Jiwan Thursday Breast Lump Fna

8/13/2019 Jiwan Thursday Breast Lump Fna

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History

1 Giemsa stained slide from a 66 yrs female

with breast mass


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Slide description

Cellular smears

Small to large clusters of cells

Some cells are also found scattered in thesmear

Lakes of extracellular mucin visible in different

areas Branching blood vessels present in many areas

giving chicken wire appearance


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Cell description

Abundant mildly granular cytoplasm with

well-defined borders in scattered cells

Cellular borders are predominantly distinct

Most cells have large hyperchromatic nuclei

placed centrally to eccentrically

Mild pleomorphism Nucleoli inconspicuous in most of the nuclei

Some cells show binucleation


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No mitoses/necrosis visible

Background contains macrophages.


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Points helping in diagnosis

Elderly patient

Abundant background mucin

Clusters of cells Chicken wire blood vessels

Relatively mild nuclear abnormalities


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Diagnosis

Mucinous carcinoma breast


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Discussion


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Other conditions simulating

Mucinous carconoma breast

Mucocele-like lesion

Mucinous fibroadenoma

Mucinous DCIS


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Mucinous carcinoma breast

WHO: a tumor that contains large amount of

extracellular epithelial mucous, sufficient to

be visible grossly, and recognizable

microscopically surrounding and within thetumor cells.

Other names: gelatinous, colloid, mucous and

mucoid carcinoma


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Epidemiology

Occur throughout the age range of ca breast

Mean age of women with pure mucinous

carcinoma is greater than those with

nonmucinous carcinoma


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G/F

Usually round and well-circumscribed

May be clinically and mammographically

mistaken for a benign lesion such as

fibroadenoma or cyst


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Cytology

Characteristic: abundant mucus forming the

background of the smear and dispersed

clusters of cancer cells.

Clusters are coheisve, and show only slight

nuclear abnormalities such as nuclear

enlargement and small nucleoli

Small clusters and single isolated cells also

seen.


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Diagnosis based on the presence of mucus

bathing the clusters and

Chicken wire blood vessels are often very

prominently present in smears (suggestive but

not diagnostic of mucinous carcinoma as they

occur in other lesions too, particularly

fibroadenoma.)


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Histology

Pure mucinous carcinoma is characterized by

the accumulation of abundant EC mucin

around invasive tumor cells

The relative proportions of mucin and

neoplastic epithelium vary from one case to

another but the distribution in any one tumor

tends to be constant

Infiltrating duct carcinoma with focal

mucinous fratures have a lower mean

proportion of EC mucin.


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Mucinous carcinomas are variants of invasive

duct carcinoma and intraductal carcinoma is

found associated with app. 75% of cases,

generally at the periphery.

Tumor cells are arranged in a variety of

patterns in the mucinous secretion

Usually the epithelial arrangement duplicates

the pattern of associated intraductal

carcinoma


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i.e. tumor cells in strands, alveolar nests and

papillary clusters as well as larger sheets that

may have cribriform areas or focal

comedonecrosis

Tubule and gland formation are uncommon.


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Mucocele-like lesions

The lesions occur in the setting of fibrocystic

disease

Abundant mucus

Smaller cell population compared to mucinous

carcinoma

All breast lesions containing abundant mucus

should be excised for H/E because FNA of

these lesions may be highly misleading


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Summary of other types of Ca

breast


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Infiltrating ductal carcinoma of No

Special type

Criteria for diagnosis:

More or less cell-rich smears

Single population of epithelial cells; nomyoepithelial cells, no single bare bipolar

nuclei

Variable loss of cell cohesionirregular

clusters and single cells

Single epithelial cells with intact cytoplasm


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Moderate to severe nuclear atypia:

enlargement, pleomprphism, irregular nuclear

membrane, and chromatin

Fibroblasts and fragments of collagen (stromal

dysplasia) associated with atypical cells

Intracytoplasmic neolumina in some cases

Necrosis unusual, more s/o DCIS


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DCIS

High nuclear grade DCIS, solid or comedo

growth pattern:

Usual findings:

Usually cell reach smears

Neoplastic cells in sheets, irregular aggregates and

single

Large pleomorphic cells showing obviousmalignant nuclear features

Necrotic debris , granular calcium, lymphocytes

and vacuolated macrophages


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The cells of DCIS higher nuclear grade (large

cell, solid and comedo) are large, pleomorphic

and show standard cytological criteria of

malignancy.

The soft, boggy, palpable mass with a highly

cellular aspirate usually indicates a significant

intraductal lesion worthy of excision.


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Low grade DCIS, cribriform, solid or

micropapillary, non-invasive intracystic

papillary carcinoma:

Epithelial cells mainly cohesive forming large

sheets, often with holes or papillary fragments

Bare bipolar nuclei absent

Variable, mild to moderate epithelial atypia Necrotic debris, often calcium granules

macrophages


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Tubular carcinoma

Moderately cellular smears

Cells predominantly in cohesive clusters

Epithelial fragments with an angular or

tubular shape

Relatively uniform, mildly to moderately

atypical epithelial cells

Single bipolar nuclei of benign type often

present in small numbers

Fibroblastic cells, fragments of fibromyxoid or


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A cytological challenge

High false negative rate

But most lesions are stellate on

mammography and suspicious by ultrasound

and are selected for excision

Core biopsy useful for confirmation of dx.


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Medullary carcinoma

Highly cellular smears

Poorly cohesive cells in clusters and single

Large, pleomorphic and obviously malignant

nuclei

Many lymphocytes

Tends to be mammogrphically rounded and well

circumscribed and has a soft feel to the needle


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Pagets disease of nipple

Background of keratin, squamous cells,

inflammatory cells and debris

Large malignant cells, single and in small

groups, closely a/w sq and infl. Cells.

Abundant pale cytoplasm with distinct

borders

Obvious nuclear features of malignancy

Scrape smears from the nipple are an excellent

way to doagnose Pagets disease.

I fil i l b l i


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Infiltrating lobular carcinoma

A variable, often poor cell yield

Cells single and in small clusters, single files

characteristic

Scanty cytoplasm, many naked nuclei, nuclear

moulding in cell clusters

Small hyperchromatic nuclei of relatively

uniform size

Irregularity of nuclear shape

I/C lumina/mucin vacules/signet ring cells


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Few if any naked bipolar nuclei

Traumatized cell pattern

The stroma is abundant, desmoplastic or fibrous

separating small groups and single files of

neoplastic epithelial cells


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Thank you

Jiwan Thursday Breast Lump Fna

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