Breast Lecture 2

Question 1

What techniques are used to gain samples for breast cytology?

Answer 1

Fine Needle Aspiration (FNAC)

Smear from nipple discharge

Scrape nipple with scalpel

Question 2

When is breast cytology used?

Answer 2

Symptomatic assessment

Breast screening (mostly core biopsy)

Question 3

What features may you find on breast palpation?

Answer 3

Discrete mass - solid, cystic

Diffuse thickening

Nipple lesion

Discharge

Question 4

What equipment is needed for FNAC?

Answer 4

23G needle

10ml syringe

Alcohol swab

Cotton wool/plaster

Glass slides

Question 5

Outline the technique for FNAC?

Answer 5

Swab lump area

Localise with fingers

Insert needle 45^o

Aspirate using in/out action

Question 6

What is this?

Describe it

Answer 6

Benign Breast Mass cytology

• low/ moderate cellularity
• cohesive groups of cells
• flat sheets of cells
• bipolar nuclei in background
• cells of uniform size
• uniform chromatin pattern

Question 7

What is this?

Describe it

Answer 7

Malignant breast mass cytology

• high cellularity
• loss of cohesion
• crowding/overlapping of cells
• nuclear pleomorphism
• hyperchromasia
• absence of bipolar nuclei

Question 8

What does malignant cytology tell us?

Answer 8

Diagnosis not specific

May suggest type

Question 9

Cytoplasmic vacuoles on breast cytology suggest what?

Answer 9

Lobular carcinoma

Question 10

Tubular cell arrangement in breast cytology tell you what?

Answer 10

Tubular carcinoma

Question 11

What is the cytology scoring system?

Answer 11

C1 Unsatisfactory

C2 Benign

C3 Atypia (probably benign)

C4 Suspicious (probably malignant)

C5 Malignant

Question 12

What is the use of aspiration for cysts?

Answer 12

Aspiration is curative

Question 13

What are the advantages of FNAC?

Answer 13

Simple

Well tolerated

Inexpensive

Immediate results

Question 14

What are the disadvantages of FNAC?

Answer 14

False +ves/-ves

Invasion cannot be assessed

Cannot be graded

Sampling may miss lesion

Operator dependent for cell examination

Question 15

Complications of FNA?

Answer 15

Pain

Haematoma

Fainting

Infection, pneumothorax

Question 16

Nipple scraping can be used to differentiate what? How?

Answer 16

Paget’s Disease and Eczema

Paget’s - Squamous cells + malignant cells

Eczema - Squamous cells only

Question 17

Macrophages alone on nipple discharge cytology suggests what?

Answer 17

Duct ectasia

Question 18

Benign cells in papillary groups alone on nipple discharge cytology suggests what?

Answer 18

Intraduct papilloma

Question 19

Malignant cells alone on nipple discharge cytology suggests what?

Answer 19

Intraduct carcinoma (DCIS)

Question 20

When is core biopsy indicated for breast mass?

Answer 20

All cases of clinical/radiological/cytological suspicion

Breast screening for microcalcification

Pre-operative classification

Rarely open biopsy

Question 21

What is the use of breast mass core biopsy?

Answer 21

Confirm invasion

Tumour typing and grading

Immunohistochemistry - receptor status

Question 22

What equipment is needed for a core biopsy?

Answer 22

14G needle

Intact tissue strand

Formalin (for fixation)

Question 23

What are the most common breast imaging modalities?

Answer 23

Mammogramography

USS

MRI

Nuclear medicine

CT

Question 24

What are the standard views used in mammography?

Answer 24

Mediolateral Oblique (MLO)

Craniocaudal (CC)

Question 25

What are the less common views used in mammography?

Answer 25

Coned Magnification True lateral Extended CC Eclund views

Question 26

When is mammography indicated in patients?

Answer 26

Over 40 Under 40 if: * Strong suspicion of cancer * FH risk \>40%

Question 27

What radiation dose is given in mammography?

Answer 27

1mSv

Question 28

How is cancer seen on mammography?

Answer 28

Mass Assymetry Architectural distortion Calcifications Skin changes

Question 29

How does a malignant soft tissue mass appear on mammography?

Answer 29

Irregular, ill-defined Spiculated Dense Distorted architecture

Question 30

How does a benign soft tissue mass appear on mammography?

Answer 30

Smooth Lobulated Normal density Halo

Question 31

What is shown here?

Answer 31

Mammogram - Calcified fibroadenomas

Question 32

What is shown here?

Answer 32

Mammogram - Cyst

Question 33

Why is USS used in breast imaging?

Answer 33

Differentiate solid from cystic First line for under 40s No radiation Less informative than mammography

Question 34

How does a solid benign mass present on breast USS?

Answer 34

Smooth outline Oval shape Acoustic enhancement Orientation

Question 35

How does a malignant mass present on breast USS?

Answer 35

Irregular outline Interrupting breast architecture Acoustic shadowing Anterior halo

Question 36

What is the triple assessment used for breast mass?

Answer 36

Clinical Examination Imaging FNA Cytology

Question 37

What are the main types of image guided needle biopsy?

Answer 37

Stereotactic (upright or prone) Ultrasound (guided or freehand) FNA/Core biopsy

Question 38

What are the indications for MRI of breast?

Answer 38

Recurrent disease Implants Indeterminate lesion following triple assessment Screening high-risk women

Question 39

What are the adv/disadvantages of breast MRI?

Answer 39

Advantages * 94-98% sensitivity * Great for problem solving Disadvantages * Poor specificity * Claustraphobic, noisy, IV contrast * Expensive

Question 40

How is sentinel node sampling performed?

Answer 40

Peritumoral injection of 99m Tc sulphur colloid + isosulphan blue dye Lymphoscintigraphy Intraoperative gamma probe Single lymph node removal