Table 1 Histologic follow-up stratified by cytologic diagno

CytologyHistology

PRO PWA ATY SUSP/POS

“BENIGN” (Number, %) 49 (94%) 48 (80%) 47 (73%) 1 (2%)Benign/miscellaneous 1 1 8 -Fibrocystic change 7 9 14 -Usual ductal hyperplasia 8 6 7 -Sclerosing adenosis/radial scar 1 2 2 -Tubular adenoma 1 - - -Fibroadenoma 19 17 12 1

S8 Abstracts

squamous metaplasia, foamy histocytes, and lymphocytic infiltrate (none,mild, marked).Results: 36 TNBC cases were eligible and typically exhibited cellularclustering, naked nuclei, and nuclei >3 RBCs in size (see Table 1 andTable 2). Nuclear margins for TNBC are typically smooth-slightlyirregular.Conclusion: TNBC typically exhibits cellular clustering, enlarged nuclearsize, and naked nuclei. These features may help elucidate TNBC duringrapid on-site evalution.

Table 1 Features Present in Triple Negative Breast Cancer

Score Naked NucleiNZ35

Nuclear SizeNZ36

ClusteringNZ35

1 6 (17%) 2 (6%) 2 (5.7%)2 20 (57%) 17 (47%) 22 (63%)3 9 (26%) 17 (47%) 11 (31%)

Table 2 Features Absent in Triple Negative Breast Cancer

Score

NZ36

Mitoses Nuclear

Margins

Nucleoli

Size

Nucleoli

Number

Squamous

Metaplasia

Necrosis Foamy

Histiocytes

Lymphocytic

Infiltration

NZ33

1 33 (91.7%) 15 (42%) 27 (75%) 23 (63.9%) 35 (97.2 %) 19 (52.8%) 27 (75 %) 26 (79 %)

2 2(5.6%) 18 (50%) 8 (22%) 8 (22%) 1 (3%) 14 (39%) 6 (17%) 5 (15%)

3 1 (2.8%) 3 (8%) 1 (3%) 5 (14%) 0 (0%) 3 (8%) 3 (8%) 2 (6%)

Intraductal papilloma 12 13 4 -“ATYPICAL/MALIGNANT” 3 (6%) 12 (20%) 17 (27%) 52 (98%)Phyllodes tumor, low grade 1 - 1 -Flat epithelial atypia - 1 - -Atypical Ductal Hyperplasia 1 3 - 2Atypical Lobular Hyperplasia - - 1 -Ductal Carcinoma In Situ - 3 2 2Lobular carcinoma In Situ - 1 1 -Invasive Ductal Carcinoma 1 3 9 42Invasive Lobular carcinoma - 1 1 4Invasive Mammary carcinoma - - 2 2Total 52 60 64 53

2

The Effect of Breast FNA in Guiding the Optimal Management ofBreast Lesions: A 5-year Retrospective Review of Outcome

Stephanie Barak, MD, Sana O. Tabbara, MD, M. Katayoon Rezaei, MDThe George Washington University, Washington, District of Columbia

Introduction: Fine needle aspiration (FNA) and core needle biopsy (CNB)are important adjuncts to clinical examination and imaging in themanagement of cystic and/or solid lesions of the breast. At our institution,FNA is used predominantly for cystic lesions. CNB is performed in “non-resolving” lesions, or for FNAs yielding atypia or malignancy. This studyaims to determine the accuracy of cytology in stratifying breast lesions intothose that may be followed clinically and those requiring biopsy and/orsurgical excision (SE).Materials and Methods: Between 2007 and 2012, breast FNAs inthe following categories were identified: Proliferative breast aspirate(PRO), proliferative breast aspirate with atypia (PWA), atypical cellspresent (ATY), suspicious/positive for malignancy (SUSP/POS). Onlycases with histologic follow-up were included in the analysis.Results: 376 FNAs were available; 229 (60.9%) had histologic follow-up.Results are summarized in Table 1. Patient age ranged from 15-97 years(mean 55); all but two patients were female. In the PRO category, threecases with “Atypical/Malignant” follow-up had discordant clinical/imagingfindings, prompting SE. One case was a low-grade phyllodes tumor; onecase with ADH was associated with an intraductal papilloma, and onewith invasive carcinoma was adjacent to a fibroadenoma, all likely theresult of sampling error. Cases with atypia showed a lesion requiring SEin 20% of PWA and 27% of ATY. In 98% of SUSP/POS cases, cytologyprompted further diagnostic/therapeutic management; in the case withbenign follow-up, the atypia was attributed to treatment effect of an ipsilat-eral breast cancer.Conclusions: The overwhelming majority of PRO cases correlates with“benign” diagnoses, allowing for conservative management, as indicated.Discordant clinical/imaging findings should guide the decision for SE.Recognition of cytologic atypia more frequently identifies cases requiringSE. SUSP/POS has the highest degree of correlation with “Atypical/Malignant” disease and should trigger appropriate management.

3

Preoperative Fine Needle Aspiration of Axillary Lymph Nodes:Diagnostic Accuracy, Potential Pitfalls, and Clinical Correlates

Syed Gilani, MD, Lamia Fathallah, MD, Basim M. Al-Khafaji, MDSt. John Hospital & Medical Center, Detroit, Michigan

Introduction: Axillary lymph node (ALN) status is very important for stagingand prognosis of breast cancer. This study evaluates the diagnostic accuracy,potential pitfalls and clinical utility of fine needle aspiration (FNA) of ALNs.Materials and Methods: A total of 95 (females, 54.56 + 13.1; meanage+S.D) underwent FNA of ALNs at our institution from January 2007 toFebruary 2013 with no rapid on-site evaluation (ROSE). Three diagnosticcytology categories were identified; positive/suspicious (PM), negative formalignancy (NM), or non-diagnostic, by one of the four Cytopathologists.Results: Fifty-one cases (53.6%)hadhistologic follow-up (4.09+2.85months),of these 27 (53%) were true positive (TP), 8 (16%) true negative (TN), 2 (4%)false negative (FN), 5 (10%) false positive (FP), and 9 (18%) non diagnostic.Sensitivity, specificity, positive predictive value, and negative predictive valuewere 93%,62.0%,84.4%, and80%respectively.However, cytological reviewofall FP and FN confirmed the presence and absence of tumor, respectively. All FPcases had undergone preoperative neoadjuvant chemotherapy, with no residualtumor present, andonly treatment effect identified histologically.Meanwhile, the2 FN casesweremicrometastasis (< 1.5mm). Thus, if reclassified as TP and TNall statistical indices would be at 100%. Also 70% of TP cases showed grade 2/3differentiation and vascular invasion (52.1%). All preoperative FNA positiveALN were spared from sentinel lymph node biopsy (SLNB), where indicated,except for 4 (14.2%), while 70 % of cytology negative cases underwent SLNB.Conclusion: Pre-operative FNA of ALN can provide diagnostic accuracy of100%, and aid in appropriate selection of either SLNB or ALND; thusprecluding the need for SLNB in FNA positive cytology. Meanwhile,recognition of potential pitfalls to include therapy effect and micrometa-stasis is essential. Furthermore, the non-diagnostic rate and sampling errorscan be reduced by the practice of ROSE.

4

Intraoperative Imprint Cytology Evaluation of Sentinel Lymph Nodesin Breast Carcinoma

Marilin Rosa, MD, Laila Khazai, MD, Marilyn M. Bui, MD, PhD,Nancy J. Mela, CT(ASCP), Barbara A. Centeno, MDMoffitt Cancer Center, Tampa, Florida

Introduction: Intraoperative evaluation (IE) of sentinel lymph node (SLN)in breast carcinoma (BC) plays an important role in patient care. This studyassesses our experience using imprint cytology (IC).

Abstracts S9

Materials and Methods: SLN evaluation using IC of BC patients fromJanuary to December 2011 were identified using Moffitt Cancer Center'sAnatomic Pathology cytology-histology correlation database. IC slides (air-dried and Diff-Quik stained) were classified as negative, positive or deferred(atypical and suspicious). The corresponding SLN histologic samples wereevaluated with one Hematoxylin and eosin section and immunohistochem-istry (AE1/3). The final diagnosis was classified into negative or positive formacrometastasis. After reviewing the IC smears of discrepant cases, errorswere classified as: sampling, screening or interpretation.Results: 915 IC of SLNs were performed. The average number of SLN percase was 2.1. Eighty-two SLN were positive on final diagnosis, and 33 ofthese were accurately diagnosed as positive on IC (40%). Twelve SLN weredeferred (9 atypical, 3 suspicious) (15%). There were 37 false negative (FN)SLN (45%) due to sampling (17, 46%), screening (14, 38%) andinterpretative (6, 16%) errors. Screening errors occurred with less than 3groups or isolated malignant cells only. Interpretation errors occurred whenthe malignant cells were not recognized and/or interpreted as macrophages.The sensitivity of IC was 69%, specificity 100%, positive predictive value100%, and negative predictive value 96%.Conclusions: Our results are comparable with the previously reportedsensitivity of IC (33 to 96%) and support the usefulness of this technique.We had no false positives. The majority of FN were due to sampling error,in which the malignant cells were not sampled by the IC. Improvement ofSLN sampling technique by IC could improve sensitivity.

Figure 1 Diagram displaying histologic type and reason for discrepancy in falsenegative SLN (37).

Table FNA of Breast Masses in Pregnant and Lactating Women

LAd CA AS Other Inadequate

Cytology 19 2 0* 4 (abscess, cyst) 3 (including 1 AS*)Histopathology 17 2 1 1 -

Abbreviations: LAd: Lactating adenoma; CA: Invasive carcinoma; AS: Angiosar-coma*Blood only. No lesional cells present.

5

Cytologic Features of Metastatic Micropapillary Breast Carcinoma inFine Needle Aspiration and Effusion Cytology

Gabriela Rosa, MD, Natalie Freed, MD, Deborah J. Chute, MDCleveland Clinic Foundation, Cleveland, Ohio

Introduction: Micropapillary carcinoma of the breast (MPBC) is anaggressive variant of invasive ductal carcinoma. Features of this tumoron fine needle aspiration (FNA) of the breast include: tumor moruleslacking fibrovascular cores, isolated malignant cells, high cellularity,apocrine change, and hobnail nuclei. Only limited information is availableon FNA cytology of metastatic MPBC, and the cytologic features of MPBCon effusion cytology have not been previously described.Materials and Methods: The archives of one institution over 15 years weresearched for histologically confirmed MPBC with a subsequent positivecytology specimen available for review. Six cases were identified: four FNAs(3 axillary lymph node and 1 vertebral body), one pleural fluid (PF) and onecerebrospinal fluid (CSF). The cytologic preparations were evaluated formajor and minor criteria of MPBC. Major criteria included tumor morules/

papillae without fibrovascular cores, high cellularity, and isolated malignantcells. Minor criteria included presence of mucin, apocrine change,psamomma bodies, hobnail nuclei and absence of a tumor diathesis.Results: On FNA cytology, tumor morules/papillae lacking fibrovascularcores and isolated malignant cells were the most common major criteriapresent. Only one FNA, however, showed high cellularity. Of the minorcriteria, apocrine change was present in all FNAs and hobnail nuclei werepresent in three FNAs. Mucin and psamomma bodies were absent in allFNAs. Tumor diathesis was present in two FNAs. The CSF and pleuralfluid had tumor morules/papillae lacking fibrovascular cores and isolatedmalignant cells, with an apocrine appearance.Conclusion: The most consistent FNA features seen in metastatic MPBCwere tumor morules, papillae lacking fibrovascular cores, and apocrinechange. High cellularity was only present in one FNA. The cytologicfeatures of metastatic MPBC in effusion cytology are similar to that seen inFNA cytology.

6

Fine Needle Aspiration of Breast Masses in Pregnant and LactatingWomen: A Study of 28 Cases with Emphasis on ThinPrep Appearanceof Lactating Adenoma

Jonas J. Heymann, MD, Allison M. Halligan, MS,Kirk E. Facey, CT(ASCP), Syed A. Hoda, MD, Rana S. Hoda, MD, FIACNew York-Presbyterian Hospital-Weill Cornell Medical College, New York,New York

Introduction: Fine needle aspiration (FNA) of breast masses in pregnant orlactating women is uncommon. Interpretation in such cases is consideredproblematic due to cytological atypia inherent to secretory change.Cytomorphology of lactating adenoma (LAd), the most common tumor inthis population, has been based on Papanicolaou (Pap) and Diff-Quik (DQ)stained direct smears (DS). Cytological features of LAd on ThinPrep (TP)remain largely uncharacterized.Materials and Methods: FNA cases from breast masses in pregnant orlactating women (2005-2012) were retrospectively reviewed. Availablecorresponding histopathological material was reviewed. FNA specimenswere processed as Pap and DQ stained DS, and/or DS+Pap stained TP, and/or TP alone.Results: 28 cases from as many patients, with mean age of 36 years (range:22-47) were reviewed. FNA was performed from 25 weeks of pregnancy to10 months postpartum. Mass size ranged from 1.0 to 4.5 cm. Correspondinghistopathology was available in 21/28 cases. TP was available in 24/28cases (Table). LAd showed lacy fragments and globular clumps of milkybackground material with embedded dispersed bare epithelial nucleicontaining prominent cherry-red nucleoli. Architecture appeared disruptedin TP with isolated or clustered epithelial cells in lobules. Cells were betterpreserved in TP compared to DS, and cytoplasm was uniformly foamy inintact cells. Associated fibroadenomatous changes (4 cases), containedsmaller staghorn epithelial cell clusters dissociated from myoepithelial cellsand stromal fragments in TP. Cytological features of invasive carcinoma onTP (2 cases) were similar to those in non-pregnant and non-lactatingwomen. There were no false positive cases.Conclusions: LAd is the most common diagnosis for breast masses inpregnant and lactating women (71% of cases in this series). LAd appearsdifferent on TP than on conventional preparations. In this setting,malignancy is an important consideration and was encountered in 3/28(11%) cases in this series.