breast - radiology and cytology

Question 1

what is cytology

Answer 1

microscopic examination of a thin layer of cells on a slide obtained by:

• Fine needle aspiration
• direct smear from nipple discharge
• scrape of nipple with scalpel

Question 2

what is the role of cytology

Answer 2

• symptomatic clinic
• triple assessment of patient (by surgeon, radiologist and cytologist)
• sample of main lesion/FNA of axillary node/satellite lesions
  (- breast screening - asymptomatic women invited for mammogram, mostly get core biopsy)

Question 3

what might be felt in a palpable mass

Answer 3

discrete mass
cystic - fluid
solid
diffuse thickening

Question 4

FNA equipment

Answer 4

23G needle
20ml syringe +/- Cameco holder
alcohol swab
cotton wool, sticking plaster
glass slides, pencil
+/- vial with saline for needle washings

Question 5

FNA technique - before taking sample

Answer 5

ensure patient is comfortable
examine to locate lump
swab area
localise lump between fingers

Question 6

FNA technique - taking the sample

Answer 6

insert needle 45 degrees
aspirate using in and out action applying negative pressure on syringe
release pressure and remove needle
- can also use non-suction aspiration technique

Question 7

when is ultrasound guided FNA used

Answer 7

for an impalpable area seen on US

Question 8

FNA important considerations - patient

Answer 8

informed of procedure
comfort
chaperone

Question 9

FNA important considerations - safety

Answer 9

appropriate PPE
dispose of needle
care handling fresh material/infection risk

Question 10

features of benign cytology - 6

Answer 10

low/moderate cellularity
cohesive groups of cells
flat sheets of cells
bare oval (bipolar) nuclei in background
cells of uniform size
uniform chromatin pattern

Question 11

features of malignant cytology - 6

Answer 11

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

Question 12

what is shown in this image

Answer 12

benign breast cytology

Question 13

what is shown in this image

Answer 13

malignant breast cytology

Question 14

making a diagnosis from malignant cytology

Answer 14

usually diagnosis is non-specfic i.e. adenocarcinoma NOS

ocassionally features may suggest type

Question 15

what is shown here

what are the defining features

Answer 15

lobular carcinoma

cytoplasmic vacuoles

Question 16

what is shown here

what are the defining features

Answer 16

tubular carcinoma

cells arranged in tubes

Question 17

what is the cytology scoring system

Answer 17

C1 - unsatisfactory/insufficient cells for diagnosis

C2 - benign

C3 - atypia, probably benign

C4 - suspicious, probably malignant

C5 - malignant

Question 18

cysts

• treatment
• when would fluid not be discarded

Answer 18

aspiration is curative

fluid discarded unless

• bloodstained
• residual mass

Question 19

advantages of FNA

Answer 19

simple procedure, can be done at clinic

well tolerated by patients

inexpensive

immediate results

Question 20

limiatations of FNA

Answer 20

accuracy not 100%, false-ve/+ve

invasion cannot be assessed

grading cannot be done

sampling (lesion missed): small lesions, small tumour in larger area of thickening

technical (difficult to examine cells): suboptimal smears - blood, thick, cells smeared

interpretation - features similar

Question 21

complications of FNA

Answer 21

pain

haematoma

fainting

infection, pneumothorax - rare

Question 22

contraindications of FNA

Answer 22

none

Question 23

indications for nipple lesions

Answer 23

bloody discharge from single duct

Question 24

what diseases can be seen from nipple discharge

what features would be seen

Answer 24

duct ectasia - macrophages only

intraduct papilloma - benign cells in papillary groups

intraduct carcinoma (DCIS) - malignant cells

Question 25

what diseases would be seen on nipple scrape

what features would be seen

Answer 25

Paget’s disease - squamous cells and malignent cells

Eczema - squamous cells from epidermis only

Question 26

axillary node FNA - normal or malignant

Answer 26

normal lymph node

Question 27

axillary node FNA - normal or malignant

Answer 27

metastatic adenocarcinoma

Question 28

core biopsy - when is it used

Answer 28

all cases with clinical/radiological/cytological suspicion

breast screening - especially architectural distortion and microcalcification

pre-op classification

rarely open biopsy

Question 29

core biopsy

• what G needle is used
• what is produced
• how is it stored

Answer 29

14G needle

intact tissue strand

formalin fixed

Question 30

what can be done from a core biopsy

Answer 30

confirm invasion

tumour typing and grading

immunohistochemistry - receptor status