Ch. 9 - Breast

Question 1

What is the role of FNA in breast evaluation?

Answer 1

Used for palpable masses and cysts. In most cases it is superceded by core needle biopsy which offers architecture and staining.

Question 2

What uses does nipple discharge cytology have?

Answer 2

Can be used to evaluate papilloma, carcinoma, or hormonal abnormality. Generally not very accurate.

Question 3

What is the “triple test” of breast FNA?

Answer 3

FNA + Mammography + Clinical findings.

Question 4

What kinds of lesions can cause hypocellular aspirates?

Answer 4

Fibroadenoma
Fibrocystic changes
Fat necrosis
Radiation

Question 5

What could background necrosis on an FNA represent?

Answer 5

Could represent carcinoma, but also apocrine metaplasia or lactation.

Question 6

What are the normal elements of breast on cytology?

Answer 6

Lactiferous ducts, connective tissue & glands, sometimes foam cells.

Question 7

How many breast cysts are malignant? What are some high-risk radiologic features?

Answer 7

2%; more concerning if complex, thick-walled, or with thick septae. Especially if solid with cystic degeneration.

Question 8

In cytology, how are the many fibrocystic changes categorized?

Answer 8

Nonproliferative: Apocrine metaplasia, foam cells…
Proliferative: ADH, ALH, UDH, etc.

Question 9

Describe the cytology of fibroadenoma.

Answer 9

Hypercellular large sheets with an antler-like configuration, bipolar cells and spindled nuclei.

Question 10

How can fibroadenoma be distinguished from phyllodes tumor on cytology?

Answer 10

Phyllodes tumor will have more spindled nuclei and “fibroblastic pavements”.

Question 11

Describe the cytology of pregnancy/lactational changes.

Answer 11

Isolated cells or stripped nuclei with prominent nucleolus but little size variation. Foamy.

Question 12

Describe the cytology of fat necrosis.

Answer 12

Hypocellular specimen with histiocytes and a low N:C ratio.

Question 13

Describe the cytology of radiation change.

Answer 13

Hypocellular specimen with large nuclei with large cytoplasm (preserved N:C ratio) and multinucleation.

Question 14

What are the different types of mastitis?

Answer 14

Acute: Neutrophilic, generally not sampled.
Chronic: Sequelae of acute
Granulomatous: Many causes
Granulomatous lobular mastitis: Distinct entity..

Question 15

Describe the cytology of subareolar abscess

Answer 15

Acute inflammatory exudate plus keratin plugs

Question 16

Describe the cytology of papillary neoplasms. How can you distinguish papilloma from papillary carcinoma?

Answer 16

Papillary architecture with accompanying blood. Hard to distinguish the two; look for cribriforming, isolated cells, more atypia in general.

Question 17

Describe the cytology of phyllodes tumor.

Answer 17

Hypercellular specimen with many stromal elements and variable atypia. “Fibroblastic pavements”.

Question 18

What consistency does IDC have on FNA? What role does FNA play?

Answer 18

Feels gritty. Grading cannot be done on FNA and should be reserved for CNB. Maybe FNA is useful for checking nodes.

Question 19

Describe the cytology of IDC.

Answer 19

Poorly cohesive clusters of “comet cvells” with intracytoplasmic lumina pushing eccentric nuclei. Irregular nucleolus.

Question 20

Describe the cytology of ILC.

Answer 20

Isolated medium-sized relatively uniform cells often with signet ring morphology. Quite hard to diagnose by FNA.

Question 21

Describe the cytology of medullary carcinoma.

Answer 21

Numerous highly atypical cells with bizarre nuclei and background lymphocytes & plasma cells.

Question 22

Describe the cytology of mucinous (colloid) carcinoma.

Answer 22

Tightly cohesive 3D balls of uniform cells in a mucinous background. May have some branching, plasmacytoid morphology, or psammoma bodies.

Question 23

Describe the cytology of tubular carcinoma.

Answer 23

Hypocellular specimen (densely firbotic). May see tubular clusters with peripheral perpendicular cells.

Question 24

Describe the cytology of metaplastic carcinoma.

Answer 24

Pleomorphic, large, sometimes spindled cells which may appear squamous or glandualr. Reactive multinucleated giant cells. May see cartilage or bone.

Question 25

Describe the cytology of apocrine carcinoma.

Answer 25

Hypercellular specimen with abundant granular cytoplasm, indistinct cell borders, and enlarged nucleus with prominent nucleolus.

Question 26

Describe the cytology of adenoid cystic carcinoma.

Answer 26

Hypercellular nests of cohesive small cells with round globules. Basaloid. Cells surround basement membrane material.

Question 27

What lymphomas may be found in the breast?

Answer 27

MALT lymphoma, DLBCL, implant-associated ALCL.

Question 28

What sarcomas may be found in the breast?

Answer 28

Angiosarcoma, lymphangiosarcoma, liposarcoma, leiomyosarcoma and osteosarcoma?

Question 29

How can DCIS be distinguished from IDC on cytology?

Answer 29

They cannot be distinguished; this is an architectural feature.

Question 30

What should be considered in the differential with medullary carcinoma?

Answer 30

Chronic mastitis, lymphoma, intramammary lymph node.