Breast Lecture 2 Flashcards
What techniques are used to gain samples for breast cytology?
Fine Needle Aspiration (FNAC)
Smear from nipple discharge
Scrape nipple with scalpel
When is breast cytology used?
Symptomatic assessment
Breast screening (mostly core biopsy)
What features may you find on breast palpation?
Discrete mass - solid, cystic
Diffuse thickening
Nipple lesion
Discharge
What equipment is needed for FNAC?
23G needle
10ml syringe
Alcohol swab
Cotton wool/plaster
Glass slides
Outline the technique for FNAC?
Swab lump area
Localise with fingers
Insert needle 45o
Aspirate using in/out action
What is this?
Describe it
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
What is this?
Describe it
Malignant breast mass cytology
- high cellularity
- loss of cohesion
- crowding/overlapping of cells
- nuclear pleomorphism
- hyperchromasia
- absence of bipolar nuclei
What does malignant cytology tell us?
Diagnosis not specific
May suggest type
Cytoplasmic vacuoles on breast cytology suggest what?
Lobular carcinoma
Tubular cell arrangement in breast cytology tell you what?
Tubular carcinoma
What is the cytology scoring system?
C1 Unsatisfactory
C2 Benign
C3 Atypia (probably benign)
C4 Suspicious (probably malignant)
C5 Malignant
What is the use of aspiration for cysts?
Aspiration is curative
What are the advantages of FNAC?
Simple
Well tolerated
Inexpensive
Immediate results
What are the disadvantages of FNAC?
False +ves/-ves
Invasion cannot be assessed
Cannot be graded
Sampling may miss lesion
Operator dependent for cell examination
Complications of FNA?
Pain
Haematoma
Fainting
Infection, pneumothorax
Nipple scraping can be used to differentiate what? How?
Paget’s Disease and Eczema
Paget’s - Squamous cells + malignant cells
Eczema - Squamous cells only
Macrophages alone on nipple discharge cytology suggests what?
Duct ectasia
Benign cells in papillary groups alone on nipple discharge cytology suggests what?
Intraduct papilloma
Malignant cells alone on nipple discharge cytology suggests what?
Intraduct carcinoma (DCIS)
When is core biopsy indicated for breast mass?
All cases of clinical/radiological/cytological suspicion
Breast screening for microcalcification
Pre-operative classification
Rarely open biopsy
What is the use of breast mass core biopsy?
Confirm invasion
Tumour typing and grading
Immunohistochemistry - receptor status
What equipment is needed for a core biopsy?
14G needle
Intact tissue strand
Formalin (for fixation)
What are the most common breast imaging modalities?
Mammogramography
USS
MRI
Nuclear medicine
CT
What are the standard views used in mammography?
Mediolateral Oblique (MLO)
Craniocaudal (CC)
What are the less common views used in mammography?
Coned
Magnification
True lateral
Extended CC
Eclund views
When is mammography indicated in patients?
Over 40
Under 40 if:
- Strong suspicion of cancer
- FH risk >40%
What radiation dose is given in mammography?
1mSv
How is cancer seen on mammography?
Mass
Assymetry
Architectural distortion
Calcifications
Skin changes
How does a malignant soft tissue mass appear on mammography?
Irregular, ill-defined
Spiculated
Dense
Distorted architecture
How does a benign soft tissue mass appear on mammography?
Smooth
Lobulated
Normal density
Halo
What is shown here?
Mammogram - Calcified fibroadenomas
What is shown here?
Mammogram - Cyst
Why is USS used in breast imaging?
Differentiate solid from cystic
First line for under 40s
No radiation
Less informative than mammography
How does a solid benign mass present on breast USS?
Smooth outline
Oval shape
Acoustic enhancement
Orientation
How does a malignant mass present on breast USS?
Irregular outline
Interrupting breast architecture
Acoustic shadowing
Anterior halo
What is the triple assessment used for breast mass?
Clinical Examination
Imaging
FNA Cytology
What are the main types of image guided needle biopsy?
Stereotactic (upright or prone)
Ultrasound (guided or freehand)
FNA/Core biopsy
What are the indications for MRI of breast?
Recurrent disease
Implants
Indeterminate lesion following triple assessment
Screening high-risk women
What are the adv/disadvantages of breast MRI?
Advantages
- 94-98% sensitivity
- Great for problem solving
Disadvantages
- Poor specificity
- Claustraphobic, noisy, IV contrast
- Expensive
How is sentinel node sampling performed?
Peritumoral injection of 99m Tc sulphur colloid + isosulphan blue dye
Lymphoscintigraphy
Intraoperative gamma probe
Single lymph node removal
