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Fnac breast

  1. 1. Patterns of FNAC in benign & malignant breast lesions Dr Neha Mahajan MD Pathology Copyright © Wondershare Software
  2. 2. • 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 Copyright © Wondershare Software
  3. 3. 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 Copyright © Wondershare Software
  4. 4.  Normal  Inflammatory  Benign  Suspicious of malignancy  Atypical/indeterminate  Malignant  Unsatisfactory Copyright © Wondershare Software
  5. 5. Copyright © Wondershare Software
  6. 6. Copyright © Wondershare Software
  7. 7. 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 Copyright © Wondershare Software
  8. 8.  Uncommon, account for <1% of women with breast symptoms  Erythematous, swollen, painful breast  Inflammatory breast cancer mimics inflammation Copyright © Wondershare Software
  9. 9. 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) Copyright © Wondershare Software
  10. 10. Breast abscess Plenty of PMN`s scattered ductal cells necrotic material Copyright © Wondershare Software
  11. 11. Subareolar abscess  Young & nulliparous women  Squamous metaplasia of lactiferous ducts  Painful subareolar mass  D.D: Contaminant squamous epithelium Ruptured Epidermoid cysts Copyright © Wondershare Software
  12. 12. Subareolar abscess Aspirate :Purulent inflammation Keratin flakes & debris Mature squamous cells Copyright © Wondershare Software
  13. 13. 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 Copyright © Wondershare Software
  14. 14. 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 Copyright © Wondershare Software
  15. 15. Lipoma A well defined rounded soft mass,firm,tender Empty sensation on needling Fat only in multiple aspirates-fat vacuoles & fragments of adipose tissue Copyright © Wondershare Software
  16. 16. 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 Copyright © Wondershare Software
  17. 17.  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 Copyright © Wondershare Software
  18. 18.  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 Copyright © Wondershare Software
  19. 19. Apocrine cells Copyright © Wondershare Software
  20. 20. Fibrocystic changes Copyright © Wondershare Software
  21. 21. Cytology Histopathology Copyright © Wondershare Software
  22. 22.  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 Copyright © Wondershare Software
  23. 23. 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 Copyright © Wondershare Software
  24. 24. Staghorn clusters Copyright © Wondershare Software
  25. 25. Intracanalicular Pericanalicular Copyright © Wondershare Software
  26. 26.  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 Copyright © Wondershare Software
  27. 27. • 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 Copyright © Wondershare Software
  28. 28. 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 Copyright © Wondershare Software
  29. 29.  Lobular ca(alveolar variant)  Ca breast during pregnancy & lactation  Secretory activity unrelated to pregnancy & lactation  Galactocoele with unusual features Copyright © Wondershare Software
  30. 30.  Solitary subareolar mass  Bloody nipple discharge  Papillary lesions cannot be distinguished on cytology, diagnosis left to histology  All papillary lesions should be excised Copyright © Wondershare Software
  31. 31. 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 Copyright © Wondershare Software
  32. 32. • 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 Copyright © Wondershare Software
  33. 33.  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 Copyright © Wondershare Software
  34. 34. Granular cell tumor Copyright © Wondershare Software
  35. 35. • 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 . Copyright © Wondershare Software
  36. 36. Phyllodes tumor Copyright © Wondershare Software
  37. 37. Leaf like architecture Malignant stroma Copyright © Wondershare Software
  38. 38. • 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?? Copyright © Wondershare Software
  39. 39. CARCINOMAS OF MAMMARY DUCT  Infiltrating duct  Inflammatory  Medullar  Colloid/mucinous  Signet ring type  Apocrine  Tubular  Papillary Copyright © Wondershare Software
  40. 40. 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 Copyright © Wondershare Software
  41. 41. • 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 Copyright © Wondershare Software
  42. 42.  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 Copyright © Wondershare Software
  43. 43.  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 Copyright © Wondershare Software
  44. 44. 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. Copyright © Wondershare Software
  45. 45. DCIS(comedocarcinoma) Copyright © Wondershare Software
  46. 46. Copyright © Wondershare Software
  47. 47.  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 Copyright © Wondershare Software
  48. 48. Invasion Copyright © Wondershare Software
  49. 49.  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 Copyright © Wondershare Software
  50. 50. Infiltrating carcinoma Copyright © Wondershare Software
  51. 51. Copyright © Wondershare Software
  52. 52. • • • • • Representative sampling Smearing artefacts Fibrosclerotic lesions In situ & low grade carcinoma Nuclear atypia in other lesions Copyright © Wondershare Software
  53. 53. Medullary carcinoma Soft, fleshy well defined mass mimics benign 6th decade L.N metastasis common Prognosis favourable Copyright © Wondershare Software
  54. 54. Medullary carcinoma Highly Cellular smears Large pleomorphic ,undifferentiated malignant cells with irregular coarsely granular nuclei with v large nucleoli Many lymphocytes in background Copyright © Wondershare Software
  55. 55. Copyright © Wondershare Software
  56. 56.  Metastatic malignancy (melanoma) to axillary nodes  Malignant lymphoma  High grade DCIS(comedocarcinoma) Copyright © Wondershare Software
  57. 57. 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 Copyright © Wondershare Software
  58. 58. Colloid/mucinous carcinoma Copyright © Wondershare Software
  59. 59. Colloid carcinoma (tumor cells floating in mucin pools) Copyright © Wondershare Software
  60. 60.  Lack of nuclear pleomorphism  Mucinous DCIS or ADH  Mucocoele like lesions  Mucinous fibroadenoma  Myxoid stromal matrix resembling mucin  Metastatic carcinoma  Ultrasound gel Copyright © Wondershare Software
  61. 61. 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 Copyright © Wondershare Software
  62. 62. Copyright © Wondershare Software
  63. 63. Apocrine carcinoma Copyright © Wondershare Software
  64. 64. 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 Copyright © Wondershare Software
  65. 65. Copyright © Wondershare Software
  66. 66. Copyright © Wondershare Software
  67. 67.  Fibroadenoma  Mixed tubular & usual ductal carcinoma  Complex sclerosing lesion/scar, adenosis Copyright © Wondershare Software
  68. 68. Papillary Carcinoma Rare tumors Cell clusters resembling benign papillomas Nuclear enlargement & evidence of mitotic activity Definitive diagnosis cannot be made Confirmation by histopath Copyright © Wondershare Software
  69. 69. Copyright © Wondershare Software
  70. 70. Copyright © Wondershare Software
  71. 71. 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 Copyright © Wondershare Software
  72. 72. Lobular carcinoma Copyright © Wondershare Software
  73. 73. Lobular carcinoma ( H&E ) L.P Copyright © Wondershare Software
  74. 74.  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 Copyright © Wondershare Software
  75. 75. Copyright © Wondershare Software
  76. 76.  Aspirate shows hyaline globules surrouned by epithelial hyperplasia  Have to be distinguished from collageous spherulosis  Prognosis significantly better Copyright © Wondershare Software
  77. 77. Adenoid cystic carcinoma Copyright © Wondershare Software
  78. 78. • 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 Copyright © Wondershare Software
  79. 79. Metaplastic carcinoma Copyright © Wondershare Software
  80. 80.  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 Copyright © Wondershare Software
  81. 81. Ca with neuroendocrine features Copyright © Wondershare Software
  82. 82. • 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 Copyright © Wondershare Software
  83. 83. Angiosarcoma Copyright © Wondershare Software
  84. 84. 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 Copyright © Wondershare Software
  85. 85. Cytology Histopath Copyright © Wondershare Software
  86. 86.  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 Copyright © Wondershare Software
  87. 87. • 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 Copyright © Wondershare Software
  88. 88.  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 Copyright © Wondershare Software
  89. 89. Paget`s disease smear Copyright © Wondershare Software
  90. 90. Copyright © Wondershare Software
  91. 91. • 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 Copyright © Wondershare Software
  92. 92. Copyright © Wondershare Software
  93. 93. 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 Copyright © Wondershare Software
  94. 94. 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 Copyright © Wondershare Software
  95. 95. Copyright © Wondershare Software
  96. 96. 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 Copyright © Wondershare Software
  97. 97. • 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. Copyright © Wondershare Software
  98. 98.       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 Copyright © Wondershare Software
  99. 99. 1 2 3 4 Copyright © Wondershare Software
  100. 100. Copyright © Wondershare Software
  101. 101.  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 Copyright © Wondershare Software
  102. 102. Copyright © Wondershare Software