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Deb R, Laokulrath N, Chagla L, Tan PH. Challenges and Clinical Relevance of Modern Breast Pathology Reporting: Your Questions Answered. Pathobiology 2024; 91:299-312. [PMID: 38330933 DOI: 10.1159/000536638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/31/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Breast pathology reporting, especially for breast cancer, has evolved through the years, from terse succinct diagnostic conclusions with scant histological details to the current comprehensive reporting guidelines issued by major pathology colleges and bodies, including the International Collaboration on Cancer Reporting. Pathology elements included in reporting guidelines are evidence based and contribute significantly to individualised and personalised patient management. SUMMARY This article is based on the lively interactive question and answer session that followed the breast pathology segment in the symposium jointly organised by the British Association of Urological Pathology, British Association of Gynaecological Pathologists, British Society of Gastroenterology and the Association of Breast Pathology, in November 2022, titled "Personalised histopathology reporting for personalised medicine." KEY MESSAGES The breast pathology session emphasised the clinical utility of breast pathology data items, incorporating a case-based approach by highlighting the relevance of pathology information in various clinical scenarios. This review included clinico-pathological discussion points on florid lobular carcinoma in situ, atypical apocrine adenosis, post-neoadjuvant chemotherapy reporting, atypical ductal hyperplasia presenting at the margin, flat epithelial atypia versus columnar cell change, papilloma on core needle biopsy, margin status, mucocele-like lesion, total duct excision/microdochectomy specimen, and anterior and nipple margins in skin-sparing mastectomy. Effective communication and regular involvement of pathologists in breast multidisciplinary tumour boards are crucial.
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Affiliation(s)
- Rahul Deb
- Department of Cellular Pathology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Natthawadee Laokulrath
- Department of Pathology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Leena Chagla
- Burney Breast Unit, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Puay Hoon Tan
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore, Singapore
- Luma Medical Centre, Singapore, Singapore
- Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Pathology, University of Western Sydney, Sydney, New South Wales, Australia
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The Value of Fine Needle Aspiration Biopsy in the Pre-Operative Assessment of the Axilla in Breast Cancer Patients. JOURNAL OF MOLECULAR PATHOLOGY 2022. [DOI: 10.3390/jmp3040020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This paper reviews the role of fine needle aspiration biopsy (FNAB) in assessing the axilla prior to definitive surgery or neoadjuvant therapy in breast cancer patients. The radiological criteria for biopsy are discussed and pathological techniques and pitfalls illustrated. The sensitivity and specificity of the technique and the clinical utility are addressed, with particular reference to the current controversies in the management of the axilla in the light of the American College of Surgeons Oncology Group Z0011 trial results. The low morbidity procedure of FNAB is recommended when the radiological and clinical features suggest a high yield from the abnormal axillary nodes, with consideration of core biopsy if an expected positive result is not obtained or the circumstances require tissue for ancillary studies. In conclusion, FNAB of the axilla is a highly sensitive procedure which can offer further valuable information to assist in clinical decision making. The technique is of particular value in the setting of a large primary tumour size and multiple enlarged nodes. A summary flow chart is provided to facilitate pre-operative management of the axilla and to encourage a universal approach.
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Agrawal N, Kothari K, Tummidi S, Sood P, Agnihotri M, Shah V. Fine-Needle Aspiration Biopsy Cytopathology of Breast Lesions Using the International Academy of Cytology Yokohama System and Rapid On-Site Evaluation: A Single-Institute Experience. Acta Cytol 2021; 65:463-477. [PMID: 34515039 DOI: 10.1159/000518375] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 07/07/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Breast cancer is rapidly emerging as the leading cause of cancer in Indian women. Robust cytopathology and histopathology services are required to tackle this growing burden. The use of rapid on-site evaluation (ROSE) and the International Academy of Cytology (IAC) Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy (FNAB) Cytopathology, which offers structured protocols, are expected to improve breast cytopathology reporting. METHODS We retrieved the cytopathology slides, categorized them by the IAC Yokohama System and histopathology data of all the patients who had been investigated for breast lesions from September 2016 to December 2018, and compared the cytopathology and histopathology. Risk of malignancy (ROM) and performance metrics, like sensitivity, specificity, predictive values, accuracy, and area under the curve were computed. RESULTS A total of 1,147 FNABs were evaluated, of which 442 (38.5%) underwent ROSE and 624 (54.4%) histopathology. Reported using IAC categories, our cohort recorded 4.9% inadequate, 65.3% benign, 7.8% atypical, 3.3% suspicious for malignancy, and 18.7% malignant lesions. The overall sensitivity and specificity for identifying in situ and malignant lesions were 99.1% and 99.3%, respectively, and were substantially improved by ROSE. ROSE improved the concordance between cytopathology and histopathology from 76.9% to 90.2%, by reducing inadequate (p < 0.001) cases. The ROM increased along a gradient from inadequate to malignant categories, with the gradient being sharpened by ROSE. The false negativity rate was 0.7% and false positivity rate 0%. CONCLUSION Incorporating ROSE and the IAC Yokohama System for breast cytopathology reporting improves accurate diagnosis of breast lesions, prevents missed diagnoses, and provides reliable estimates of ROM. These protocols also aid in standardizing a reproducible system for monitoring and auditing of breast pathology services, identify areas that need strengthening, and improve training at pathology centers.
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Affiliation(s)
- Neha Agrawal
- Department of Cytopathology, Seth GSMC & KEMH, Parel, Mumbai, India
| | - Kanchan Kothari
- Department of Cytopathology, Seth GSMC & KEMH, Parel, Mumbai, India
| | - Santosh Tummidi
- Department of Pathology, All India Institute of Medical Sciences (AIIMS), Mangalagiri, India
| | - Prashant Sood
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Bilaspur, India
| | - Mona Agnihotri
- Department of Cytopathology, Seth GSMC & KEMH, Parel, Mumbai, India
| | - Vyoma Shah
- Sir HN Reliance Foundation Hospital, Mumbai, India
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Chung HL, Le-Petross HT, Leung JWT. Imaging Updates to Breast Cancer Lymph Node Management. Radiographics 2021; 41:1283-1299. [PMID: 34469221 DOI: 10.1148/rg.2021210053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Metastatic lymph node involvement in breast cancer is a key determinant of the overall stage of disease and prognosis. Historically, lymph node status was determined by surgery first, with adjuvant treatments determined based on the results of the final surgical pathologic analysis. While this sequence is still applicable in many cases, neoadjuvant systemic treatment (NST) is increasingly being administered as the initial treatment. In cases that demonstrate good therapeutic response to drug therapies, NST may permit the option to perform less radical surgeries subsequently. Current breast cancer treatment has become multidisciplinary, with overlapping roles from the different disciplines. As surgery may be postponed, imaging and image-guided lymph node interventions have gained importance as the primary means of lymph node assessment. Imaging enables evaluation of all regional nodal basins, including locations where surgery is not usually performed. By differentiating limited versus extensive nodal involvement, imaging findings help determine whether initial treatment should be surgical or medical. If medical treatment with NST is indicated, imaging is performed to monitor the in vivo nodal response to drug therapy and ultimately to help determine the surgical technique to perform on the basis of the final imaging findings after NST. The authors discuss the imaging features of nodal metastases and the indications and techniques for the various image-guided procedures. The relative usefulness and shortcomings of the various imaging examinations are reviewed to discuss how they can be applied when biopsy results are not available. The role of imaging in the multidisciplinary team approach is emphasized based on past clinical trials of lymph node management and recent evolving knowledge of breast cancer staging. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Hannah L Chung
- From the Department of Breast Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Huong T Le-Petross
- From the Department of Breast Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Jessica W T Leung
- From the Department of Breast Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
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Abe M, Yamada T, Nakano A. Prospective Comparison of Intraoperative Touch Imprint Cytology and Frozen Section Histology on Axillary Sentinel Lymph Nodes in Early Breast Cancer Patients. Acta Cytol 2020; 64:492-497. [PMID: 32450564 DOI: 10.1159/000508016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/20/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Since the late 1970s, sentinel lymph node biopsy (SLNB) has been used for several solid malignancies to identify lymph node metastases. This procedure is associated with less surgical morbidity than complete lymphadenectomy. Recent evidence suggests that axillary lymphadenectomy is not required for breast sentinel nodes with micrometastases (≤2 mm). Current clinical management of sentinel nodes indicates that only macrometastases (>2 mm) should be detected intraoperatively. In Japan, an intraoperative histopathological frozen section (FS) method is used to identify lymph node metastases, but this method takes more than 30 min and requires complex techniques and expensive equipment. Touch imprint cytology (TIC) is an easier, less expensive, and faster method, but its sensitivity has been shown to be low. OBJECTIVE The purpose of this study was to determine if TIC is more useful than FS in identifying macrometastases in sentinel lymph nodes in preoperative node-negative breast cancer operations. METHODS A prospective review of 49 consecutive patients with node-negative breast cancer treated with SLNB and intraoperative TIC and FS between November 2017 and June 2019 was performed. TIC samples were stained using Papanicolaou and Diff-Quick stains. Results were compared with routine postoperative paraffin sections. RESULTS With TIC, the Papanicolaou stain took a mean of 12 min, and the Diff-Quick stain took a mean of 10 min. Results of both TIC stain methods were the same. In contrast, the FS method took a mean of 80 min (including the transfer of specimens to a different hospital with the necessary equipment). TIC confirmed macrometastases in 5 cases. All macrometastases were diagnosed equally by the 2 techniques. Both the sensitivity and specificity of TIC were 100% for detection of macrometastases. CONCLUSION TIC of SLNB for breast cancer is an easy and useful method for the detection of macrometastases of breast sentinel nodes.
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Affiliation(s)
- Makoto Abe
- Department of Breast Surgery, Tajimi City Hospital, Tajimi, Japan,
| | - Tetsuya Yamada
- Department of Pathology, Kizawa Memorial Hospital, Minokamo, Japan
| | - Akinobu Nakano
- Department of Pathology, Tajimi City Hospital, Tajimi, Japan
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Field AS, Raymond WA, Schmitt FC. The International Academy of Cytology Yokohama System for Reporting Breast Fine Needle Aspiration Biopsy Cytopathology. Acta Cytol 2019; 63:255-256. [PMID: 31137023 DOI: 10.1159/000501055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Andrew S Field
- University of NSW and University of Notre Dame Medical Schools, and Department of Anatomical Pathology, St Vincent's Hospital, Sydney, New South Wales, Australia,
| | - Wendy A Raymond
- South Australian Pathology, Department of Surgical Pathology, Flinders Medical Centre, Flinders University of South Australia, and Clinpath, Adelaide, South Australia, Australia
| | - Fernando C Schmitt
- Institute of Molecular Pathology and Immunology of Porto University (IPATIMUP), Instituto de Investigação e Inovação em Saúde and Medical Faculty, University of Porto, Porto, Portugal
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Field AS, Raymond WA, Rickard M, Arnold L, Brachtel EF, Chaiwun B, Chen L, Di Bonito L, Kurtycz DFI, Lee AHS, Lim E, Ljung BM, Michelow P, Osamura RY, Pinamonti M, Sauer T, Segara D, Tse G, Vielh P, Chong PY, Schmitt F. The International Academy of Cytology Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy Cytopathology. Acta Cytol 2019; 63:257-273. [PMID: 31112942 DOI: 10.1159/000499509] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 03/07/2019] [Indexed: 01/29/2023]
Abstract
The International Academy of Cytology (IAC) gathered together a group of cytopathologists expert in breast cytology who, working with clinicians expert in breast diagnostics and management, have developed the IAC Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy (FNAB) Cytology. The project was initiated with the first cytopathology group meeting in Yokohama at the 2016 International Congress of Cytology. This IAC Yokohama System defines five categories for reporting breast cytology, each with a clear descriptive term for the category, a definition, a risk of malignancy (ROM) and a suggested management algorithm. The key diagnostic cytopathology features of each of the lesions within each category will be presented more fully in a subsequent atlas. The System emphasizes that the crucial requirements for diagnostic breast FNAB cytology are a high standard for the performance of the FNAB and for the making of direct smears, and well-trained experienced cytopathologists to interpret the material. The performance indicators of breast FNAB, including specificity and sensitivity, negative predictive value, positive predictive value and ROM stated in this article have been derived from the recent literature. The current practice of breast FNAB has evolved with the increasing use of ultrasound guidance and rapid on-site evaluation. Two recent publications have shown a range of ROM for the insufficient/inadequate category of 2.6-4.8%, benign 1.4-2.3%, atypical 13-15.7%, suspicious of malignancy 84.6-97.1%, and malignant 99.0-100%. The management algorithm in the System provides options because there are variations in the management of breast lesions using FNAB and core-needle biopsy in those countries utilizing the "triple test" of clinical, imaging, and FNAB assessment, and also variations in the availability of CNB and imaging in low- and middle-income countries. The System will stimulate further discussion and research, particularly in the cytological diagnostic features of specific lesions within each category and in management recommendations. This will lead to continuing improvements in the care of patients with breast lesions and possible modifications to the IAC Yokohama System.
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Affiliation(s)
- Andrew S Field
- Department of Pathology, St Vincent's Hospital, and University of NSW and University of Notre Dame Medical Schools, Sydney, New South Wales, Australia,
| | - Wendy A Raymond
- South Australian Pathology, Department of Surgical Pathology, Flinders Medical Centre, Flinders University of South Australia, and Clinpath, Adelaide, South Australia, Australia
| | - Mary Rickard
- BreastScreen NSW and Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Lauren Arnold
- Sydney Breast Clinic, Sydney, New South Wales, Australia
| | - Elena F Brachtel
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Benjaporn Chaiwun
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Lan Chen
- Pathology Department, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Luigi Di Bonito
- Department of Anatomical Pathology, University of Trieste, Trieste, Italy
| | - Daniel F I Kurtycz
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Wisconsin State Laboratory of Hygiene, University of Wisconsin, Madison, Wisconsin, USA
| | - Andrew H S Lee
- Department of Histopathology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Elgene Lim
- Connie Johnson Breast Cancer Research Laboratory, Garvan Institute of Medical Research, St Vincent's Hospital, UNSW Medical School, Sydney, New South Wales, Australia
| | - Britt-Marie Ljung
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Pamela Michelow
- Department of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | - Robert Y Osamura
- Nippon Koukan Hospital, Kawasaki, Japan
- Keio University School of Medicine, Tokyo, Japan
| | | | - Torill Sauer
- Institute of Clinical Medicine, Department of Pathology, Faculty of Medicine, Akershus University Hospital, University of Oslo, Oslo, Norway
| | - Davendra Segara
- Breast Surgical Oncologist, St Vincent's Private Hospital, Sydney, New South Wales, Australia
| | - Gary Tse
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, Sha Tin, Hong Kong
| | - Philippe Vielh
- Laboratoire National de Santé, Departement de Pathologie Morphologique et Moleculaire, Dudelange, Luxembourg
| | - Phek Y Chong
- Department of Pathology, Sengkang General Hospital, SingHealth Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Fernando Schmitt
- Institute of Molecular Pathology and Immunology, Instituto de Investigação e Inovação em Saúde and Medical Faculty, University of Porto, Porto, Portugal
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