FNA of BREAST The 6 th Arab-British School of Pathology

2. FNA of BREASTThe 6th Arab-British School of Pathology Nina S Shabb, M.D. American University of Beirut Medical center, Beirut Lebanon

3. Objectives • Overview of breast FNA • AUBMC data 2003-200 • CNB vs FNA of palpable and non palpable lesions

4. Status of breast FNA • 1930: Introduced • 1980-90: ↑ ↑ ↑ • Late 90’s-now: ↓ • Non palpable masses: Replaced CNB • Palpable masses: CNB = FNA ? (institution dependent)

5. Reasons for ↓ popularity • Lack of experienced cytopathologists • ↑ Diagnostic errors • ↑ Insufficient samples • False positives • False negatives • Medico legal issues • Inability to distinguish In situ from invasive carcinoma

6. Trend of FNA of breast at AUBMC Total number: 1794

7. AUBMC data • All breast FNAs with corresponding surgical pathology material were reviewed over 5 years (Jan 2003 - Dec 2007) • FNA reports were categorized C1-C5 • Palpable and non palpable masses were segregated • Data analyzed

8. Diagnostic categories • C1: Unsatisfactory • C2: Benign lesion • C3: Atypical, probably benign • C4: Suspicious for malignancy • C5: Malignant The uniform approach to breast FNA. NCI recommendations

9. “Triple test” • FNA results • Clinical findings • Radiologic findings Combining these 3 tests improves false negative and false positive results

10. FNA/Pathology correlation, AUBMC,2003-2007 FN: 6. FP: 1. Unsatisfactory:5%

11. Who should perform the FNA? • The person who is going to read it! (pathologist adequately trained) • Gleans information from gross findings and feel of the needle • Less unsatisfactory results (multiple passes as needed) • Less interpretative errors • Highest sensitivity and specificity

24. Complications of FNA • Very rare • Pain • Bleeding/hematoma: Pressure • Infection: Proper cleaning • Pneumothorax: Tangential aspirate • Vasovagal reaction: Legs up • Needle tract seeding? No

25. C1 Unsatisfactory

26. FNA/Pathology correlation, AUBMC,2003-2007 C1: 5%

27. C1 palpable vs non palpable C1: 3.5% (2.3%pos) C1: 8%

28. C1 (Unsatisfactory) • When FNA does not explain the mass • Lesions responsible for C1 • Small • Fibrotic • Hypocellular benign and malignant • Operator dependent • Range in literature: 0.7-47% (5%) • CNB: advantage

29. C1 • Management: More tissue

30. C2 Benign

31. C2 benign • FNA: Adequate and representative material of benign disease • FCC (cysts) • Abscess • Fat necrosis • Fibroadenoma • Other

32. FNA/Pathology correlation, AUBMC,2003-2007 FN: 1

33. FNA/pathology correlation of palpable masses

34. FNA/pathology correlation of non palpable masses

35. C2 (benign) • 1 False negative: (1%) DCIS Cribriform and micropapillary. Misinterpreted on FNA as FCC

39. FCC • Cyst content: Clear, few macrophages • Hypocellular • Benign duct epithelial cells • Naked nuclei • Apocrine metaplastic cells

42. Fibroadenoma • Pigeon egg, rubbery feel • Smears (pattern recognition) • Very cellular • 3 components • Staghorn epithelial cohesive honeycombed duct cells • Stromal fragments • Numerous myoepithelial cells (naked bipolar nuclei)

45. C2 (Benign) • Negative triplet: Follow up • FNA: Benign • Clinical: Benign • Radiologic: Benign

46. C5 Malignant

47. C5 Malignant • Primary • IDC nos • ILC • Mucinous • Tubular • Papillary • Other • Metastatic • Hematopoetic

48. FNA/Pathology correlation, AUBMC,2003-2007 False positive: Adenomyoepithelioma

49. FNA/pathology correlation of palpable masses

50. FNA/pathology correlation of non palpable masses