Specificity: TN/TN+FP = 44/44+0 = 100% False negative: 1 False positive: 0

105 FNA/pathology correlation of non palpable masses PATHOLOGY FNA np Negative Positive FCCFAOtherTotal negIDCILCDCISOtherTotal posTotal C C21551 LN C C C5001 (ame) Total Sensitivity: TP/TP+FN = 23/ % Specificity: TN/TN+FP = 26/26+1 =96% False negative: 0 False positive: 1

106 Pitfalls Low grade carcinomas (lobular, tubular, low grade ductal) Apocrine metaplasia and lactational change Have large nuclei and prominent nucleoli

107 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

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109 Acknowledgments Dr Fuad Boulous Dr Zaher Chakhachiro Dr Alexis Bousamra Ms. Nisrine Hashem

110 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

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113 Papilloma Cellular, bloody background Macrophages 3 dimensional papillary clusters, cell balls Tall columnar cells, apocrine cells and ME cells

114 Papillary carcinoma Papilloma + Necrotic debris Atypical cytology High N/C ratio, hyperchromasia, nucleoli Absence of apocrine cells and ME cells

115 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 Palp ableNegativePositiveTotal C1325 C C3606 C4012 C5073 Total

116 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 palpableNegativePositiveTotal C1134 C2210 C3303 C4011 C Total262349


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