cnb breast

1. Core Needle Biopsy of
Breast: Practical Issues &
Updates
Dr Chhanda Datta,
Professor,
IPGME&R
Dr Diya Das
JR, IPGME&R

2. Need for Core Needle Biopsy :
 CNB:
 More reliable than
cytology
 Less invasive than
surgical biopsy
 Allows planning of therapy
 CNB Disadvantages:
 More expensive than
cytology
 More invasive than
cytology
 Difficult areas:
subareolar zone, close
to pectoral muscle
 Underestimation of
lesions
35% of the lumps that were non-diagnostic or benign at cytological
examination had a positive biopsy
Use of Core Needle Biopsy rather than Fine-Needle Aspiration Cytology in the Diagnostic Approach of Breast
Cancer. Case Reports in Oncology 7.2 (2014): 452–458.

3. Core Needle Biopsy : Indications:
 1st approach:
 Large lesions clearly malignant at imaging (where future
treatment will be neoadjuvant therapy)
 Microcalcifications without palpable mass
 Added after FNA:
 When result was non-diagnostic or inconclusive
 Discordance between clinical/radiological and cytological
findings
Use of Core Needle Biopsy rather than Fine-Needle Aspiration Cytology in the Diagnostic Approach of Breast Cancer. Case Reports in

4. Core Needle Biopsy : Devices:
 CNB device:
 Stereotactic-guided Vacuum-assisted Core Biopsy
 Conventional Tru-cut Biopsy
 Choice of CNB device:
 Nature of the abnormality (palpable/impalpable)
 Availability of the instruments
 Imaging modalities (mammography, ultrasound or MRI)
 Patient specific factors (e.g. age and ability to undergo the biopsy
procedure)
Breast core needle biopsy: issues and controversies. Mod Pathol

5. Core Needle Biopsy Device:

6.  US-CNB performed with smaller needles (16G/18G)
has the same diagnostic accuracy of 14G US-CNB,
regardless of lesion characteristics.
Major advantage of smaller needles:
 Smaller needles are much sharper and penetrate more easily
through firm, dense breast tissue.
 Potentially decreases bleeding.
 No need to make a skin incision and local anaesthetic
administration is not always required (in 18G needle).
•Ultrasonographically guided 18-gauge automated core needle breast biopsy with post-fire needle position verification (PNPV). Breast Cancer
2007
•Accuracy of 16/18G core needle biopsy for ultrasound-visible breast lesions. World J Surg Oncol 2014
Core Needle Biopsy Device: Choice of needle :
Smaller gauge needles can be confidently used for ultrasound-guided breast
CNB.
Breast core biopsy should be performed with a spring-loaded device, usually 14G
diameter - Guidelines for non-operative diagnostic procedures and reporting in breast cancer screening, June 2016, The
Royal College of Pathologists, UK

7.  Sections: a minimum of three H&E-stained sections cut at
50µ intervals
 Specimen Radiography : For microcalfications
Core Needle Biopsy Device: Processing:

8. Three H&E-stained
section levels:
e.g. if 9 serial sections
are cut, stain sections 1,
4 and 7 for H&E, and the
rest 6 preserved for IHC
and special stains
Core Needle Biopsy Device: Processing:
Breast core needle biopsy: issues and controversies. Mod Pathol

9.  Recording basic information
 Centre/location
Centre, department, etc. Where the specimen was obtained.
 Side
 Localisation technique
 Palpation
 Ultrasound guided
 Stereotactic
 MRI.
 Number of cores
 Calcification present on specimen x-ray
 Histological calcification
 Date
 Pathologist
Core Needle Biopsy Device: Reporting:

10.  Most core biopsy samples can be readily
categorised as normal, benign or malignant
 A small proportion (probably less than 10%) of
samples cannot.
Core Needle Biopsy Device: Reporting:
UK BSP Category: Description:
B1 (normal tissue): Normal breast or other normal tissue, including adipose tissue,
may include microcalcifications associated with atrophic or
normal TDLUs
B2 (benign lesion): FA, fat necrosis, duct ectasia.
B3 (lesion of
uncertain malignant
potential):
Includes ADH, LN, fibroepithelial lesions with cellular stroma and
phyllodes tumours (PTs), papillary lesions, FEA and radial scar.
B4 (suspicious): A definite malignant diagnosis (DCIS or invasive carcinoma) is
not possible because of crush artifact, poor fixation or a small
questionable
focus of non-diagnostic cells.

11. CNB Reporting of DCIS:
 Nuclear grade (low, intermediate, or high)
 Architectural type(s)
 Presence of necrosis (comedo or punctate type)
 Microcalcification
Core Needle Biopsy Device: Reporting:
•Good
concordance
with excised
specimen
•Risk of
recurrence,
progression
to carcinoma

12. CNB Reporting of Invasive Carcinoma:
 Generally good correlation between prognostic factors
derived from CNB and the subsequently excised
specimen
 CNB histological grade understimation : lower mitotic rate
being seen with the small amount of tissue
 Histological type
 Histological grade
 The presence of lymphovascular invasion, if definitely
identified
Core Needle Biopsy Device: Reporting:

13. ER/PR/HER2: Which report to rely on: CNB vs Excised
Specimen:
 Recommended fixation, processing and antigen retrieval are
optimised for larger specimens
 Absence of a negative control (normal ducts) in the CNB could lead
to a false-positive result
 Tumour hetrogeneity could be missed as a result of sampling
 Discordant cases the HER2 result on the core or the excision
specimen: lack of data to confirm which one most accurately reflects
treatment response
Core Needle Biopsy Device: Reporting:

14.  HER2 testing is currently recommended for all primary,
recurrent, and metastatic breast tumors
 Repeat testing of HER2-negative cases if CNB testing is
suboptimal, or if the result is equivocal using both IHC and
ISH
 ASCO/CAP guidelines specifically state that a repeat test
should be done in the case of grade 3 tumors that are HER2
negative on CNB specimens
Core Needle Biopsy Device: Reporting:
•Recommendations of human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical
Oncology/College of American Pathologists clinical practice guideline update. J Clin Oncol. 2013
•Updated UK Recommendations for HER2 assessment in breast cancer. J Clin Pathol. 2015

15.  CNB correctly identifies benign and malignant disease in
more than 90% of cases.
Problem Areas:
 Fibroepithelial lesions with cellular stroma and PTs.
 Spindle cell lesions.
 Residual or recurrent carcinoma (in situ or invasive) after
radiation therapy.
 Papillary lesions.
 Mucinous lesions.
 Radial scar.
 Atypical proliferative lesions including FEA, ADH and LN.
 Microcalcifications not associated with a specific pathology
but suspicious of origin in DCIS.
When to recommend excision after CNB?

16. Normal Mod
Increase
Marked
Increase
PT vs FA with cellular stroma
Problem Areas: Fibroepithelial lesions :
•Markedly increased stromal
cellularity
Are most likely to be PT
Excision, with clear margins
•Moderately increased stromal
cellularity
•Stromal mitoses
•Elevated ki67 or topo II
High probability of being PT
Excision with clear margins
•Moderately increased stromal
cellularity
•No stromal mitoses and low
ki67 or topo II
Either PT or FA
Should be excised, attention
to margins is less Important
Fibroepithelial lesions with cellular stroma on breast core needle biopsy; are there predictors of outcome on surgical excision? Am J Clin

18. Problem Areas: Spindle cell lesions :
 Metaplastic carcinoma
 Phyllodes tumour
 Myofibroblastoma
 Angiosarcoma
 Fibromatosis
 Nodular fasciitis

19.  To assess microcalcifications in irradiated breast after breast
conservation and RT for invasive carcinoma or DCIS
Problem Areas: Residual/Recurrent Carcinoma after RT:
Fat necrosis with associated
hyalinized fibrous scar tissue
Within sutures or other
intraoperative material
Recurrent/residual DCIS or
invasive carcinoma
Benign ducts and tdlus
subjected to irradiation
RT induced changes:
•Atrophy of the epithelium of the ducts &
TDLU. Cytological atypia of the epithelial
cells—may be patchy and focal
• Prominent myoep cells,
• Increased collagen in the breast stroma.
• Atypical stromal fibroblasts.
• Microcalcification within the TDLU and
ducts
Recurrent DCIS in irradiated
breast:
•Presence of mitoses
•Similarity of the changes to DCIS
in the pre-irradiated breast – both
architecture and nuclear grade

20.  Current policy in most units is to excise all
papillary lesions diagnosed on CNB
 Intraductal papilloma vs Intraductal papillary
carcinoma:
 Intraduct papillary lesions are frequently heterogenous
 Intraduct papillomas can have areas of epithelial
hyperplasia or atypia equivalent to ADH
 Smooth muscle myosin heavy chain, CD10 and p63
Problem Areas: Papillary Lesions :
•Follow up carcinoma incidence : 0–25% after a CNB
diadnosis of a papillary lesion without atypia
•Risk of carcinoma in those patients with multiple
papillomas
Breast core needle biopsy: issues and controversies. Mod Pathol ,.2010

21. Mucinous carcinoma vs Mucocoele like lesions:
Problem Areas: Mucinous lesions :
Mucinous carcinoma in a CNB is
uncomplicated if neoplastic epithelial
cells are seen within the mucin
Mucocoele-like
lesion with a frequently minimal
epithelial component : more
difficult
Excision is
suggested

22. 1. Radial scar vs carcinoma
2. DCIS (and/or invasive carcinoma) focally present at the periphery
3. ?Risk factor for the development of invasive carcinoma
Problem Areas: Radial Scar:
Recommendation:
surgical excision
?? Microscopic radial
scars thoroughly
sampled (excised) in a
VACB and
showing no atypical
features

23.  DCIS : extensive periductal and
intraductal fibrosis after necrosis
 Deeper levels and use of cytokeratin
IHC to identify any residual DCIS
cells
Problem Areas: Isolated Microcalfications:
Surgical excision is frequently needed

24. Core Needle Biopsy: IHC:
ER CK5
ADH
DCI
S
UDH
Application of Immunohistochemistry in Breast Pathology A Review and Update, Arch Pathol Lab Med

25. Core Needle Biopsy: IHC:

26. Core Needle Biopsy: IHC:
Lymphoid
malignancies
AE1/AE
3
CD20 CD79a Bcl 6 MUM1
Primary Breast Lymphoma in a Woman: A Case Report and Review of the Literature Am J Case
DLBCL

27. Ki67 p63
CK
5
CD10 SMA p63
Core Needle Biopsy: IHC:
Application of Immunohistochemistry in Breast Pathology A Review and Update, Arch Pathol Lab Med

28. Core Needle Biopsy: IHC:
Application of Immunohistochemistry in Breast Pathology A Review and Update, Arch Pathol Lab Med

29. Core Needle Biopsy: IHC:
CD34
Spindle Cell Lipoma
Myofibroblastoma
CD34 SMA

30. Potential Pitfalls:
 Nuclear ß catenin : Positive in some metaplastic spindle cell
carcinoma & phyllodes
 CK: Few cases of Phyllodes
 P63: Few cases of Phyllodes
 Negative CD34: Some cases of Malignant Phyllodes
 E-Cadherin: Some cases of ILC may not have loss of E-
Cadherin
Core Needle Biopsy: IHC:

31.  Significant haematoma
 Fainting
 Infection
 Pneumothorax
 Bleeding (H/O anticoagulant)
Complications:

32.  Haemorrhage, granulation/fibrous tissue, inflammation in
CNB track (often with associated histiocytes and
haemosiderin-laden macrophages)
 Disruption and fragmentation of ducts and TDLUs.
 Epidermal inclusion cysts
 Displacement of epithelium within the CNB track &
adjacent breast tissue, and occasionally epithelial
fragments & cellular debris within ducts
 Epithelium within lymphovascular spaces
Pathological findings after CNB:
Overdiagnosis of Invasive
Carcinoma
Myoepithelial markers
???Misplaced DCIS
cells

33.  57 year old female.
 Presented with a 7x4 cm sized lump in the left breast
 Underwent a modified radical mastectomy

34. PA
S
Mucinous carcinoma of
breast
WT1

35.  53 year old female.
 Presented with a bilateral breast lumps, each measuring 10x8
cm
 Previous CNB reported it as IDC (NST) MBR Grade 3
 Underwent bilateral modified radical mastectomy

36. Bilateral Pleomorphic Lobular
Carninoma

37. 74%
26%
Breast Lesions (88 cases)
Malignant Benign
48
3
8
1 1 2
Number
of
Cases
65 Malignant breast lesions
6 month data from IPGME&R
(2016)

38. 8
2
1
5
1 2
1 1 1 1
Number
of
Cases
23 Benign Breast Lesions

39.  CNB and IHC study on CNB specimans have become
standardized procedures in the pathological services.
 There are international guidelines on how to report CNBs of
breast lesions.
 Many of the diagnostically dubious lesions warrant the use
of IHC, and excisional biopsies for categorical opinions.
 Interpretation of IHC and morphology necessitates the
knowledge of the potential pitfalls of IHC.
 Optimisation of all resources is an essential part of the
rationale of all algorithms.
Take Home Message: