Week 8 Part 2 - Malignant Breast Tumours

Question 1

Clinical Indication and Diagnosis - Soft, Rubbery and Gritty Feel

Answer 1

Soft - Mucoid carcinoma, medullary carcinoma
Rubbery - Lobular carcinoma
Gritty - carcinomas, partial calcification

Question 2

Complications of FNA

Answer 2

Bruising at site of FNA
Haematomas
Pneumothorax - rare but occur in thin, women when medial breast or axilla are sampled.
Pain/swelling
Infection
Puncture of prosthesis

Question 3

Radiological Tabar Scores

Answer 3

1: Normal looking breast tissue, no significant abnormality.
2: Benign looking lesion - FA, cyst, hamartoma
3: Indeterminate - spiculated, stellate
4: Suspicious of malignancy
5: Malignancy

Question 4

Infiltrating Duct Carcinoma

Answer 4

Moderate to highly cellular smears
Single population of cells, no myoepithelial cells, no bare oval nuclei
Variable loss of cell cohesion
Single epithelial cells with intact cytoplasm
Moderate to severe nuclear atypia
Fibroblasts and fragments of collagen
Intracytoplasmic neolumina

Question 5

Cytology of Invasive Ductal Carcinoma

Answer 5

Varying cellularity from abundant to sparsely cellular
Cells may present singly, in loose aggregates, cohesive groups, may have 3D appearance
Varying cellular and nuclear atypia
Cell may be vacuolated with occasional signet ring appearance
Microcalcification
Mitoses are uncommon and usually seen in HG ca
Necrosis

Question 6

Problems when Sampling

Answer 6

Representative sampling
Smearing artefacts
US gel
Carcinoma with small cells
Fibrosclerotic lesions
Nuclear atypia in other lesions
Gynaecomastia
Metastatic carcinoma

Question 7

Low Grade Ductal Carcinoma in Situ (DCIS)

Answer 7

Non-invasive breast ca, has not spread into surrounding breast tissue and is confined to the duct.
Monotonous epithelial proliferation - solid cribriform or micropapillary pattern
Nuclear grade - low/intermediate
No population of myoepithelial cells (bon)/Monoclonal
Growth pattern - solid, cribriform, micropapillary, intracystic papillary
Necrosis
Calcification
Increases risk of Ca (10X)

Question 8

High Nuclear Grade DCIS

Answer 8

Cell rich smears
Neoplastic cells in sheets, irregular aggregates and single
Large pleomorphic cells showing obvious malignant nuclear features
Necrotic debris, calcium, lymphocytes and macrophages
High nuclear grade atypia
Solid, cribriform, comedo
Often HER2 positive

Question 9

Cytological Findings in Breast Aspirates – Malignant pattern

Answer 9

Highly cellular
Single dispersed cell population
Aggregates of cells of one cell type
No bare oval nuclei
Usual cytological features of pleomorphism, hyperchromatism, enlargement of nuclei
Cytoplasm very variable

Question 10

Tubular Carcinoma

Answer 10

Cells predominantly in cohesive clusters
Monolayered folded sheets
Anatomical or rigid or palisaded borders (columnar arrays)
Nuclear atypia
Absence of bare bipolar nuclei, fibroblastic cells
Nucleoli indistinct or small
Evidence of stromal fragments (pink stuff in picture)

Question 11

Tubular Carcinoma - Differential Dx

Answer 11

Bland appearance may lead to a false negative diagnosis for epithelial hyperplasia or fibroadenoma
Looks similar to fibroadenoma except with no bare oval nuclei

Question 12

Mucinous (Colloid) Carcinoma

Answer 12

Abundant background mucin
Low grade, slow growing with a 5yr survival of >80%
Cellular smears with atypical cells in small solid aggregates and single intact epithelial cells
Mild to moderate nuclear atypia, bland chromatin
Bare bipolar nuclei absent
Chicken wire blood vessels

Question 13

Mucinous (Colloid) Carcinoma - Differential Dx

Answer 13

Mucocele like lesions, myxoid FA, myxoid matrix, metastatic ca, gel material
Mucin is stringy, parallel lines, blue purple on MGG/DQ; green-pink/purple on PAP (often less conspicuous)
Myxoid - more fibrillary and granular
As they are cytologically bland, if present in younger women they may be dx as benign

Question 14

Medullary Carcinoma

Answer 14

Highly cellular smears
Material is easy to obtain
Poorly cohesive cells in clusters and singly
Pale staining cytoplasm, syncytial aggregates
Large pleomorphic obviously malignant nuclei with nucleoli and coarse chromatin
Evidence of mitotic figures - bare malignant nuclei
Background of lymphocytes and plasma cells

Question 15

Medullary Carcinoma - Differential Dx

Answer 15

High grade carcinoma, melanoma, lymphoma, High grade DCIS

Question 16

Infiltrating Lobular Carcinoma

Answer 16

Usually a poor cell yield
Often single cells and in small clusters
Short single files ‘strips’ common/linear arrays
Scanty/indistinct/delicate cytoplasm
Small hyperchromatic nuclei, often uniform size
Irregularity of nuclear shape, subtle
Intracytoplasmic mucin vacuole (neolumina)
Inconspicuous nucleolus
There is overlapping with IDC
Cannot distinguish from a mass forming LCIS

Question 17

Infiltrating Lobular Carcinoma - Differential Dx

Answer 17

Lobular Ca accounts for several false negative cases.
Difficult to differentiate lobular from ductal ca
Cases with intracytoplasmic neolumina may be mistaken for signet ring carcinoma GIT
Because of the diffuse infiltrative nature, it is common for lobular ca to have a background of benign epithelial cells.
Problems in Dx:
- sparse cellularity
- lack of pleomorphism
- bg of benign ductal epithelium
- specific tumour typing difficult

Question 18

Papillary Carcinoma

Answer 18

Smears may produce cystic backgrounds
Highly cellular smears
Monotonous cell population
Large papillary clusters, fibrovascular cores
Cells are distinctly columnar in appearance

Question 19

Papillary Carcinoma - Differential Dx

Answer 19

Benign intraductal papillomas, usually in cohesive sheets
Background in papillomas are cystic but clean
Papillary Ca; can be necrotic with apoptotic debris

Question 20

Paget’s Disease of the Nipple

Answer 20

Background of keratin, squamous cells, inflammatory cells and debris
Large malignant cells singly and in small groups closely associated with squamous and inflammatory cells
Abundant pale cytoplasm with distinct borders

Question 21

Clinical Features of Paget’s Disease of the Nipple

Answer 21

Flaky/scaly skin on and around nipple
Crusty, oozing or hardened skin - eczema
Itching
Redness
Tingling or burning sensation
Straw or bloodstained nipple discharge
Flattened or inverted nipple
Thickening of surrounding breast tissue

Question 22

Advantages of FNA

Answer 22

Easiest Dx of radiologically benign lesions (freq specific Dx)
- clearance of “minimal radiological abnormalities”
Most inexpensive test - ideal in rural and low resource settings
Rapid result → patient reassurance.
Rapid confirmation of radiologically malignant lesions (incl. FNA abnormal axillary nodes)
Allows immediate treatment planning if required

Question 23

Disadvantages of FNA

Answer 23

Does not confidently distinguish in situ from invasive disease
Requires expertise in breast disease (major consequences of a false positive diagnosis)
Less sensitive in low grade cancers – tubular, lobular, papillary lesions and mucinous lesions
Does not allow ancillary tests (eg for neoadjuvant therapy) unless cell block

Question 24

Advantages of Core Biopsy

Answer 24

Unequivocal diagnosis of invasion
More definitive assessment of benign lesions especially if FNA fails to correlate (i.e. superior negative predictive value)
Assessment of radiologically detected calcifications
Clarification of suspicious or atypical FNA diagnoses - especially low nuclear grade ca
Some papillary lesions
Tissue available for adjunctive tests

Question 25

Disadvantages of Core Biopsy

Answer 25

Risk of Cx greater (haematoma, haemorrhage)
Needle tract implantation*
Need for local anaesthetic/patient discomfort
Disruption or removal of lesion → difficulty in assessing size, invasion etc
More expensive
Result not immediate