It’s not always cancer: Biopsies, Breast Health and

PreventionTeresa Alasio, MD

Director, Cytodiagnostic CenterCairo Diagnostics, LLC

www.cairodiagnostics.com

MD from Mount Sinai Internship in General Surgery Residency in Anatomic Pathology Fellowship in Cytopathology Past:

Director of Cytology, SUNY Downstate Cytopathologist, Private Laboratory

Current: Director, Cytology and Cytodiagnostic Center, Cairo Diagnostics

About Me

Cytodiagnostic Center Ultrasound guided Fine Needle Aspiration

biopsies Head and neck, thyroid, breast

Immediate assessment Preliminary results to patient Final report within 24 hours

Current Practice

Screening Mammogram Ultrasound Breast Self Exam (BSE)

Testing Biopsies

Fine Needle Aspiration Core biopsy

What else could it be? Risk Factors

What we will talk about

Mammogram (film mammography) USPSTF recommends screening women starting at age 50

every 2 years Routine mammogram in women 40-49 not recommended

Controversial Insufficient evidence to recommend screening mammogram

in women >75 years and older

Ultrasound Recommended as additional test for women who have dense

breast tissue Not a primary screening tool

Breast Cancer Screening

Multidisciplinary Breast Cancer Symposium, 2011 Records of >5000 women diagnosed with early

stage breast cancer Cancers found on screening mammography were:

More likely to be lower stage (0 or 1) than higher stage (2 or 3)

41% less likely to be treated with mastectomy (compared to lumpectomy)

31% less likely to require chemotherapy (and generally required less aggressive treatment overall)

Mammogram

Clinical Breast Examination (CBE) Helps detect a significant portion of breast cancers if the only

test available May produce false positive results, increasing patient anxiety

and unnecessary biopsies Breast Self Examination (BSE)

Controversial 2008 study May do more harm than good 20% of breast cancers detected on BSE

Does not reduce breast cancer mortality Should be used in conjunction with mammography and CBE

Recommendation from Breastcancer.org

Breast Exam – Clinical and BSE

Breast Self Exam

1. 2, 3.

Breast Self Exam

4. 5.

Ultrasound Guided Fine Needle Aspiration Biopsy (USFNA)

Core Needle Biopsy (CNB)

Testing

Increasing use of core needle biopsy (CNB) for breast lesions has led to diminished use of FNA in recent years

BUT….there is still a place for FNA in the evaluation of both palpable and mammographically identified breast abnormalities

The Case for Breast Cytology

Cost Minimally invasive procedure Spares patient open biopsy, especially if benign Complications are rare

Bleeding Infarction

Adequacy Are you in the lesion?

Triage Markers, lymph node assessment

Rapid diagnosis allows for pre-operative/pre-treatment discussion of therapeutic options

Advantages of Breast FNA

Nipple discharge cytology Benign vs. malignant nipple secretions Patient usually does not have a palpable or

mammographic abnormality FNA

Some limitations Accuracy of FNA is highly operator dependent IDC vs. invasive carcinoma Papilloma vs. papillary carcinoma (“papillary lesion”)

Specimen Types

If it’s not cancer,what else could it be?

15-25 lactiferous ducts Begin at nipple, branch and then end in

terminal duct lobular unit (TDLU) Lobule

Terminal duct and many small ductules (acini)

All ducts are lined by a double layer of cells Epithelial and myoepithelial cells

Normal Breast

Fibrocystic changes Non-proliferative Proliferative

Fibroadenoma Pregnancy and lactational changes Fat necrosis Radiation change Mastitis Subareolar abscess Gynecomastia

Benign Conditions of Breast

Most common Cysts of varying size Apocrine metaplasia Fibrosis Adenosis

Fibrocystic Changes

Significant intraductal hyperplasia is not present

Lesion is predominantly fibrous Apocrine cells Foam cells Small ductal cells

Non-proliferative FCC

Non-proliferative FCC

Variable in severity and degree of atypia Moderate and florid ductal hyperplasia, ADH,

ALH Histologic criteria, not cytologic

Crowding and nuclear atypia give clues to cytologic diagnosis of ductal proliferative lesions

Proliferative FCC

Proliferative FCC

Without atypiaSheets and tight

clusters of cells without significant overlapRegular cellular

spacingFinely granular

chromatin patternInconspicuous to

small nucleoli

With atypiaSheets and tight

clusters of cells with significant nuclear overlapRegular to irregular

cellular spacingFinely to coarsely

granular chromatinProminent to multiple

nucleoli

Proliferative FCC

Without atypia With atypia

Most common benign tumor of female breast Seen in women of any age Circumscribed, freely movable, rubbery

masses that result from both stromal and glandular proliferation

Fibroadenoma

Fibroadenoma

Pregnancy Associated Changes

Uniform cells Granular vacuolated cytoplasm Prominent nucleoli Proteinaceous background

Lactating Adenoma

Cytoplasm easily strips away

Foamy proteinaceous backgroundMany naked nuclei

Occasional small ductal cell clusters and portions of lobules

Do not confuse with invasive lobular carcinoma which can look similar (also NHL can look similar!)

Galactocele

Abundant foamy macrophages Benign epithelial cells

Can mimic carcinoma both clinically and mammographically

History very important Many patients have had previous surgery or

trauma to the breast

Fat Necrosis

Fat Necrosis

Increasing frequency due to widespread use of lumpectomy and radiation to treat patients with breast cancer

Often seen in conjunction with fat necrosis

Radiation Change

Radiation Change

Hypocellular aspirate Nuclear and cellular

enlargement Low N/C ratio Hyperchromatic nuclei

with round, regular outline and prominent nucleoli

Coarse cytoplasmic vacuoles, some containing inflammatory cells

Binucleation and multinucleation

Acute mastitis = bacterial infection Lactating women

Chronic mastitis can be a sequel to acute mastitis or associated with duct ectasia Dilatation of large and intermediate-size ducts with

surrounding inflammatory infiltrate of lymphocytes and plasma cells with or without a mass

Granulomatous mastitis Infectious (tb or fungal) Presents as a firm mass

Mastitis

Mastitis – Cytomorphology

Acute mastitisAbundant

neutrophilsOccasional groups

of reactive ductal cells with enlarged nuclei and prominent nuceloli

Chronic Mastitis

Abundant, amorphous, granular debris from inspissated ducts

Inflammatory infiltrate composed of lymphocytes and plasma cells

Granulomatous Mastitis

Clustered epithelioid histiocytes

Abundant vacuolated cytoplasm

Round or folded nuclei Dispersed chromatin

texture Large nucleoli Giant cells,

lymphocytes, plasma cells and eosinophils

Rare clusters of benign ductal cells

“recurring subareolar abscess” Inflammatory condition Arises in the areola

squamous metaplasia of lactiferous ducts subsequent keratin plugging and rupture of the

ducts Can recur and form sinus tracts

Subareolar Abscess

Subareolar Abscess

Numerous anucleate squames admixed with neutrophilsHistiocytes and MNGsOccasional groups of atypical reactive ductal cellsFragments of granulation tissue

Gynecomastia

Resembles fibroadenoma

Low, moderate or high cellularity

Groups of ductal cells with small oval nuclei, scant cytoplasm and little variation in size and shape

Isolated bipolar cells Naked nuclei

Intraductal papillomas (IDP) usually solitary Arise in subareolar lactiferous ducts

Bloody nipple discharge Can present with subareolar mass requiring

FNA

Papillary Neoplasms

1-2% of breast carcinomas Predominant growth pattern is frond-like Invasive or non-invasive Cystic or solid Favorable prognosis

Papillary Carcinoma

Impossible to establish by FNA Call it a “papillary lesion” and leave it Recommend excisional biopsy

Papilloma vs. Papillary Carcinoma

Papillary Neoplasms

Papillary lesion on cytologyPapilloma on excision

Papillary Neoplasm

Papillary lesion on cytologyDCIS, papillary type on excision

Breast Cancer Risks

Non-modifiable Female Age Family History Genetics Personal history Menstrual history Radiation Race Dense breasts

Modifiable Obesity Pregnancy Breastfeeding Alcohol use HRT Lack of Exercise Smoking

Breast Cancer Risks Cont’d

Emerging Risks Lack of Vitamin D Light Exposure at Night DES exposure Processed food Methods of cooking

Hetrocyclic Amines (HCA) Grilling

Polycyclic Aromatic Hydrocarbons (PAH) Smoking foods

Chemical Exposure Cosmetics Food Water Sunscreen Plastic