Fnac breast

Patterns of FNAC
in benign & malignant
breast lesions
Dr Neha Mahajan
MD Pathology
Copyright © Wondershare Software

• Diagnosis of simple cysts
• The investigation of suspected recurrence or metastasis in
cases of previously diagnosed cancer
• Confirmation of inoperable, locally advanced cancer
• Preoperative confirmation of clinically suspected cancer
• Investigation of any clinically palpable lump, clinically benign
or malignant as a guide to clinical management
• As a complement to mammography in the screening
situation
• To obtain tumor cells for special diagnosis


Adequacy of smears:
Presence of at least six clusters of epithelial cells in all
smears
or
Presence of 10 or more myoepithelial (bipolar cells) in 10
consecutive medium power viewing fields


 Normal
 Inflammatory
 Benign
 Suspicious of malignancy
 Atypical/indeterminate
 Malignant
 Unsatisfactory


CLASSIFICATION OF LESIONS OF FEMALE BREAST
INFLAMMATORY LESIONS
Acute & chronic inflammatory processes
LESIONS CAUSED BY TRAUMA
Fat necrosis
Reaction to foreign bodies
Lesions resulting from breast aumentation /reduction
BENIGN PROLIFERATIVE DISEASES
Cysts
Fibrous mastopathy & other fibrous lesions
BENIGN TUMORS
Fibroadenoma
Lactating Adenoma
Intraductal papilloma
Granular cell tumor
MALIGNANT TUMORS
Carcinomas of various types
Sarcomas
Rare tumor & tumor like conditions

METASTATIC TUMORS


 Uncommon, account for <1% of women with breast
symptoms
 Erythematous, swollen, painful breast
 Inflammatory breast cancer mimics inflammation


Mastitis:
 A benign bimodal component of non neoplastic
breast tissue
 Inflammatory cells, chronic/acute
 Regenerative epithelial atypia
 Histiocytes, epitheloid cells, multinucleated giant
cells and plasma cells(granulomatous pattern)
 Microorganisms(infectious mastitis)


Breast abscess
Plenty of PMN`s
scattered ductal cells
necrotic material


Subareolar abscess
 Young & nulliparous women
 Squamous metaplasia of lactiferous ducts
 Painful subareolar mass

 D.D: Contaminant squamous epithelium
Ruptured Epidermoid cysts


Subareolar abscess
Aspirate :Purulent
inflammation
Keratin flakes & debris
Mature squamous cells


Fat necrosis
 Painless,palpable mass,thickening or retraction of
skin
 History of breast trauma ,repeated palpation or
aspiration or surgery
 D.D: Lipid cyst
Macrophages mistaken for atypical epithelial cells
Carcinoma cells with macrophage like appearance


Fat necrosis
Dirty background of
granular debris, fat
droplets & fragments of
adipose tissue
Foamy macrophages,
multinucleated giant
cells & adipocytes with
bubbly cytoplasm

Absence of epithelial
cells

Lipoma
A well defined rounded
soft mass,firm,tender
Empty sensation on
needling
Fat only in multiple
aspirates-fat vacuoles &
fragments of adipose
tissue

BENIGN EPITHELIAL BREAST LESIONS

Non proliferative breast
disease/fibrocystic changes
Cysts with apocrine
metaplasia
Fibrosis
Adenosis

Proliferative disease
with atypia
Atypical ductal hyperplasia
Atypical lobular
hyperplasia

Proliferative disease
without atypia
Epithelial hyperplasia
Sclerosing adenosis
Complex sclerosing scar
Papillomas

 Clinician LUMPY BUMPY breast
 Radiologists Dense breast with cysts
 Pathologist Benign breast lesion
 Sequential proliferation & atrophy of ducts &
lobules and fibrosis of parenchyma of breast
 On cytology, impossible to differentiate subgroups


 Sheets of ductal epithelial cells of apocrine type
 Fragments of usual epithelial cells
 Scattered single bare bipolar nuclei
 Background of variable amounts of cyst fluid and
macrophages
 Fibrous stroma


Apocrine cells


Fibrocystic changes


Cytology

Histopathology

 Complete dissapearance of the lump after
aspiration of the fluid
 Absence of altered blood or necrotic material in the
aspirated fluid
 Cyst macrophages and more or less degenerate
oxyphil/apocrine epithelial cells
 Inflammatory cells(polymorphs) variable


Fibroadenoma
A high yield of cells, myxoid substance & some
macroscopically visible tissue fragment
Large ,branching sheets of bland epithelial
cells(staghorn pattern of epithelial cells)
Numerous single, bare bipolar nuclei
Fragments of fibromyxoid stroma


Staghorn
clusters


Intracanalicular

Pericanalicular


 Overlap with other hyperplastic lesions(papilloma)
 Epithelial atypia mimicking
carcinoma(premenopausal & HRT)
 Fibromyxoid stroma occuring in some invasive
cancers
 Cystic/mucinous change
 Distinction from phylloides tumor


• Solitary/multiple freely movable breast mass during
pregnancy/puerperium
• Numerous densely packed lobular units in clusters
or as isolated structures with myoepithelial cells at
the periphery


Lactating adenoma
Cell rich smears
Poorly cohesive mainly
dispersed cells of acinar
type
Cells have abundant
fragile cytoplasm,some bare
nuclei
Rounded vesicular nuclei
& central nucleoli
Background of abundant
lipid secretion


 Lobular ca(alveolar variant)
 Ca breast during pregnancy & lactation
 Secretory activity unrelated to pregnancy &
lactation
 Galactocoele with unusual features


 Solitary subareolar mass
 Bloody nipple discharge
 Papillary lesions cannot be distinguished on
cytology, diagnosis left to histology
 All papillary lesions should be excised


Papilloma
Cellular smears
Complex folded &
branching epithelial sheets
& finger like fragments
True papillary fragments
with stromal cores
Dispersed epithelial cells
with mild nuclear atypia
Rows of pallisaded
columnar epithelial cells
Macrophages & variable
amount of cyst fluid
Bare bipolar nuclei


• Low grade papillary carcinoma
• Cell dispersed mimicking a malignant smear pattern
• Pseudopapillary structures in smears of low grade
invasive duct carcinoma
• Overlap with fibroadenoma
• Infarcted papilloma


 Uncommon, benign ,firm tumor of breast clinically
mimics carcinoma
 Large cells with abundant granular cytoplasm,
monotonous ,generally spherical small nuclei
 In smears ,break up of cytoplasm results in naked nuclei
 Often confuses with large cell duct carcinoma


Granular cell tumor


• Cohesive fragments of highly cellular stroma
composed of spindle cells with nuclear atypia and
background atypical bare spindle nuclei, are highly
suggestive of phylloides tumor
• Marked nuclear pleomorphism & mitotic activity
seen in frank malignant phylloides tumor .


Phyllodes tumor


Leaf like architecture

Malignant stroma


• Is the lesion an ordinary fibroadenoma? Or can it
quantify as a phyllodes??
• In case of marked abnormalities of stromal cells ,is
it a phyllodes or carcinoma??


CARCINOMAS OF MAMMARY DUCT
 Infiltrating duct
 Inflammatory
 Medullar
 Colloid/mucinous
 Signet ring type
 Apocrine
 Tubular
 Papillary

INTRADUCTAL CARCINOMA(IN SITU Ca OF DUCTS)
Solid type
Comedo type
Solid papillary carcinoma
CARCINOMA OF MAMMARY LOBULES
Infiltrating lobular carcinoma
Lobular carcinoma in situ
MIXED TYPES
RARE:
Spindle cell
Adenoid cystic
Metaplastic
Ca mimicking giant cell tumor of bone
Secretoty/juvenille ca


• Abundant pure population of tumor cells ,singly &
in clusters
• Backround no inflammation/necrosis
• Clusters of aspirated cancer cells are 3D, either
loosely arranged,cells at the periphery become
detached
• Isolated cancer cells show N:C ratio,nuclear
abnormalities
• Absence of myoepithelial cells


 Diagnosis of DCIS in tissue section includes
assessment of nuclear grade, growth pattern,
presence or absence of necrosis & calcification
 Specific diagnosis or classification of DCIS cannot
be made on FNAC
 Lesions with high nuclear grade, invasion cannot be
predicted accurately


 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


High gradeDCIS
(solid or comedo growth pattern)
Soft, boggy, palpable mass with highly cellular indicates
significant intraductal lesion worthy of excision.
Neoplastic cells in sheets, irregular aggregates and single
pleomorphic cells showing obvious malignant nuclear
features .
Necrotic debris, granular debris, granular calcium
,lymphocytes and vacuolated cytoplasm.


DCIS(comedocarcinoma)


 Findings of tubular or angular epithelial structures,
malignant cells adherent to fibrous stroma
 Presence of intracytoplasmic neolumina in
malignant cells
 Fibroblast proliferation
 Fragments of elastoid stroma


Invasion


 Cell rich smears, single population of epithelial cells
no myoepithelial cells,no single bare bipolar nuclei
 Variable loss of cell cohesion irregular clusters and
single cells
 Single epithelial cells with intact cytoplasm
 Mod to severe nuclear atypia, enlargement,
pleomorphism, irregular nuclear membrane&
chromatin
 Fibroblasts & fragments of collagen( stromal
desmoplasia) a/w atypical cells
 Intracytoplasmic neolumina in some cases
 Necrosis unusual

Infiltrating carcinoma


•
•
•
•
•

Representative sampling
Smearing artefacts
Fibrosclerotic lesions
In situ & low grade carcinoma
Nuclear atypia in other lesions


Medullary carcinoma
Soft, fleshy well defined mass mimics benign
6th decade
L.N metastasis common
Prognosis favourable


Medullary carcinoma
Highly Cellular
smears
Large pleomorphic
,undifferentiated
malignant cells with
irregular coarsely
granular nuclei with v
large nucleoli
Many lymphocytes
in background


 Metastatic malignancy (melanoma) to axillary
nodes
 Malignant lymphoma
 High grade DCIS(comedocarcinoma)


Colloid Carcinoma/Mucinous carcinoma
Elderly women circumscribed tumor
Abundant background mucin
Atypical cells in small solid aggregates, runs single files,
singly
Moderate nuclear atypia
Benign epithelial cells & bipolar nuclei absent
Chicken wire blood vessels
Can confuse with mucocele like lesions


Colloid/mucinous carcinoma


Colloid carcinoma (tumor cells floating in mucin pools)


 Lack of nuclear pleomorphism
 Mucinous DCIS or ADH
 Mucocoele like lesions
 Mucinous fibroadenoma
 Myxoid stromal matrix resembling mucin
 Metastatic carcinoma
 Ultrasound gel


Apocrine carcinoma
Elderly women
Cellular smears with large cells with eosinophilic granular
cytoplasm similar to that of benign apocrine cells
Nuclei are large with multiple nucleoli


Apocrine carcinoma


Tubular carcinoma
Moderately cellular smears
Cohesive 3D complex, often branching & angulated
tubular clusters of epithelial cells
Single bipolar nuclei of benign type with fat in the
background
Nuclear abnormalities are trivial
May mimic fibroadenoma


 Fibroadenoma
 Mixed tubular & usual ductal carcinoma
 Complex sclerosing lesion/scar, adenosis


Papillary Carcinoma
Rare tumors
Cell clusters resembling benign papillomas
Nuclear enlargement & evidence of mitotic activity
Definitive diagnosis cannot be made
Confirmation by histopath


Lobular carcinoma
Difficult to aspirate because of fibrosis
Small monotonous cancer cells showing cytoplasmic
vacuolation
Cells either dispersed, clusters or singe files
Nuclei granular of similar sizes
Cytoplasmic vacuolation with central condensed mucus in
cancer cells(air dried geimsa) Target cells


Lobular carcinoma


Lobular carcinoma ( H&E ) L.P


 Sparse cellularity
 Resemblance to non neoplastic breast tissue in L.P
 Component of benign epithelium
 Lobular hyperplasia in pregnancy & lactation
 Distinction from low grade ductal carcinoma
 Intracytoplasmic neolumina in other lesions


 Aspirate shows hyaline globules surrouned by
epithelial hyperplasia
 Have to be distinguished from collageous
spherulosis
 Prognosis significantly better


Adenoid cystic carcinoma


• Highly aggressive malignant tumor combine features
of carcinoma with that of well differentiated
sarcoma(lipoma,oste or chondroSa,fibrosarcoma)
• Diagnostic: two or more population of malignant
cells
• Spindle cell variant resembles soft tissue sarcoma,
difficult to distinguish from phyllodes


Metaplastic carcinoma


 Smears cell rich composed of dispersed small &
relatively uniform cells with coarse granular nuclear
chromatin resembling carcinoid
 Mistaken for lymphoma,look for possibility of
metatstatic neuroendocrine ca


Ca with neuroendocrine features


• Aspiration : plenty of blood, few tumor cells(low
grade)
• Tumor cells spindly, attenuated basophilic cytoplasm
without distinct borders& have dark pleomorphic,
elongated or plump spindle nuclei(High grade )
mistaken for sarcoma


Angiosarcoma


Gynecomastia
Smears similar to fibroadenoma
Sheets of cuboidal ductal cells & fragments of loose
connective tissue stroma
Bipolar, spindly myoepithelial cells & oncocytes
Fragments of fibrous stroma & adipose tissue


Cytology

Histopath


 Bloody nipple secretions are more likely to be
malignant
 Two subtypes in spontaneous nipple secretions:
1.Solid/papillary ductal carcinoma
2.Ductal carcinoma with paget`s disease


• Cancer cells desquamate singly or in clusters
• Clusters may be loosely structured, and are
sometimes thick or spherical, but may show a
relatively orderly arrangement of cancer cells in
papillary clusters
• Necrosis is common comedo type DCIS


 Background of keratin, squamous cells, inflammatory
cells & debris(scrape smears from nipple)
 Large malignant cells, single and in small groups, closely
associated with squamous & inflammatory cells
 Abundant pale cytoplasm with distinct borders
 Obvious nuclear features of malignancy


Paget`s disease smear


• If cytological pattern does not fit any of the
recognised types of primary breast cancer,then
possibility of metastasis need to be considered
• Mets are common from melanoma, SCC of cervix,
bronchogenic carcinoma, mucin secreting
adenocarcinoma stomach, ovarian adenoca,
alveolar RMS, soft tissue sarcoma


False positive
1. Papillary lesions
2. Epithelial hyperplasia with nuclear atypia
3. Radial scar/complex sclerosing lesion
4. Fibroadenoma
5. Regenerative epithelial atypia
6. Pregnancy & lactation
7. Skin adnexal tumor


False negative
1. Tumors with central necrosis/sclerosis
2. Small carcinoma next to a dominant benign lesion
3. Complex proliferative lesion
4. Low grade ductal carcinoma
5. Lobular carcinoma Ca and small cell ductal Ca


Cytoarchitectural pattern
Favourable
Extremely bad
Bad
Tubular
Lobular carcinoma
Squamous cell ca
Cribriform
(Signet ring ca)
Metaplastic Ca
Medullary
Carcinoma with
Pure mucinous
neuroendocrine
Papillary
Adenoid cystic
Secretory/juvenille

• As the prognosis and thereby the line of
management of each group of breast lesions varies,
it is important to recognize the spectrum of
morphological changes seen and separate them into
benign, premalignant and malignant categories.










Masood et al, cytological grading system based on
Cellular arrangement (relationship of cells to one another in
a sheet of ductal epithelial cells),
The degree of cellular pleomorphism (the variation in cell
size of the ductal epithelial cells),
Anisonucleosis,
The presence of myoepithelial cells,
Nucleoli
The status of chromatin pattern like clumping of chromatin


1
2
3
4


 Leopald G.Koss,Myron R.Melamed`s Koss` Diagnostic Cytology and its
histopathologic bases.5th ed.New York:Lippincott & Williams &
Wilkins;2006;p1148-1185.vol 2.
 Svante R Orell,Gregory F Sterrett,Darell Whitaker`s Fine Needle Aspiration
Cytology.4th ed.Australia:Churchilll Living An Imprint of Elsevier,2005;p165276.
 Vinay Kumar,Abul.Kabbas,Nelson Fausto. Robbins & Cotran Pathological
Basis of Disease.8th ed. Chicago,Illinois:Elsevier.2010 .p. 905-969
 Stephen S sternburg,Donald A.A,Daryl.Carter,Stacey.E,Oberman
H.A.Diagnostic Surgicl Pathology.3rd ed.Newyork:Lippincort Williams
&Wilkins;1999.p.1701-1784.
 Rosai Juan.Rosai and Ackerman`s Surgical Payhology.9
ed.Milan,Italy:Elsevier;2005.p.1164-1316
 Nandini NM,Rekha TS,Manjunath GV,Evalaution of scoring system in
cytoloical diagnosis & management of breast lesion.Indian jounal of
cancer;2011 vol28,p240 -245

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