Fine-Needle Aspiration Cytodiagnosis of Breast Masses in Pregnant and Lactating Women and Its Impact on Management Raj K. Gupta M.D., F.I.A.c., Andrew G.R. McHutchison B.SC., C.T.(i.A.C.), Carl S. Dowle, M.B., cm., F.R.A.c.s., and John s. SimpSon, M.B., Ch.B., F.R.C.S., F.R.A.C.S.

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We reviewed our experience with 9,726 cases ofjine-needle aspira- tion cytology of the breast that were done from January 1983 to February 1992. During our review, we found that 214 aspirates had been submitted from pregnant and lactating women for the investigation of breast mass(es). Despite a variable clinical presen- tation and spectrum of cytologic findings, we considered the appli- cation of aspiration cytology in these women as useful as in the nonpregnant-nonlactating women for management decision. A team approach between the clinician and cytopathologist was al- ways maintained; with this approach, the false-positive or -nega- tive diagnoses were reduced to almost nil. In all cases in which the cytodiagnosis of carcinoma of breast was made, the findings corre- sponded with subsequent cell blocks from the aspirate and tissue examination. Benign lesions were diagnosed cytologically with minimal dificulty, and all aspirates that were less than optimal for cytodiagnosis were repeated to minimize the chance of missing an abnormality. All the benign lesions were followed throughout pregnancy, postpartum, and thereafter: if the mass persisted, the aspiration was repeated. With this protocol of follow-up, the need for a customary liberal surgical biopsy was reduced to a mini- mum. Diagn Cytopathol 1993;9:156-159. @ 1993 Wiley-Liss, Inc.

Key Words: Breast; Aspiration; Cytology; Pregnancy; Lactation

In recent years, the utility of fine-needle aspiration (FNA) cytology of the breast has been shown in a number of studies in the diagnosis of palpable breast masses. ' - ' I It is also true that judicious use of this method can be quite decisive for management without the need for excisional biopsy, especially in women with benign breast disease. 3-5

We have reviewed our experience with FNA's of the breast at Wellington Hospital from January 1983 to Feb-

Received February 24, 1992. Accepted July 15, 1992. From the Department of Pathology and Surgery, Wellington Hospital

and the School of Medicine, Wellington, New Zealand. Address reprint requests to Raj K. Gupta, M.D., F.I.A.C., Cytology

Unit. Wellington Hospital, Wellington, New Zealand.

ruary 1992 from pregnant or lactating women referred for the investigation of breast mass that appeared during pregnancy or lactation.

It is known that pregnant women in comparison to nonpregnant women have above-average physician con- tact, yet face a delay in the diagnosis of serious breast disease. ' * , I 3 While a few recent studies have emphasized the role of FNA cytology in pregnant and lactating women to decrease the delay in diagnosis of breast cancer, such studies have been limited to a few cases. l4-I7 In this presentation we describe our experience with a detailed analysis of all types of breast lesions which were investi- gated in a nine year period using FNA cytology in preg- nant and lactating women with a breast mass.

Materials and Methods From January 1983 to February 1992, 9,726 needle aspi- rates from patients between 15 to 96 yr of age were exam- ined cytologically; from these 214 were from pregnant and lactating women between 22 to 39 yr of age. All needle aspirates were obtained using a disposable 10-ml syringe and 20-gauge disposable needle. Aspirations were per- formed using multiple passes in the lesion, maintaining negative pressure. The aspirated material was immedi- ately washed in a cytology container in which 5 ml of 30% ethyl alcohol in physiologic saline was present. The cytosieve method " using Sartorius or Gelman filters with 5-pm pore size was used to prepare specimens in all cases, and staining was done by modified Papanicolaou method. " Additionally, cell block preparations from as- pirate material were made in cases in which the filter preparations showed features of fibroadenoma, lactating adenoma, suspicious features, and carcinoma.

In this study, although a review of results from NAC of the breast was done in all types of cases, a particular emphasis was placed on the FNA diagnosis of cases with

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FNA CYTODIAGNOSIS OF BREAST MASSES

a breast mass that was detected during pregnancy and lactation. Information on these cases was obtained by re- viewing the charts for pertinent details of clinical, surgi- cal, postsurgical information, and findings on follow-up.

Results The cytologic diagnosis in the 214 pregnant or lactating women is summarized in Table I. The estimated gesta- tional age at the time of FNA ranged from about 8 wk to 28 wk, postpartum or after breast feeding.

None of the cases with benign diagnoses (201/214) subsequently developed carcinoma. The clinical follow-up of these cases was done regularly for a period of 1 - 1.5 yr, and the mass(es) had regressed considerably within a few months to 1.5 yr after delivery or discontinuation of breast-feeding. Nondiagnostic (scanty) samples due to a paucity of cellular material were found in 4 (1.8%) cases despite two to three repeated aspirations. A possible expla- nation could be due to an absence of any significant pa- thology in the breast. Additionally, the remote possibility of inadequate sampling by an inexperienced aspirator and possible blockage of needle could not be excluded in the cases in this group. In one case, suspicious cytologic fea- tures were seen repeatedly on at least two repeat aspirates that were done within 4 weeks of the initial FNA diagno- sis; on biopsy, this case showed features of ductal carci- noma of the breast. In 8 cases, the cytodiagnosis of breast carcinoma was made without any difficulty on the first aspiration sample, and in all these cases subsequent cell blocks of aspiration sample and tissue examination further confirmed the cytodiagnosis. Four of these were infiltrat- ing ductal carcinomas, three were lobular type, and one case was diagnosed as the rare pleomorphic giant cell carcinoma of breast. l6

In all cases of carcinoma, Papanicolaou-stained filter preparations and hematoxylin and eosin (H&E)-stained

Table I. Pregnancy and/or Lactation

Fine-Needle Aspiration Cytodiagnosls in 214 Cases:

No. of crises %

Benign findings consistent with pregnancy 01

lactational changes Nondiagnostic (scanty) Cysts (includes galactocele) Fibroadenoma with secretory effects Lactating adenoma Inflammatory Suspicious” Carcinomab

Total:

103 4

26 36

2 34

1 8

214 -

48.13 1.87

12.15 16.82 0.93

15.89 0.47 3.74

100.00 __

~~

”On biopsy, ductal carcinoma of breast was confirmed. hAll carcinomas were confirmed on histology. All cases with a diagnosis of other than “suspicious” or “carcinoma” were followed for a period of 1 - 1 .S yr; in none of these was any evidence of carcinoma found, and the initial lesion was found to regress within a few months to a year after delivery or discontinuation of breast-feeding.

preparations from subsequent cell blocks and tissue showed a high cellularity with numerous malignant cells with moderate cytoplasm, ovoid to angulated or lobulated nuclei, anisocytosis, mitosis, coarse chromatin, irregular nuclear membrane, and prominent irregular nucleoli. The one case in which a “suspicious” diagnosis was made showed a somewhat lesser degree of nuclear change in comparison to ductal carcinoma and the majority of nu- clei appeared monotonous (Figs. 1-4).

Discussion The subject of aspiration cytodiagnosis of breast masses in pregnant and lactating women has been addressed in only a few studies. l 4 9 l 5 The association of breast malignancy in pregnancy or lactation is quite rare, 12,14,19,20 and it is be- lieved that the carcinoma in these females disseminates rapidly and generally has a poor prognosis. 16,’7,21-24 Th e

Fig. 1. Filter preparation from a case of infiltrating ductal carcinoma of the breast showing malignant ductal structures (Papanicolaou stain, x450).

Fig. 2. Filter preparation from a case of lobular carcinoma of the breast showing dissociated malignant cells (Papanicolaou stain, X 450).

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GUPTA ET AL.

Fig. 3. Filter preparation from the case in which highly suspicious fea- tures were seen on repeat aspirations (Papanicolaou stain, X 450).

Fig. 4. Histologic features of the case shown in Fig. 3 in a cell block preparation. This case on biopsy showed features of ductal carcinoma (H&E stain, x 450).

incidence of carcinoma in pregnancy is about 3 in 10,000, and the average age of the patient is about 35 yr.25-29 Certain factors that result in an altered physiology during pregnancy and lactation and the resultant breast enlarge- ment, increased vasularity, and lymphatic permeability due to the changes in hormonal environment, are said to be responsible for the rapidity of growth, dissemination, and early axillary metastasis of the breast carcinoma in these women.

The possibility of a false-positive aspiration cytodiagno- sis of carcinoma in the samples obtained from pregnant or lactating women has been mentioned by Kline; a recent study also indicates that aspirates from benign breast masses under gestational or lactational influences may show increased cellularity, anisonucleosis, prominent nu- cleoli, variable granular chromatin within a proteinaceous background with lipid secretion; these findings can result in a false-positive diagnosis by those who are unfamiliar with the aspirates from pregnant or lactating women. In

our series of cases, we have had no such difficulties, and our criteria for such a differentiation were similar to that suggested in the recent study. ” Furthermore, we had pre- pared cell blocks from aspirates in a number of our cases, making it quite useful. This was because the cell blocks provided us with additional histological findings in stained sections, just as in an excised tissue, giving the added confidence of rendering a definitive cytodiagnosis and minimizing the chance of a false-positive diagnosis. In our cases, we did not notice any differences in the cytologic spectrum of changes due to degree of lactational change or with gestational age, as the other study has claimed. ”

Based on our study, we are of the opinion that an inves- tigation by FNA in pregnant and lactating women with suspected breast pathology is quite important over and above the existing methods, such as careful and frequent physical examination. It is crucial that breast cancer dur- ing pregnancy or lactation be diagnosed without delay. We also believe that the “liberal” surgical biopsy policy in these women is not desirable, since with such a policy a number of these women with benign breast lesions would be subjected to unnecessary biopsies. In our practice, we have used FNA as a first line of investigation in all women presenting with breast disease and have performed open biopsy only when FNA suggested “suspicious” findings on repeated aspirations. All women with an FNA diagno- sis of malignancy have always been treated, and all women with a benign diagnosis on FNA with a persistent breast lesion have been regularly followed up with repeated aspi- rations.

In summary, we suggest that FNA is an effective method in the diagnosis of carcinoma of breast during pregnancy or lactation. Also, we believe that with the use of FNA as a first line of investigation, the need for an unnecessary invasive surgery can be avoided in these women.

Acknowledgements The authors gratefully acknowledge the fine secretarial and typing assistance of Christine Christoforou in this manuscript. The technical assistance of Robert Fauck, Sarla Naran, Sharda Lallu, and photographic assistance of Louise Goossens from the audiovisual unit is also ac- knowledged.

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