BreastBreastCytopathologyCytopathology--TechniquesTechniques--MorphologyMorphology
JerzyJerzy KlijanienkoKlijanienko MDMD
Institut Curie, Paris, FranceInstitut Curie, Paris, France
HistoryHistory of FNAof FNA
19261926 Martin, Martin, Ellis Ellis ((MemorialMemorial Hospital)Hospital)19541954 CardozoCardozo (Pays Bas)(Pays Bas)19541954 ZajicekZajicek ((KarolinskaKarolinska))19541954 ZajdelaZajdela (Institut Curie)(Institut Curie)19721972 Rilke (Milan)Rilke (Milan)19801980 USA, CanadaUSA, Canada
Avantages for Avantages for thethe patientpatient
SimpleSimpleNo No anaesthesiaanaesthesiaCan Can bebe repeatedrepeatedNot time Not time consumingconsuming
Avantages for Avantages for thethe clinicianclinician 11
AmbulatoryAmbulatoryCan Can bebe performedperformed duringduring pregnancypregnancyImmediateImmediate resultsresultsCan Can bebe therapeutictherapeutic ((cystcyst, , abcessabcess))Multiple localisationsMultiple localisationsN (+) or N (N (+) or N (--))
Avantages for Avantages for thethe clinicianclinician 22
Can Can identifyidentify a a recurrencerecurrenceCan Can identifyidentify nonnon--palpable palpable lesionslesionsCan Can identifyidentify metastasismetastasis ((liverliver, distant , distant organsorgans))Can Can determinedetermine proliferationproliferation indexindexCan Can identifyidentify malignancymalignancy for palliative for palliative treatmenttreatmentProcedure explanationProcedure explanation to patient to patient isis easyeasyHospitalHospital occupation occupation cancan bebe plannedplanned
Avantages for Avantages for thethe laboratorylaboratory
MGG MGG andand DQ, DQ, fastfast stainingstainingSimple Simple materialmaterialLowLow costcostPossibilityPossibility of FCM, of FCM, BacteriologyBacteriology, HR, HRLymphomaLymphoma, , SarcomaSarcoma
ComplicationsComplications
Distant Distant disseminationdissemination: : nevernever observedobservedLocal Local disseminationdissemination: : nevernever observedobservedHematomaHematoma: 40: 40--50% of cases50% of casesPneumothoraxPneumothorax: 1 in 28 000 cases: 1 in 28 000 casesInfectionInfection: 3 in 200 000 cases: 3 in 200 000 cases
ResultsResults (1)(1)
ExactExact: M/M, B/B, S/S: M/M, B/B, S/SSuspiciousSuspicious: S/M, S/B: S/M, S/BFalseFalse negativenegative: B/M: B/MFalseFalse positivepositive: M/B: M/BNon Non significantsignificant: NS/M, NS/B, NS/S: NS/M, NS/B, NS/S
ResultsResults (2)(2)
((excludingexcluding NS)NS)
SensitivitySensitivity = VM / VM+FB x 100= VM / VM+FB x 100
SpecificitySpecificity = VB / VB+FM x 100= VB / VB+FM x 100
MalignantMalignant TumorsTumors
93.293.26.16.16.66.683.783.7173721737220002000CurieCurie
96964455909076276219931993SneigeSneige
97973399828299099019811981BriffodBriffod
9696443388881745174519751975ZajdelaZajdela
929288151577771068106819701970ZajicekZajicek
SensibilitySensibility(%)(%)
FBFB(%)(%)
SuspSusp(%)(%)
ExactExact(%)(%)
# # CasesCases
YrYrAuthorsAuthors
BenignBenign TumorsTumors
0.20.2
0.40.4
0.30.3
0.10.1
FPFP(%)(%)
99.799.73.83.889.289.29662966220012001KlijanienkoKlijanienko
92926678781449144919871987FessiaFessia
95954489891027102719751975ZajdelaZajdela
93937793931009100919701970ZajicekZajicek
SpecificitySpecificity(%)(%)
SuspSusp(%)(%)
ExactExact(%)(%)
# # CasesCases
YrYrAuthorsAuthors
FalseFalse--positivepositive
0.020.02 % in % in ourour seriesseriesAdenofibromaAdenofibromaDuctalDuctal ectasiaectasiaSclerosingSclerosing adenosisadenosisPapillomasPapillomas
WhyWhy are are thethe resultsresults differentdifferentbetweenbetween studiesstudies??
InterpretationInterpretation-- numbernumber of of pathologistspathologists-- competencecompetence-- numbernumber of FNA of FNA perper daydayUnsatisfactoryUnsatisfactory samplessamples-- multiple localisationsmultiple localisations-- tumor tumor fibrosisfibrosis
How to How to improveimprove
9999868681819595248248PowlesPowles
1001008080868680.880.89494HermasenHermasen
98.998.994.294.294.294.288.488.4223223BriffodBriffod
98.898.887.187.188.788.792.192.113001300CornillotCornillot
All All threethree(%)(%)
FNAFNA(%)(%)
RadioRadio(%)(%)
ClinicalClinical(%)(%)
# # CasesCases
AuthorsAuthors
TechniquesTechniques
SampleSample (1)(1)
MaterialMaterial23 G 23 G needlesneedlesSlidesSlidesDisinfectantDisinfectant andand bandagesbandagesMicroscope + Microscope + DiffDiff--QuikQuik
SampleSample (2)(2)
Clinical Clinical impressionimpression, tissue , tissue resistanceresistanceand and smearingsmearing modality modality are the are the THREETHREEimportant criteria to provide a high important criteria to provide a high quality FNAquality FNA
The procedure should be simple and The procedure should be simple and reproducible reproducible
SampleSample (3)(3)
ErrorsErrorsSlow or violent Slow or violent needleneedle introductionintroductionTooToo long or long or numerousnumerous needleneedle passespassesUse of Use of pistolpistolBandagingBandaging tootoo quicklyquickly cancan cause cause ulteriorulteriorhematoma hematoma
QualityQuality control (1)control (1)
ClinicalClinical impressionimpressionRound, mobile: Round, mobile: cystscysts, FA, , FA, mucinousmucinousRound Round withwith marginsmargins: FA, : FA, phyllodesphyllodes tumortumorPoorlyPoorly delimiteddelimited: : mastopathiamastopathia, , lobularlobular cacaFixedFixed +/+/-- fossette: fossette: carcinomascarcinomasproximityproximity to to scarsscars: fat : fat necrosisnecrosis, , recurrencerecurrence
QualityQuality control (2)control (2)
Tissue Tissue resistanceresistance
No No resistanceresistance: : cystscysts, FA, fat , FA, fat necrosisnecrosisFibrousFibrous: : mastopathiamastopathia, FA, , FA, lobularlobular cacaHeterogenousHeterogenous: : mastopathiamastopathia, , carcinomascarcinomas, , necrosisnecrosis
QualityQuality control (3)control (3)
SmearSmear macroscopymacroscopyColorColor
White, White, pinkpink: : galactophotiritisgalactophotiritis, , cystscysts, FA, , FA, mucinousmucinousGray: Gray: carcinomacarcinomaAdipousAdipous: fat : fat necrosisnecrosis, , lipomalipoma, NS, NS
CellularityCellularitywetwet samplesample, , ovaloval, , centeredcentered on on slideslideDiffDiff--QuikQuik
NonNon--palpable palpable lesionslesions (1)(1)
No No microcalcificationsmicrocalcificationsUS image (FNA) > 2mm < 8mmUS image (FNA) > 2mm < 8mmFNA plus CNB > 8mmFNA plus CNB > 8mmMultiple Multiple lesionslesionsRadioRadio-- suspicioussuspicious lesionslesions (ACR 3(ACR 3--4)4)WellWell--trainedtrained staffstaff
NonNon--palpable palpable lesionslesions (2)(2)
MaterialMaterialUS 7US 7--10 MHz10 MHzStandard FNA Standard FNA materialmaterialNeedleNeedle attachedattached to syringe: aspirationto syringe: aspiration
NonNon--palpable palpable lesionslesions techniquetechnique
The The shortestshortest waywayOptimal Optimal cutaneouscutaneous point point AngularAngular insertioninsertionVertical insertionVertical insertionAspirationAspirationVisualizedVisualized on on screenscreen duringduring aspiration aspiration PossibilityPossibility of of completioncompletion by USby US--CNBCNB
CytologyCytology analysisanalysisClinicalClinical datadata: age, size, site, tumor : age, size, site, tumor kineticskinetics, , clinicsclinics, , radiologyradiology, N, M, , N, M, previousprevious treatmenttreatmentFNA componentsFNA components:: cellularitycellularity, , distribution, distribution, cohesivenesscohesiveness, , chromatinchromatin, , stroma, stroma, necrosisnecrosis, , secretionssecretionsSimple report, one Simple report, one diagnosisdiagnosis
Cell Cell blocbloc
ER
PR
cerbB2
ReferencesReferences for for diagnosisdiagnosis of of breastbreast lesionslesionsInstitut Curie, ParisInstitut Curie, Paris
20082008
# patients# patients
29.229.256561767176720012001
29.529.556.356.31252125219991999
31.931.956561130113019971997
31.831.855.755.71161116119891989
36.336.355.855.898298219851985
41.241.255.955.994194119811981
DiameterDiameter((meanmean))
Age Age ((meanmean))
##
Diagnostic Diagnostic circumstancescircumstances
61%61%33%33%19991999
61%61%33%33%19971997
60%60%33%33%19931993
68%68%23%23%19891989
74%74%6%6%19851985
71%71%4%4%19811981
PalpationPalpationMammographyMammography
Stage Stage atat diagnosis diagnosis 11
Stage Stage atat diagnosis diagnosis 22
8%8%38%38%40%40%14%14%19991999
8%8%40%40%42%42%10%10%19971997
8%8%41%41%44%44%7%7%19931993
11%11%48%48%36%36%5%5%19891989
16%16%60%60%21%21%3%3%19851985
23%23%61%61%14%14%2%2%19811981
IIIIIIIIIIII00
Initial Initial surgicalsurgical treatment treatment
62%62%1999:1999:
60%60%1997:1997:
52%52%1993:1993:
41%41%1989:1989:
30%30%1985:1985:
19%19%1981:1981:
DiagnosisDiagnosis
AnamnesisAnamnesisClinicalClinical examinationexaminationRadiologyRadiology
MammographyMammographyUSUSCTCT--scanscan andand IRM (if IRM (if necessarynecessary))
PathologyPathology reportreport
But But alsoalso ……..
FCM for DNA ploidy FCM for DNA ploidy andand SPhaseSPhaseKiKi--67, c67, c--erbB2, p53, erbB2, p53, ……..HR HR usingusing ICCICCMicrobiologyMicrobiologyFCM for FCM for lymphomalymphoma membrane markersmembrane markersCellCell andand tissue tissue banks banks –– molecular molecular profileprofile
PathologyPathology reportreport
To To obtainobtain thethe diagnosisdiagnosis in in orderorder to to informinform thethe patient about patient about treatmenttreatmentmodalitiesmodalitiesTo To indicateindicate SentinelSentinel LNLNTo To avoidavoid successive interventionssuccessive interventionsTo know To know prognosticprognostic parametersparameters andand to to predictpredict prognosisprognosis(HR, (HR, SPhSPh, MI, EE grade, cerbB2, E+), MI, EE grade, cerbB2, E+)
BreastBreast lesionslesions
Mammotome
MicrocalcificationsACR 4ACR 5
Cytoponction
Suspect < 7mm
Microbiopsie+/- Cytoponction
Suspect > 7mm
Nodule échographiqueSuspect
CytoponctionMicrobiopsie
Nodule échographiqueIndéterminé
Lésion non palpable
DRILL-BIOPSIE, 11G
MICRO-BIOPSIE AU PISTOLET 22mm, 14G
FNA vs CNB FNA vs CNB vsvs SurgicalSurgical SpecimenSpecimen
31 mm31 mm9.2%9.2%2.8%2.8%88%88%
MeanMean sizesizeFNA:MFNA:MMB:BMB:BSS:MSS:M
FNA:BFNA:BMB:MMB:MSS:MSS:M
FNA:MFNA:MMB:MMB:MSS:MSS:M
The drawbacksThe drawbacks
The The procedureprocedure maymay bebe painfulpainfulImpossible to Impossible to samplesample MCAMCAInfiltration Infiltration featuresfeatures are are seenseen in in onlyonly90% of 90% of carcinomascarcinomasProcedureProcedure needsneeds wellwell--trainedtrained staffstaff
MorphologyMorphology
HistologyHistology((BenignBenign tumorstumors))
specificspecific andand nonnon--specificspecificInflammationInflammation
Double compositionDouble compositionFibroadenomaFibroadenoma
TumorTumor vs hyperplasiavs hyperplasiaPapillomaPapilloma
i.e. i.e. oncocytic metapl oncocytic metapl MetaplasiaMetaplasia
PathologicalPathological dilatationdilatationCystCyst
IncreasedIncreased numbernumberHyperplasiaHyperplasia
IncreasedIncreased numbernumberAdenosisAdenosis
HistologyHistology ((MalignantMalignant tumors)tumors)
NON INFILTRATIVENON INFILTRATIVEDuctalDuctal in situin situLobularLobular in situin situ
INFILTRATIVEINFILTRATIVEDuctalDuctalDIC DIC withwith in situ in situ predpred..LobularLobularMucinousMucinousMedullaryMedullaryPapillaryPapillaryTubularTubularAd Ad CysticCystic CaCaApocrineApocrineMetaplasticMetaplasticPaget Paget diseasediseaseOthersOthers: MM, : MM, LymphLymph, , SarcSarc
BreastBreast PathologyPathologyin FNAin FNA
-- BenignBenign-- MalignantMalignant
InflammatoryInflammatory cytologycytology
Acute inflammationAcute inflammationChronicChronic inflammationinflammationNonNon--specificspecific granulomagranulomaForeignForeign body body granulomagranulomaTBC/TBC/sarcoidosissarcoidosisFat Fat necrosisnecrosis
Acute InflammationAcute Inflammation
Purulent collectionPurulent collectionPainfulPainful FNAFNAFeverFever+/+/-- DermatitisDermatitisMalignantMalignant clinicalclinical aspectaspectMicrobiologyMicrobiologyNo CNBNo CNB
GranulomasGranulomas
TBC or TBC or SarcoidosisSarcoidosisMicrobiologyMicrobiology ((liquidliquid, PCR, , PCR, smearssmears))
ForeignForeign body body granulomagranulomaFrequentFrequent postpost--surgicalsurgical complicationcomplication
HaematomaHaematomaSebaceousSebaceous cystcyst
Fat Fat necrosisnecrosis
DifferentDifferent chronologychronology::Initial:Initial: lipophageslipophagesAdvancesAdvances:: fibroblasticfibroblastic reparationreparation
May May bebe a a problemproblem of of diagnosisdiagnosisPossibilityPossibility of FP !!of FP !!
BenignBenign TumorsTumors (1)(1)CystsCysts
DifferentDifferent typestypesApocrineApocrine metaplasiametaplasia«« OldOld »» cystcystPossibilityPossibility of of atypicalatypical cellscells
DifferentialDifferential diagnosisdiagnosisApocrineApocrine carcinoma carcinoma PapillomaPapillomaPapillaryPapillary carcinomacarcinoma
BenignBenign TumorsTumors (2)(2)BreastBreast dystrophiadystrophia
BreastBreast dystrophiadystrophiaBenignBenign cytologycytologyVariableVariableCysticCystic backgroundbackgroundNo No atypiaatypiaClinicallyClinically benignbenign50% of patients50% of patients
BenignBenign TumorsTumors (3)(3)EpithelialEpithelial hyperplasiahyperplasia
EpithelialEpithelial hyperplasiahyperplasiasimplesimpleatypicalatypical
BenignBenign TumorsTumors (5)(5)AtypicalAtypical hyperplasiahyperplasia
AtypicalAtypical hyperplasiahyperplasia33--D clustersD clustersIrregularIrregular nucleinucleiBenignBenign//AtypicalAtypical FNA FNA morphologymorphology
BenignBenign TumorsTumors (6)(6)FIBROADENOMAFIBROADENOMA
UsuallyUsually 2020--35 35 yrsyrsMultiple in 20% of casesMultiple in 20% of casesCharacteristicCharacteristic cytologycytology
EpithelialEpithelial cellscellsNakedNaked nucleinucleiConnective fragmentsConnective fragmentsMucinMucin (+/(+/--))DigitiformDigitiform clusters (+/clusters (+/--))
BenignBenign TumorsTumors (7)(7)PHYLLODES PHYLLODES TumorTumor
RareRareLarge sizeLarge size«« malignantmalignant »» or or «« benignbenign»» behaviourbehaviourFNA: pseudoFNA: pseudo--FAFA
AbundantAbundant connective fragmentsconnective fragments«« normalnormal »» epithelialepithelial cellscellsSomeSome C/N C/N atypiaatypiaMitoses +/Mitoses +/--
BENIGN TUMORS (8)BENIGN TUMORS (8)DUCTAL ECTASIA, PAPILLOMADUCTAL ECTASIA, PAPILLOMA
DuctalDuctal ectasiaectasiaPossibilityPossibility of of nipplenipple retractionretractionPseudoPseudo--cysticcystic morphologymorphologyCentral Central localizationlocalization
PapillomaPapillomaCysticCystic backgroundbackgroundPapillaryPapillary clustersclustersVascularVascular structuresstructuresMacrophagesMacrophagesMyoepithelialMyoepithelial cellscells
PossibilityPossibility of FP !!!!of FP !!!!
BENIGN TUMORS (9)BENIGN TUMORS (9)RARE CONDITIONSRARE CONDITIONS
LipomaLipomaGranularGranular cellcell tumortumorIntramammaryIntramammary LymphLymph NodeNodeGynecomastiaGynecomastia
MALIGNANT TUMORS (1)MALIGNANT TUMORS (1)DUCTAL CARCINOMADUCTAL CARCINOMA
-- 8080--85%85%-- PolymorphousPolymorphous cellscells
-- GlandularGlandular structures.structures.-- IsolatedIsolated cellscells withwith preservedpreserved cytoplasmcytoplasm-- IrregularIrregular nucleinuclei-- HugeHuge nucleinuclei-- NecrosisNecrosis-- Mitoses +/Mitoses +/--
MALIGNANT TUMORS (2)MALIGNANT TUMORS (2)LOBULAR CARCINOMALOBULAR CARCINOMA
5%5%Variable Variable cellularitycellularityMonomorphicMonomorphic nucleinucleiIsolatedIsolated cellscellsSmall clustersSmall clustersCellsCells in in indianindian filefileDiscreteDiscrete C/N C/N atypiaatypiaConnective tissueConnective tissue
MALIGNANT TUMORS (3)MALIGNANT TUMORS (3)MUCINOUS CARCINOMAMUCINOUS CARCINOMA
2%2%Mixed variantsMixed variantsCharacteristicCharacteristic mucinmucinInconspiciousInconspicious C/N C/N atypiaatypiaDifferentialDifferential diagnosisdiagnosis::
FibroadenomaFibroadenomaDuctalDuctal ectasiaectasia
MALIGNANT TUMORS (4)MALIGNANT TUMORS (4)MEDULLARY CARCINOMAMEDULLARY CARCINOMA
Round Round –– clinicallyclinically benignbenignVariable size of Variable size of cellscellsHugeHuge nucleolinucleoliLymphocytesLymphocytesPlasma Plasma cellscells +/+/--DifferentialDifferential diagnosisdiagnosis::
InflammatoryInflammatory carcinomacarcinoma
MALIGNANT TUMORS (5) MALIGNANT TUMORS (5) PAPILLARY CARCINOMAPAPILLARY CARCINOMA
Rare (2%)Rare (2%)MalignantMalignant cellscells in in papillarypapillary clustersclustersIsolatedIsolated cellscells andand nakednaked nucleinucleiCysticCystic backgroundbackgroundNecroticNecrotic backgroundbackgroundDifferentialDifferential diagnosisdiagnosis::
PapillomaPapilloma ((atypiaatypia!)!)CysticCystic carcinomacarcinoma
Actine smooth
MALIGNANT TUMORS (6)MALIGNANT TUMORS (6)TUBULAR CARCINOMATUBULAR CARCINOMA
Super grade ISuper grade ITubularTubular clustersclustersDifferentialDifferential diagnosisdiagnosis::
AtypicalAtypical hyperplasiahyperplasiaFibroadenomaFibroadenomaPossibilityPossibility of of falsefalse--negativenegative
MALIGNANT TUMORS (7)MALIGNANT TUMORS (7)ADENOID CYSTIC CARCINOMAADENOID CYSTIC CARCINOMA
0.1%0.1%CharacteristicCharacteristic smearssmearsRound Round cellscells, , «« fingerfinger--likelike »»EosinophilicEosinophilic fragmentsfragmentsDifferentialDifferential diagnosisdiagnosis::
MetaplasticMetaplastic carcinomacarcinoma
MALIGNANT TUMORS (8)MALIGNANT TUMORS (8)APOCRINE CARCINOMAAPOCRINE CARCINOMA
1%1%ApocrineApocrine cellscells ((benignbenign +/+/-- morphologymorphology))Important C/N Important C/N atypiaatypiaNecrosisNecrosisDifferentialDifferential diagnosisdiagnosis::
ComedocarcinomaComedocarcinomaCystsCysts withwith dystrophicdystrophic cellscells
MALIGNANT TUMORS (9)MALIGNANT TUMORS (9)METAPLASTIC METAPLASTIC CARCINOMACARCINOMA
SCCSCCSpindleSpindle cellcell carcinomacarcinomaChondroidChondroid, , osseousosseousMixedMixed
MALIGNANT TUMORS (10)MALIGNANT TUMORS (10)SpecificSpecific variantsvariants
Neuroendocrine Neuroendocrine carcinomacarcinomaPagetPaget’’s s diseasediseaseGiantGiant cellcell carcinomacarcinoma11°° SarcomaSarcomaSarcomasSarcomas afterafter RTRTLymphomasLymphomasMetastasesMetastases
IsIs itit possible to possible to distinguishdistinguish????????
InfiltrativeInfiltrative
Not Not infiltrativeinfiltrative
REFERENCESREFERENCESZajdelaZajdela A, A, VielhVielh P, Di Bonito L. Manuel et Atlas P, Di Bonito L. Manuel et Atlas
de Cytologie Mammaire. de Cytologie Mammaire. PiccinPiccin 19951995
Cytopathologie Mammaire par Cytopathologie Mammaire par MonctionMonction. Marsan . Marsan C coordination, C coordination, DieboldDiebold J J editeurediteur, Elsevier 2001, Elsevier 2001
KlijanienkoKlijanienko J et al. J et al. CriticalCritical clinicopathologicclinicopathologicanalysisanalysis of 23 cases of fineof 23 cases of fine--needleneedle breastbreastsamplingsampling initiallyinitially recordedrecorded as as falsefalse--positive. The positive. The 4444--year year experienceexperience of of thethe Institut Curie. Cancer Institut Curie. Cancer 93: 13293: 132--139, 2001139, 2001
CasesCases
FN
Sa
LMS
ThankThank youyou !!!!!!!!!!!!!!!!
WouawWouaw
NowNow itit isis finishedfinished !!