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Histopathology and Cytology for Breast lesions

Histopathology and Cytology for Breast lesions. Britt-Marie Ljung MD Professor 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

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Histopathology and Cytology for Breast lesions

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  1. Histopathology and Cytology for Breast lesions Britt-Marie Ljung MD Professor of Pathology, Dir. of Cytology University of California at San Francisco

  2. Palpable Breast masses • Fine needle aspiration biopsy (FNA)-cytology • Core needle biopsy (CNB) - histopathology • Open surgical biopsy incisional/excisional -histopathology

  3. FNA biopsy • Sampling with 22-25 gauge needle • Clinic procedure • Immediate check of sample for adequacy and preliminary diagnosis • 2-4 samples depending on size of mass, nature and abundance of material • Local anesthetic optional • Post procedure pain minimal • Processing time for permanent material <1 hour

  4. 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%)

  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

  6. Core needle biopsy • Grading estimate possible, but limited sample, may change after excision • No surgical margins • Size of lesion not reliable • Most cases containing invasive disease will show on core (70+%) depending on number of cores • Immediate preliminary dx can be done using touch preparations

  7. 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

  8. 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

  9. Accuracy issues in common for all modalities • Specimen handling including fixation and staining • Skills in interpretation • Sampling errors, varying degrees

  10. 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

  11. 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

  12. Impact of training in FNA procurement Formally Trained No Formal Training Missed Cancers Missed Cancers 2% 25% Non dx Non dx 2% 37% Ljung et al Cancer 2001:93 (4):263-68

  13. 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

  14. 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

  15. 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

  16. Accuracy Breast Core biopsies, meta-analysis Guided by: False Negative Palpation 0 – 13% Ultrasound 0 - 12% Stereotactic 0.2 – 8.9% Dillon M et al Annals of Surgery Vol 242 No. 5 Nov 2005

  17. Image Guided Core Needle Biopsy Accuracy Strategy: Increase number of cores/weight of tissue Sensitivity Recommended with 5 no of cores 14 gauge cores 14 gauge Mass Lesions 98% 5-6 Ca++ 91% 15 Arch. Dist 86% 15 US-guided 98% 5-12 cores Operator dependent Brenner RJ et al AJR Am J Roentgenol 166:341-346 1996

  18. 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

  19. 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 al The Breast Journal Vol 10 No 6 2004 p. 487-491

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