NONOPERATIVE DIAGNOSIS

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NON-OPERATIVE DIAGNOSIS
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NON-OPERATIVE DIAGNOSIS

• Pathology is part of triple assessment
  clinical, radiological and pathological
• Pathological methods
• Fine Needle Aspiration
• Needle Core biopsy
• Mammotome

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FINE NEEDLE ASPIRATION

• Uses 21G, 23G, 25G needle
• Highly operator dependent
• Well tolerated by patients
• Suitable for rapid diagnosis one stop clinics
• Method of choice for palpable lumps and
  impalpable masses??

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FINE NEEDLE ASPIRATION

• Diagnostic categories
• C1 Insufficient
• C2 Benign
• C3 Atypical, probably benign
• C4 Suspicious of malignancy
• C5 Unequivocally malignant

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FINE NEEDLE ASPIRATION

• Major diagnostic criteria
• Cellularity, cohesion, nucler size,
  presence/absence of myopeithelial bare nuclei
• Minor diagnostic criteria
• Pleomorphism, nuclear irregularity, prominent
  nucleoli, nuclei overlapping/evenly spaced

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CORE NEEDLE BIOPSY

• Uses a spring loaded biopsy gun, 14G needle which
  removes a core of tissue
• Requires formalin fixation, processing and
  embedding which require approx 24 hours not
  suitable for one stop clinics

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CORE NEEDLE BIOPSY

• Advantages of core biopsy
• Many pathologists are more familiar with
  histology rather than cytology
• Can see microcalcification on specimen X-ray
• Can distinguish in situ from invasive carcinoma

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CORE NEEDLE BIOPSY

• Reporting categories
• B1 normal or inadequate
• B2 specific benign
• B3 lesion of uncertain malignant potential
• B4 suspicious of malignancy
• B5 malignant in situ
• B5 malignant - invasive

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Nottingham Prognostic Index

• Tumour size
• Invasive only
• If multiple largest tumour only
• If bilateral, calculate for each side

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Predictive factors

• ER/PR and HER-2
• ER often sufficient if ER negative, PR may be
  helpful
• Should be done on all tumours and all cases of
  DCIS/LCIS
• Scoring systems H score and Quik score

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HER-2

• Human Epidermal Growth Factor
• Target of Herceptin treatment
• Immunohistochemistry
• Score as -, , ,
• is regarded as positive
• requires FISH presently sent to Glasgow

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In situ carcinoma

• Ductal carcinoma in situ
• Lobular carcinoma in situ
• Mixed ductal/lobular carcinoma in situ
• Loss of e-cadherin immunoreactivity seems to be
  specific for LCIS

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In situ carcinoma

• Total mastectomy is generally curative
• If breast conserving surgery carried out, the
  risk in the ipsilateral breast is greater with
  DCIS
• Time to development of invasion is less in DCIS

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In situ carcinoma

• LCIS clinical follow up tamoxifen
• Most patients with DCIS do not go on to develop
  invasive ca risk reduced by DXT /- tamoxifen
• Risk in contralateral breast is greatest for LCIS

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In situ carcinoma

• ER status essential
• Assess invasion using collagen IV or laminin
• Microinvasion less than 1mm, often has a ductal
  NST pattern

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Van Nuys prognostic index

• Size 15mm or less 1 point, 1640mm 2, 41mm
  or more 3
• Margin 10mm or more 1, 1-9mm 2, less than 1
  3
• Pathology not HG, no necrosis 1, not HG,
  necrosis present 2, HG /- necrosis 3

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LYMPH NODE STATUS

• Factors affecting lymph node yield
• Patient
• Surgeon
• Pathologist
• Definition of lymph node positive

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LYMPH NODE STATUS

• Careful dissection of axillary fat
• Small nodes lt5mm submitted intact
• 5-10mm bisected and one half examined
• 10mm - one section per 10mm
• H and E stained sections may examine gt1 section

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LYMPH NODE STATUS

• Immunostains for cytokeratin may be helpful in
  difficult cases not used routinely
• Sentinel nodes single node 1 H and E per mm
  and 1 immunostained slide per mm