Karin Lindholm Malm University Hospital Sweden

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Karin Lindholm Malmö University Hospital
Sweden
Breast Cytology Lecture 1
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(No Transcript)
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• Clinical Cytology
• is
• Cytology
• in the
• Clinical setting

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The aim of the preoperative procedureis to
reduce

• Time
• Surgery
• Anxiety

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• On the way
• to
• correct
• diagnosis

• Without
• causing delay
• in
• treatment

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• Which information
• do you need preoperatively ?
• Which method
• could give you that information?

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Four relevant questions

• Representative/ adequate material?
• Significant lesion?
• Primary invasive cancer?
• Prognostic factors?

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How to report

• Adequacy
• Category
• Description

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Adequacy Quality

• Well preserved
• Representative

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!!!

• The aspirated well preserved material imitates
  histology
• But the degenerated aspirated material imitates
  exfoliativ cytology

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!!!

• There is a
• Macroscopical
• and
• Microscopical
• part of the cytological diagnosis

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To perform good cytopathology You need knowledge
of

• Normal cytology of the organ
• Normal histology
• The histopathology
• The cytopathology
• General histo-cytopathology

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Significant lesionwhich needs surgery

• Based on our evaluation of
• Cellular details
• Architectural details
• Background material

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Diagnosis

• Category
• Descriptive

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• Do not use
• Positive Negative
• When you mean
• Malignant Benign

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Category

• Benign
• Equivocal atypia - benign?
• Equivocal atypia suspicious?
• Malignant

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Microscopical diagnosis

• Benign
• Harmonious
• Predictible

• Malignant
• Disharmonious
• Unpredictible

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Microscopical diagnosis

• Low magnification
• Low magnification
• Low magnification
• High magnification

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Microscopical diagnosis

• Background
• Architecture
• Cellular details

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The common benign pattern

• Overall low cell yield
• Sheets of ductal and aggregates of ductular
  epithelial cells with small uniform nuclei
• Myoepithelial nuclei visible among epithelial
  cells in aggregates
• Single, bare, oval nuclei separate from
  epithelial aggregates in clean background

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The common malignant pattern

• A high cell yield
• A single population of atypical cells
• Irregular angulated clusters of atypical cells
• Reduced cohesiveness of epithelial cells
• Nuclear enlargement and irregularity of variable
  degree

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An old lecture

• One cellpopulation
• Tumor?
• Mixed cellular pattern
• Inflammatory lesion?

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But

• Material from
• necrotic or cystically
• degenerated tumours
• could show a
• mixed cellular pattern

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Hamartoma normal breast
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HormonalPregnancy/Lactation
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FibroadenomaTypical
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FibroadenomaThe common benign pattern

• A high cell yield
• Large branching, monolayered sheets of uniform
  cells
• Numerous single, bare nuclei of benign type
• Fragments of myxoid stroma

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The apocrine cell
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The apocrine cell
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Inflammatory/ reactive atypia
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Apocrine metaplasia/atypia

• In unexperienced hands
• Risk for overdiagnosis
• In experienced hands
• Risk for underdiagnosis

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Type of cell?
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Apocrine cellsMyoepithelial cells

• Apocrine cells are more common in
• cystic lesion they have a tendency
• to show degenerative changes
• Myoepithelial cells are not so common
• in the surroundings of apocrine cells

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Other benign lesionsbuilt up by the same type of
cells

• Gynecomastia
• Fibrocystic changes
• Benign epithelial proliferations

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Gynecomastia
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Benign proliferations
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Papilloma with atypia
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Papilloma with atypia
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Benign ones
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Benign ones
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Case 1

• In a lymphnode aspirate from the axilla some odd
  looking cells
• among the lymphoid ones

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Case 1
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What is this?

• Benign? Green card!
• Equvivocal? Yellow card!
• Malignant? Red card!

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Other Benign ones apocrine cells from sweat
gland
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What is this?
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Case 2

• Case story
• Superficial palpable lesion with skinretraction.
• Mammo/ US suspicious

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Case 2
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What is this?

• Benign? Green card!
• Equvivocal? Yellow card!
• Malignant? Red card!

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Benign lesionsGranularcellstumor
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Benign lesionsGranulomatous Mastitis
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Benign lesionsGranulomatous Mastitis
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Benign lesionsPostoperative-Fat Necrosis
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For and against Benign/Malignant
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Case 3

• Case story
• Palpable lesion, rather well delimited
• Mammo/ US probably benign

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Case 3
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Case 3
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What is this?

• Benign? Green card!
• Equvivocal? Yellow card!
• Malignant? Red card!

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Fibroadenoma towards the tail of the smear
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Fibroadenoma towards the very end of the tail
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Case 4Case story

• According to clinician and aspirating doctor a
  lesion high up close to the axilla.
• According to mammography nothing in the breast
  but enlarged lymphnode with pathological pattern
  in the axilla

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Case 4
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Case 4
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Case 4
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Case 4
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What is this?

• Benign Green card
• Do not know Yellow card
• Metastasis Red card

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Case 4

• Is it a lymphnode?
• Is it a breast lesion?
• Are there two lesions?
• By palpation there is one lesion in the periphery
  of the breast and that one is aspirated!

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Case 4

• The radiologist has only seen one lesion
• and
• The report should be read
• If the lesion is a lymphnode it is atypical but
  could very well be consistent with a
  fibroadenoma.

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Case 4

• This is a
• Fibroadenoma!

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Pitfalls Fibroadenoma

• Cellularity
• Dissociation
• Nuclear atypia
• No myxomatos stroma
• Hyaline stroma

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Fibroadenoma
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Pitfalls Fibroadenoma
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Pitfalls Fibroadenoma
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Fibroadenoma-cellular atypia
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Fibroadenoma with apocrine cells
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Fibroadenoma and necrosis
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Fibroadenoma and the stroma
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Fibroadenoma and the stroma A pitfall in non
palpable lesions
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What is afalse positive diagnosis

• When you give a false cancer diagnosis leading to
  mutilating surgery?
• When you give a false atypia diagnosis leading to
  unnecessary surgery?
• When you give a false atypia diagnosis leading to
  unnecessary investigations?

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Triple diagnosis forpalpable lesions

• Clinical findings
• Radiological findings
• Cytological findings

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Diagnostic aspects ofBreast Cytology

• The cytopathological diagnosis
• versus
• The histopathological diagnosis
• and/or
• The treatment protocol
• Things have changed over the years
• due to new technique

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New techniques

• Introduction of core biopsy
• Image guided FNAB and CB for nonpalpable lesions
• Prognostic and predictive tests

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Old truths

• The patients are the same
• The cytology looks the same
• The corresponding histology looks the same
• We have methods to study details but very few
  answer basic questions

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The team approach
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