Histopathology and Cytology for Breast lesions

Britt-Marie Ljung MDProfessor of Pathology, Dir. of Cytology

University of California at San Francisco

Palpable Breast masses

Fine needle aspiration biopsy (FNA)-cytology

Core needle biopsy (CNB) - histopathology

Open surgical biopsy incisional/excisional -histopathology

FNA biopsy

Sampling with 22-25 gauge needleClinic procedureImmediate check of sample for adequacy and preliminary diagnosis 2-4 samples depending on size of mass, nature and abundance of material Local anesthetic optionalPost procedure pain minimal Processing time for permanent material

<1 hour

FNA biopsy

Preliminary dx within minutes possible

Cell block material can be used for hormone receptor evaluation

Nuclear grading only

Cannot prove invasive component based on FNA alone (5%)

Core needle biopsy

11-18 gauge needles

Clinic procedure

5 to about 15 cores

Local anesthetic necessary

Post procedure pain can be significant

Processing time for permanent specimen 24+ hours

Core needle biopsy

Grading estimate possible, but limited sample, may change after excisionNo surgical margins Size of lesion not reliableMost cases containing invasive disease will show on core (70+%) depending on number of coresImmediate preliminary dx can be done using touch preparations

Open surgical biopsy

Requires operating room facility

Local or general anesthesia necessary

Immediate evaluation possible by frozen section or touch/scrape preparation

Processing time of permanent sections

2+ days

Invasive component verifyable in virtually all cases

Post op discomfort significant in all cases

Open surgical biopsy/excision

surgical margins

Size of lesion if excisional bx

Comprehensive view of DCIS vs invasive disease

Final grading

Removal of mass if excisional bx

Accuracy issues in common for all modalities

Specimen handling including fixation

and staining

Skills in interpretation

Sampling errors, varying degrees

FNAB Accuracy Palpable Breast, Meta-analysis

Sensitivity 65% - 98%

Specificity 34% - 100%

Giard R and Herman SJ

Cancer Apr 15, 1992

Vol 69, No 8, p. 2104

FNAB Accuracy – Impact of Training in Sampling Technique

Sensitivity Specificity With Training

98% 100%

Without Training 75% 100%

Definition of training in sampling technique: > 100 cases during up to one year supervised by

experienced teacher with proven track record.Ljung et al

Cancer (Cancer Cytopathology)2001; 93: 23-268

Impact of training in FNA procurement

Formally Trained No Formal Training Missed Cancers Missed Cancers

2% 25%

Non dx Non dx2% 37%

Ljung et alCancer

2001:93 (4):263-68

Impact of training in FNA procurement

Formally trained operators did on average more FNAs

Operators without formal training who did many FNAs did NOT perform better than operators without training who did few FNAs

Conclusion: Experience without training did not improve performance

Factors improving FNA accuracy

Hands-on one-to-one training in sampling technique

Frequent use of the technique (>100/y)

Immediate evaluation and use of direct smears

Sampling and interpretation by same person

Interpret FNA in clinical context (Triple test, breast)

US guidance for small and non-palpable targets

Levels of training, FNA sampling

See one, do one, teach one ~ 50% dx

10 cases in training ~ 60% dx

50 cases in training ~ 85% dx

100 cases in training ~ 90% dx

200 cases in training ~ 95% dx

Accuracy Breast Core biopsies, meta-analysisGuided by:

False Negative

Palpation 0 – 13%

Ultrasound 0 - 12%

Stereotactic 0.2 – 8.9%

Dillon M et alAnnals of Surgery

Vol 242 No. 5 Nov 2005

Image Guided Core Needle Biopsy Accuracy

Strategy: Increase number of cores/weight of tissue Sensitivity Recommended

with 5 no of cores14 gauge cores 14 gauge

Mass Lesions 98% 5-6

Ca++ 91% 15

Arch. Dist 86% 15

US-guided 98% 5-12 cores

Operator dependentBrenner RJ et al

AJR Am J Roentgenol166:341-346 1996

Accuracy Open biopsy

Sampling problems are rare but not zero particularly for small lesions and lesions found by imaging

Interpretation issues most common in lobular carcinoma with sparse and very small tumor cells that can mimmick lymphocytes

FNAB as part of Triple Testin palpable lesions

Reported False neg rate FNAB alone 7%

When applying Triple Test for Breast (clinical+imaging+cytology findings)False negative rate 0%

Conclusion: if the bx result does not fit, regardless of bx type, take additional steps

Lau S et alThe Breast Journal

Vol 10 No 6 2004 p. 487-491