Diagnosis and subclassification of breast carcinoma by fine-needle aspiration biopsy: results of the interlaboratory comparison program in non-gynecologic cytopathology

The Role of Fine Needle Aspiration Cytology in Triple Assessment of Patients with Malignant Breast Lumps

Background:

Breast cancer is the leading female malignancy in the world and now the most common cancer in Nigeria. The evaluation of patients with breast cancer requires stepwise diagnostic approach to achieve a combined diagnostic information required to make an enhanced decision on how best to approach management. The aim of this study is to evaluate the role of fine needle aspiration cytology (FNAC) in the triple assessment of patients with malignant breast lumps in our center.

Patients and Methods:

This is a descriptive prospective study of patients with palpable breast lumps over an eighteen-month period. The patients were sequentially subjected to FNAC and open biopsy. Those whose lumps were malignant were further evaluated.

Results:

There were 88 (44.9%) and 108 (55.1%) biopsy confirmed breast cancers and benign lumps, respectively. From cytology reports, there were 12 (6.1%) unsatisfactory (C1), 96 (49%) benign (C2), 8 (4.1%) atypical (C3), 10 (5.1%) suspicious of malignancy and 70 (35.7%) unequivocally malignant (C5) smears. FNAC performed better than clinical examination in the validity tests for breast malignancy. The diagnostic results for breast malignancies were 97.2% (sensitivity), 98.9% (specificity), 1.4% (false positive rate []), 2.1% (false negative rate), 98.6% (positive predictive value), 97.9% (negative predictive value), and overall diagnostic accuracy of 98.2%.

Conclusion:

Considering the high performance of diagnostic cytology noted above, FNAC has proved itself to be useful and significantly accurate in making diagnosis of breast cancers in our center.

Sub-classification of Breast Masses by Fine Needle Aspiration Cytology

OBJECTIVE

The aim of this study is to evaluate the accuracy of sub-classification of breast diseases using Fine Needle Aspiration cytology (FNAC).

MATERIALS AND METHODS

A one-year prospective study of 180 consecutive patients with palpable breast lesions who underwent FNAC and subsequently open surgical biopsy for histological confirmation. FNAC was used to sub-classify breast lesions and then correlated with histological diagnosis.

RESULTS

A total of 180 patients were enrolled into the study but only 110 patients with histology report were used for test validity. Seventeen (15.5%) smears were C1; while 46 (41.8%), 5 (4.5%), 4 (3.6%) and 38 (34.6%) were C2, C3, C4 and C5, respectively. FNAC achieved sensitivity of 90.0%, specificity of 95.5%, false positive rate of 5.3%, false negative rate of 8.7%, positive predictive value of 94.7%, negative predictive value of 91.3% and overall diagnostic accuracy of 92.9%. Only 86 (78.2%) of the 110 smears could be sub-classified into different disease conditions of the breast on cytology. FNAC accurately sub-classified 25(78.1%) of fibroadenoma and 28(87.5%) of invasive ductal carcinoma.

CONCLUSION

FNAC can reasonably sub-classify fibroadenoma, invasive ductal carcinoma and mastitis but there is still a challenge with lobular carcinomas, metaplastic carcinomas, papillary carcinomas and fibrocystic changes.

Performance Characteristics of Mucinous (Colloid) Carcinoma of the Breast in Fine-Needle Aspirates: Observations From the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytopathology

Context.—Mucinous breast carcinoma has characteristic cytologic features, but few studies exist that analyze the reproducibility of this diagnosis.

Objective.—To analyze participants' diagnosis of mucinous carcinoma in breast fine-needle aspiration (FNA) slides distributed in an educational interlaboratory peer comparison program.

Design.—Participant responses for FNA slides with a reference diagnosis of mucinous carcinoma, distributed between 2001–2008 in the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytopathology, were evaluated for concordance with the general category and reference diagnosis of mucinous carcinoma.

Results.—Of 8061 responses, 6353 (78.8%) were categorized as malignant; 775 (9.6%) as suspicious; and 933 (11.6%) as negative. The most frequent incorrect responses for the benign category included fibroadenoma (51.7%), nonspecified benign lesion (12%), fibrocystic changes (7.8%), and fat necrosis/granulomatosis/foreign body reaction (6.9%). Conventional Papanicolaou-stained preparations were reviewed for 58.7% (4732) of responses; of these, 39.4% (3177) were from modified Giemsa–stained smears and 1.9% (152) from ThinPrep slides. Papanicolaou-stained conventional smears had the lowest concordance (86.5%) when compared to modified Giemsa–stained smears (91.2%) and ThinPrep challenges (92.1%) (P < .001). Participants specifically diagnosed mucinous carcinoma 37.3% of the time, and modified Giemsa–stained challenges performed best (43.1%, P < .001). There was no significant difference between cytotechnologists' and pathologists' responses (87.9% versus 88.2%; P  =  .69).

Conclusions.—Mucinous carcinoma in FNA was not accurately identified in a glass slide interlaboratory comparison program. We observed better performance with modified Giemsa–stained and ThinPrep slides than with Papanicolaou-stained preparations. The most common response for the benign category of mucinous carcinoma was fibroadenoma. Increased awareness of the cytologic features of mucinous carcinoma may improve accuracy in breast FNA.

Non-Hodgkin's lymphoma presenting as breast masses: a series of 10 cases diagnosed on FNAC

Primary breast lymphoma (PBL) is a rare disease, which comprises 0.04-0.53% of all primary malignant tumors of the breast. The most frequent histological subtype is diffuse large B-cell type (DLBCL) (40-70%). Differentiation of PBLs from other breast tumors such as poorly differentiated carcinomas and lobular carcinoma may at times be difficult on cytomorphology alone. An audit of breast lymphomas diagnosed on fine needle aspiration cytology (FNAC) over a period of 9 years (2001-2009) was performed. Ten cases were retrieved and the cytomorphology was reviewed along with immunochemistry (IHC), flow cytometry as well as histopathology, wherever available. The age of patients ranged from 17 to 83 years. Eight cases were diagnosed as non-Hodgkin's lymphoma, high-grade on FNAC. Histopathology was available in four of these cases and cell block was available in one case. Lymphoid cells were positive for leukocyte-common antigen (LCA) and CD20 and negative for CD3 in these cases. The same was confirmed by flow cytometry on aspirated material in one case. A diagnosis of DLBCL was offered in these five cases. One case was a low-grade NHL and another case was a young male, a known case of acute leukemia and had leukemic infiltration in the breast lump. We wish to emphasize the potential importance of FNAC in breast lymphoma and the same can be helpful to avoid unnecessary surgery in these cases. The differential diagnostic entities have been discussed. IHC and flow cytometry can be performed on the aspirated material and provide valuable information.

Recent trends in quality, patient safety, and error reduction in nongyn cytology

This article reviews recent trends in nongyn cytology with an emphasis on error reduction, second opinion, and critical diagnosis. Compared with the surgical pathology literature, there is only a limited number of reports addressing these topics in nongyn cytology. Discussion of the error literature in nongyn cytology is presented with the intent to better identify error-prone cytology cases that could prompt intradepartmental consultation or an outside cytology expert's second opinion. The cytology second-opinion literature is also reviewed with the recommendation that interinstitutional second opinions add value to patient care. Last, the recent concept of critical value (critical diagnosis) in cytopathology is presented. All these initiatives promote patient safety, improve quality, decrease errors, and benefit patients.

Disease-specific gene repositioning in breast cancer

Genomes are nonrandomly organized within the three-dimensional space of the cell nucleus. Here, we have identified several genes whose nuclear positions are altered in human invasive breast cancer compared with normal breast tissue. The changes in positioning are gene specific and are not a reflection of genomic instability within the cancer tissue. Repositioning events are specific to cancer and do not generally occur in noncancerous breast disease. Moreover, we show that the spatial positions of genes are highly consistent between individuals. Our data indicate that cancer cells have disease-specific gene distributions. These interphase gene positioning patterns may be used to identify cancer tissues.

A mouse model for luminal epithelial like ER positive subtype of human breast cancer

Background

Generation of novel spontaneous ER positive mammary tumor animal model from heterozygous NIH nude mice.

Methods

Using brother-sister mating with pedigree expansion system, we derived a colony of heterozygous breeding females showing ER-Positive tumors around the age of 6 months. Complete blood picture, differential leukocyte count, and serum levels of Estrogen, Alanine amino transferase (SGPT), Aspartate amino transferase (SGOT), total protein and albumin were estimated. Aspiration biopsies and microbiology were carried out. Gross pathology of the tumors and their metastatic potential were assessed. The tumors were excised and further characterized using histopathology, cytology, electron microscopy (EM), molecular markers and Mouse mammary Tumor Virus – Long Terminal Repeats (MMTV LTR) specific RT-PCR.

Results

The tumors originated from 2^ndor 5^thor both the mammary glands and were multi-nodulated with variable central necrosis accompanied with an accumulation of inflammatory exudate. Significant increases in estrogen, SGPT, SGOT and neutrophils levels were noticed. Histopathologically, invasive nodular masses of pleomorphic tubular neoplastic epithelial cells invaded fibro-vascular stroma, adjacent dermis and subcutaneous tissue. Metastatic spread through hematogenous and regional lymph nodes, into liver, lungs, spleen, heart and dermal lymphatics was observed. EM picture revealed no viral particles and MMTV-negativity was confirmed through MMTV LTR-specific RT-PCR. High expression of ER α, moderate to high expression of proliferating cell nuclear antigen (PCNA), moderate expression of vimentin and Cytokeratin 19 (K19) and low expression of p53 were observed in tumor sections, when compared with that of the normal mammary gland.

Conclusion

Since 75% of human breast cancer were classified ER-positive and as our model mimics (in most of the characteristics, such as histopathology, metastasis, high estrogen levels) the ER-positive luminal epithelial-like human breast cancer, this model will be an attractive tool to understand the biology of estrogen-dependant breast cancer in women. To our knowledge, this is the first report of a spontaneous mammary model displaying regional lymph node involvement with both hematogenous and lymphatic spread to liver, lung, heart, spleen and lymph nodes.

Fine-needle aspiration cytology of medullary breast carcinoma: report of two cases and review of the literature with emphasis on differential diagnosis

Medullary carcinoma is a rare variant of breast carcinoma with a relatively good clinical prognosis as strictly defined. Characteristic features on fine-needle aspiration cytology (FNAC) allow medullary carcinoma to be considered in the cytologic differential diagnosis. We present two FNAC cases with such features, including high cellularity with clusters and single intact malignant cells, bizarre stripped nuclei with prominent nucleoli in a lymphoplasmacytic background, and illustrate one case in liquid-based preparation. Surgical excision revealed that one patient had medullary carcinoma, while the second patient had high-grade infiltrating ductal carcinoma. Breast FNAC samples with syncytial fragments, bizarre nuclei with prominent nucleoli, and a chronic inflammatory infiltrate should raise the possibility of medullary carcinoma. However, the differential diagnosis also includes high-grade ductal carcinoma, lymphoma, or metastasis to breast or intramammary lymph nodes; thus, histopathologic analysis is required for definitive diagnosis.

Imprint cytology of needle core-biopsy specimens of breast lesions: Is it a useful adjunt to rapid assessment breast clinics?

This study aimed at assessing the practicability of imprint cytology (IC) of core biopsy (CB) specimens in order to achieve one-stop diagnosis of breast lesions. In total, 199 symptomatic patients underwent free-hand CB of the suspected breast lesions. The slides were stained by Diff-QuikO and reported independently of histological reporting. For practical reasons cytology specimens were graded as follows: C1=inadequate, as less than 4 groups of epithelial cells were seen, C2=benign, C3=probably benign, C4=probably malignant and C5=positive for malignancy. The results of IC were correlated with CB histology. Absolute sensitivity of the IC was 85.0% and complete sensitivity was 89.2% when correlated with CB. Specificity (biopsy cases only) of IC was 53.1% while full specificity was 53.1%. Positive predictive value of C5 was 99.3%, C4 55.6 % and C3 was 100%. Overall suspicious rate was 5.5%. It was concluded that IC is a reliable way of diagnosing symptomatic breast lesions in one-stop breast clinic and retains the advantage of pre-operative availability of detailed pathological characteristics of tumours for treatment planning.

Fine-needle aspiration cytologic features of four special types of breast cancers: Mucinous, medullary, apocrine, and papillary

Recognition of special types of breast cancers by fine-needle aspiration (FNA) cytology may have prognostic implications but some difficulties still exist in the ability of cytopathologists to determine the tumor subtypes. Detailed cytomorphological features were studied in the four special and unusual types of breast cancer cases (8 cases of mucinous, 9 medullary, 9 apocrime, and 11 papillary) and compared between themselves and with those of 32 duct cell carcinomas, not otherwise specified (NOS). Papillary carcinomas were also compared with 10 benign papillary lesions. The significance of the differences was determined using Fishers' Exact Test of Probability. In mucinous carcinoma, the frequency of signet ring cells (62.5%), and background pools of mucin (87.5%) were significantly higher than those of duct cell carcinoma (NOS), medullary carcinoma, apocrine carcinoma, and papillary carcinoma (P = 0.0408 to < 0.0001). In medullary carcinomas, lymphomononuclear cell infiltration (100.0%) was observed in significantly higher number of cases than in papillary, mucinous, and apocrine types (P < 0.0001). Further, moderate to marked nuclear pleomorphism (100.0%) and nuclear irregularity (77.8%) was significantly higher than those of mucinous carcinoma and papillary carcinoma (P = 0.0294 to <0.0003). Abnormal apocrine cells and papillary formation, characterizing all the apocrine carcinomas and papillary carcinomas, respectively, were present in significantly lower number in other variants and in duct cell carcinoma (NOS) (P = 0.0002 to <0.0001). Glycogen vacuoles (63.6%) were observed in a significantly higher number of papillary carcinoma as compared to duct cell carcinoma (NOS), apocrine, and medullary carcinomas (P = 0.0047 to 0.0022). The significant parameters differentiating papillary carcinoma and benign papillary lesions were loose cohesive clusters (P = 0.001) and acinar formation by neoplastic cells (P = 0.0237). Histopathology reports available in 36 cases, confirmed the cytodiagnosis of carcinoma in all 35 cases and the benign lesion in one case. Cytological subtyping was confirmed in 13 of 16 special types of carcinomas and all the 15 duct cell carcinoma (NOS). Thus, special and unusual variants of duct cell carcinomas like mucinous, medullary, apocrine, and papillary have specific cytomorphological features, which differentiate them from one another and from duct cell carcinoma (NOS). However, differentiating features between papillary carcinoma and benign papillary lesions were very few in this study.

Role of fine needle aspiration and tru cut biopsy in diagnosis of mucinous carcinoma of breast—from a radiologist's perspective

This study was to assess whether fine needle aspiration (FNA) or core biopsy would allow diagnosis of mucinous carcinoma of breast. In 37 mucinous carcinoma in 34 patients, 20 lesions had FNA and 24 lesions with core biopsy. FNA achieved a sensitivity of 66.7% in diagnosis of malignant lesions and 56% sensitivity in diagnosis of mucinous carcinoma. Core biopsy achieved 100% sensitivity and accuracy in the diagnosis of malignant lesions and mucinous carcinoma.

Cytomorphology of Common Malignant Tumors of the Breast

A definitive cytologic diagnosis of breast cancer is usually possible when using the six major criteria of malignancy (cellularity, dyshesion, monomorphism, anisonucleosis, irregular nuclear membranes, prominent nucleoli) as part of the triple test. Carcinomas of special type have unique clinical and cytologic features that pathologists need to consider, because these may confuse interpretation. Complete subtyping of carcinomas may not always be possible by fine needle aspiration. Diagnostic accuracy for breast carcinoma is excellent. False-negative diagnoses are infrequent and chiefly due to sampling issues. False-positive diagnoses are extremely rare. Uniform report terminology should be used to ensure that diagnostic information is conveyed appropriately and consistently to guide the next diagnostic or treatment step.

Bilateral primary lymphoma of the breast: A case report initially diagnosed by FNAC

Primary lymphoma of the breast (PLB) is a rare disease, representing 0.04-0.5% of all malignant breast neoplasms. We present a patient with bilateral breast involvement by a high-grade diffuse large B-cell lymphoma, which was diagnosed initially by fine-needle aspiration cytology (FNAC). Mammography revealed a diffuse increase in density of the right breast and a large solitary mass on the left breast, suggestive of an inflammatory carcinoma. The patient underwent FNAC and the diagnosis of a non-Hodgkin's lymphoma (NHL) was suggested. Physical examination revealed palpable bilateral axillary lymph nodes but no evidence of concurrent widespread disease. The patient underwent complete staging evaluation. The only positive findings were an elevated lactate dehydrogenase (LDH) and evidence of axillary lymphadenopathy on CT. Excisional biopsy was performed on the left breast. The morphological and immunohistochemical analysis confirmed the diagnosis of a high-grade diffuse large B-cell lymphoma with an immunophenotype suggestive of a germinal center cell origin.

The poor responsiveness of infiltrating lobular breast carcinomas to neoadjuvant chemotherapy can be explained by their biological profile

The aim of this study was to determine the chemosensitivity of infiltrating lobular breast carcinoma (ILC) in comparison with infiltrating ductal carcinoma (IDC). Between 1987 and 1995, 457 patients with invasive T2>3 cm-T4 breast carcinomas were treated with primary chemotherapy (CT), surgery, radiation therapy. Clinical response, the possibility of breast preservation, pathological response and survival were evaluated according to the histological type. In order to evaluate the biological differences between ILC and IDC patients and their implication with regard to tumour chemosensitivity, additional immunohistochemical stainings (oestrogen receptor (ER), Bcl2, p53, c-erbB-2 and Ki67) were performed on 129 pretherapeutical specimens. 38 (8.3%) ILC were diagnosed by core needle biopsy before CT. ILC was an independent predictor of a poor clinical response (P=0.02) and ineligibility for breast-conserving surgery after neoadjuvant chemotherapy (P=0.03). Histological and biological factors predicting a poor response to CT (histological grade, ER, Ki67 and p53 status) were more frequent in ILC than in IDC patients. After a median follow-up of 98 months (range: 3-166), the low chemosensitivity of ILC did not result in a survival disadvantage. Our results demonstrate that ILC achieved a lower response to CT than IDC because of their immunohistochemical profile. Preoperative CT did not allow a high rate of conservative treatment for ILC and therefore the use of neoadjuvant CT for ILC patients should be questioned.