Histopathology and Cytology for Breast lesions Britt-Marie Ljung MD Professor of Pathology, Dir. of...
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Transcript of Histopathology and Cytology for Breast lesions Britt-Marie Ljung MD Professor of Pathology, Dir. of...
Histopathology and Cytology for Breast lesions
Britt-Marie Ljung MDProfessor of Pathology, Dir. of Cytology
University of California at San Francisco
Palpable Breast masses
Fine needle aspiration biopsy (FNA)-cytology
Core needle biopsy (CNB) - histopathology
Open surgical biopsy incisional/excisional -histopathology
FNA biopsy
Sampling with 22-25 gauge needleClinic procedureImmediate check of sample for adequacy and preliminary diagnosis 2-4 samples depending on size of mass, nature and abundance of material Local anesthetic optionalPost procedure pain minimal Processing time for permanent material
<1 hour
FNA biopsy
Preliminary dx within minutes possible
Cell block material can be used for hormone receptor evaluation
Nuclear grading only
Cannot prove invasive component based on FNA alone (5%)
Core needle biopsy
11-18 gauge needles
Clinic procedure
5 to about 15 cores
Local anesthetic necessary
Post procedure pain can be significant
Processing time for permanent specimen 24+ hours
Core needle biopsy
Grading estimate possible, but limited sample, may change after excisionNo surgical margins Size of lesion not reliableMost cases containing invasive disease will show on core (70+%) depending on number of coresImmediate preliminary dx can be done using touch preparations
Open surgical biopsy
Requires operating room facility
Local or general anesthesia necessary
Immediate evaluation possible by frozen section or touch/scrape preparation
Processing time of permanent sections
2+ days
Invasive component verifyable in virtually all cases
Post op discomfort significant in all cases
Open surgical biopsy/excision
surgical margins
Size of lesion if excisional bx
Comprehensive view of DCIS vs invasive disease
Final grading
Removal of mass if excisional bx
Accuracy issues in common for all modalities
Specimen handling including fixation
and staining
Skills in interpretation
Sampling errors, varying degrees
FNAB Accuracy Palpable Breast, Meta-analysis
Sensitivity 65% - 98%
Specificity 34% - 100%
Giard R and Herman SJ
Cancer Apr 15, 1992
Vol 69, No 8, p. 2104
FNAB Accuracy – Impact of Training in Sampling Technique
Sensitivity Specificity With Training
98% 100%
Without Training 75% 100%
Definition of training in sampling technique: > 100 cases during up to one year supervised by
experienced teacher with proven track record.Ljung et al
Cancer (Cancer Cytopathology)2001; 93: 23-268
Impact of training in FNA procurement
Formally Trained No Formal Training Missed Cancers Missed Cancers
2% 25%
Non dx Non dx2% 37%
Ljung et alCancer
2001:93 (4):263-68
Impact of training in FNA procurement
Formally trained operators did on average more FNAs
Operators without formal training who did many FNAs did NOT perform better than operators without training who did few FNAs
Conclusion: Experience without training did not improve performance
Factors improving FNA accuracy
Hands-on one-to-one training in sampling technique
Frequent use of the technique (>100/y)
Immediate evaluation and use of direct smears
Sampling and interpretation by same person
Interpret FNA in clinical context (Triple test, breast)
US guidance for small and non-palpable targets
Levels of training, FNA sampling
See one, do one, teach one ~ 50% dx
10 cases in training ~ 60% dx
50 cases in training ~ 85% dx
100 cases in training ~ 90% dx
200 cases in training ~ 95% dx
Accuracy Breast Core biopsies, meta-analysisGuided by:
False Negative
Palpation 0 – 13%
Ultrasound 0 - 12%
Stereotactic 0.2 – 8.9%
Dillon M et alAnnals of Surgery
Vol 242 No. 5 Nov 2005
Image Guided Core Needle Biopsy Accuracy
Strategy: Increase number of cores/weight of tissue Sensitivity Recommended
with 5 no of cores14 gauge cores 14 gauge
Mass Lesions 98% 5-6
Ca++ 91% 15
Arch. Dist 86% 15
US-guided 98% 5-12 cores
Operator dependentBrenner RJ et al
AJR Am J Roentgenol166:341-346 1996
Accuracy Open biopsy
Sampling problems are rare but not zero particularly for small lesions and lesions found by imaging
Interpretation issues most common in lobular carcinoma with sparse and very small tumor cells that can mimmick lymphocytes
FNAB as part of Triple Testin palpable lesions
Reported False neg rate FNAB alone 7%
When applying Triple Test for Breast (clinical+imaging+cytology findings)False negative rate 0%
Conclusion: if the bx result does not fit, regardless of bx type, take additional steps
Lau S et alThe Breast Journal
Vol 10 No 6 2004 p. 487-491