More Related Content Similar to Fnac breast (20) More from Dr Neha Mahajan (9) Fnac breast1. Patterns of FNAC
in benign & malignant
breast lesions
Dr Neha Mahajan
MD Pathology
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2. • Diagnosis of simple cysts
• The investigation of suspected recurrence or metastasis in
cases of previously diagnosed cancer
• Confirmation of inoperable, locally advanced cancer
• Preoperative confirmation of clinically suspected cancer
• Investigation of any clinically palpable lump, clinically benign
or malignant as a guide to clinical management
• As a complement to mammography in the screening
situation
• To obtain tumor cells for special diagnosis
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3. Adequacy of smears:
Presence of at least six clusters of epithelial cells in all
smears
or
Presence of 10 or more myoepithelial (bipolar cells) in 10
consecutive medium power viewing fields
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4. Normal
Inflammatory
Benign
Suspicious of malignancy
Atypical/indeterminate
Malignant
Unsatisfactory
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7. CLASSIFICATION OF LESIONS OF FEMALE BREAST
INFLAMMATORY LESIONS
Acute & chronic inflammatory processes
LESIONS CAUSED BY TRAUMA
Fat necrosis
Reaction to foreign bodies
Lesions resulting from breast aumentation /reduction
BENIGN PROLIFERATIVE DISEASES
Cysts
Fibrous mastopathy & other fibrous lesions
BENIGN TUMORS
Fibroadenoma
Lactating Adenoma
Intraductal papilloma
Granular cell tumor
MALIGNANT TUMORS
Carcinomas of various types
Sarcomas
Rare tumor & tumor like conditions
METASTATIC TUMORS
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8. Uncommon, account for <1% of women with breast
symptoms
Erythematous, swollen, painful breast
Inflammatory breast cancer mimics inflammation
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9. Mastitis:
A benign bimodal component of non neoplastic
breast tissue
Inflammatory cells, chronic/acute
Regenerative epithelial atypia
Histiocytes, epitheloid cells, multinucleated giant
cells and plasma cells(granulomatous pattern)
Microorganisms(infectious mastitis)
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11. Subareolar abscess
Young & nulliparous women
Squamous metaplasia of lactiferous ducts
Painful subareolar mass
D.D: Contaminant squamous epithelium
Ruptured Epidermoid cysts
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13. Fat necrosis
Painless,palpable mass,thickening or retraction of
skin
History of breast trauma ,repeated palpation or
aspiration or surgery
D.D: Lipid cyst
Macrophages mistaken for atypical epithelial cells
Carcinoma cells with macrophage like appearance
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14. Fat necrosis
Dirty background of
granular debris, fat
droplets & fragments of
adipose tissue
Foamy macrophages,
multinucleated giant
cells & adipocytes with
bubbly cytoplasm
Absence of epithelial
cells
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15. Lipoma
A well defined rounded
soft mass,firm,tender
Empty sensation on
needling
Fat only in multiple
aspirates-fat vacuoles &
fragments of adipose
tissue
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16. BENIGN EPITHELIAL BREAST LESIONS
Non proliferative breast
disease/fibrocystic changes
Cysts with apocrine
metaplasia
Fibrosis
Adenosis
Proliferative disease
with atypia
Atypical ductal hyperplasia
Atypical lobular
hyperplasia
Proliferative disease
without atypia
Epithelial hyperplasia
Sclerosing adenosis
Complex sclerosing scar
Papillomas
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17. Clinician LUMPY BUMPY breast
Radiologists Dense breast with cysts
Pathologist Benign breast lesion
Sequential proliferation & atrophy of ducts &
lobules and fibrosis of parenchyma of breast
On cytology, impossible to differentiate subgroups
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18. Sheets of ductal epithelial cells of apocrine type
Fragments of usual epithelial cells
Scattered single bare bipolar nuclei
Background of variable amounts of cyst fluid and
macrophages
Fibrous stroma
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22. Complete dissapearance of the lump after
aspiration of the fluid
Absence of altered blood or necrotic material in the
aspirated fluid
Cyst macrophages and more or less degenerate
oxyphil/apocrine epithelial cells
Inflammatory cells(polymorphs) variable
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23. Fibroadenoma
A high yield of cells, myxoid substance & some
macroscopically visible tissue fragment
Large ,branching sheets of bland epithelial
cells(staghorn pattern of epithelial cells)
Numerous single, bare bipolar nuclei
Fragments of fibromyxoid stroma
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26. Overlap with other hyperplastic lesions(papilloma)
Epithelial atypia mimicking
carcinoma(premenopausal & HRT)
Fibromyxoid stroma occuring in some invasive
cancers
Cystic/mucinous change
Distinction from phylloides tumor
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27. • Solitary/multiple freely movable breast mass during
pregnancy/puerperium
• Numerous densely packed lobular units in clusters
or as isolated structures with myoepithelial cells at
the periphery
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28. Lactating adenoma
Cell rich smears
Poorly cohesive mainly
dispersed cells of acinar
type
Cells have abundant
fragile cytoplasm,some bare
nuclei
Rounded vesicular nuclei
& central nucleoli
Background of abundant
lipid secretion
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29. Lobular ca(alveolar variant)
Ca breast during pregnancy & lactation
Secretory activity unrelated to pregnancy &
lactation
Galactocoele with unusual features
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30. Solitary subareolar mass
Bloody nipple discharge
Papillary lesions cannot be distinguished on
cytology, diagnosis left to histology
All papillary lesions should be excised
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31. Papilloma
Cellular smears
Complex folded &
branching epithelial sheets
& finger like fragments
True papillary fragments
with stromal cores
Dispersed epithelial cells
with mild nuclear atypia
Rows of pallisaded
columnar epithelial cells
Macrophages & variable
amount of cyst fluid
Bare bipolar nuclei
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32. • Low grade papillary carcinoma
• Cell dispersed mimicking a malignant smear pattern
• Pseudopapillary structures in smears of low grade
invasive duct carcinoma
• Overlap with fibroadenoma
• Infarcted papilloma
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33. Uncommon, benign ,firm tumor of breast clinically
mimics carcinoma
Large cells with abundant granular cytoplasm,
monotonous ,generally spherical small nuclei
In smears ,break up of cytoplasm results in naked nuclei
Often confuses with large cell duct carcinoma
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35. • Cohesive fragments of highly cellular stroma
composed of spindle cells with nuclear atypia and
background atypical bare spindle nuclei, are highly
suggestive of phylloides tumor
• Marked nuclear pleomorphism & mitotic activity
seen in frank malignant phylloides tumor .
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38. • Is the lesion an ordinary fibroadenoma? Or can it
quantify as a phyllodes??
• In case of marked abnormalities of stromal cells ,is
it a phyllodes or carcinoma??
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39. CARCINOMAS OF MAMMARY DUCT
Infiltrating duct
Inflammatory
Medullar
Colloid/mucinous
Signet ring type
Apocrine
Tubular
Papillary
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40. INTRADUCTAL CARCINOMA(IN SITU Ca OF DUCTS)
Solid type
Comedo type
Solid papillary carcinoma
CARCINOMA OF MAMMARY LOBULES
Infiltrating lobular carcinoma
Lobular carcinoma in situ
MIXED TYPES
RARE:
Spindle cell
Adenoid cystic
Metaplastic
Ca mimicking giant cell tumor of bone
Secretoty/juvenille ca
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41. • Abundant pure population of tumor cells ,singly &
in clusters
• Backround no inflammation/necrosis
• Clusters of aspirated cancer cells are 3D, either
loosely arranged,cells at the periphery become
detached
• Isolated cancer cells show N:C ratio,nuclear
abnormalities
• Absence of myoepithelial cells
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42. Diagnosis of DCIS in tissue section includes
assessment of nuclear grade, growth pattern,
presence or absence of necrosis & calcification
Specific diagnosis or classification of DCIS cannot
be made on FNAC
Lesions with high nuclear grade, invasion cannot be
predicted accurately
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43. Epithelial cells mainly cohesive forming large
sheets,often with holes or papillary fragments
Bare bipolar nuclei absent
Variable ,mild to moderate epithelial atypia
Necrotic debris, often calcium granules
Macrophages
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44. High gradeDCIS
(solid or comedo growth pattern)
Soft, boggy, palpable mass with highly cellular indicates
significant intraductal lesion worthy of excision.
Neoplastic cells in sheets, irregular aggregates and single
pleomorphic cells showing obvious malignant nuclear
features .
Necrotic debris, granular debris, granular calcium
,lymphocytes and vacuolated cytoplasm.
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47. Findings of tubular or angular epithelial structures,
malignant cells adherent to fibrous stroma
Presence of intracytoplasmic neolumina in
malignant cells
Fibroblast proliferation
Fragments of elastoid stroma
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49. Cell rich smears, single population of epithelial cells
no myoepithelial cells,no single bare bipolar nuclei
Variable loss of cell cohesion irregular clusters and
single cells
Single epithelial cells with intact cytoplasm
Mod to severe nuclear atypia, enlargement,
pleomorphism, irregular nuclear membrane&
chromatin
Fibroblasts & fragments of collagen( stromal
desmoplasia) a/w atypical cells
Intracytoplasmic neolumina in some cases
Necrosis unusual
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56. Metastatic malignancy (melanoma) to axillary
nodes
Malignant lymphoma
High grade DCIS(comedocarcinoma)
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57. Colloid Carcinoma/Mucinous carcinoma
Elderly women circumscribed tumor
Abundant background mucin
Atypical cells in small solid aggregates, runs single files,
singly
Moderate nuclear atypia
Benign epithelial cells & bipolar nuclei absent
Chicken wire blood vessels
Can confuse with mucocele like lesions
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60. Lack of nuclear pleomorphism
Mucinous DCIS or ADH
Mucocoele like lesions
Mucinous fibroadenoma
Myxoid stromal matrix resembling mucin
Metastatic carcinoma
Ultrasound gel
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61. Apocrine carcinoma
Elderly women
Cellular smears with large cells with eosinophilic granular
cytoplasm similar to that of benign apocrine cells
Nuclei are large with multiple nucleoli
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64. Tubular carcinoma
Moderately cellular smears
Cohesive 3D complex, often branching & angulated
tubular clusters of epithelial cells
Single bipolar nuclei of benign type with fat in the
background
Nuclear abnormalities are trivial
May mimic fibroadenoma
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67. Fibroadenoma
Mixed tubular & usual ductal carcinoma
Complex sclerosing lesion/scar, adenosis
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68. Papillary Carcinoma
Rare tumors
Cell clusters resembling benign papillomas
Nuclear enlargement & evidence of mitotic activity
Definitive diagnosis cannot be made
Confirmation by histopath
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71. Lobular carcinoma
Difficult to aspirate because of fibrosis
Small monotonous cancer cells showing cytoplasmic
vacuolation
Cells either dispersed, clusters or singe files
Nuclei granular of similar sizes
Cytoplasmic vacuolation with central condensed mucus in
cancer cells(air dried geimsa) Target cells
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74. Sparse cellularity
Resemblance to non neoplastic breast tissue in L.P
Component of benign epithelium
Lobular hyperplasia in pregnancy & lactation
Distinction from low grade ductal carcinoma
Intracytoplasmic neolumina in other lesions
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76. Aspirate shows hyaline globules surrouned by
epithelial hyperplasia
Have to be distinguished from collageous
spherulosis
Prognosis significantly better
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78. • Highly aggressive malignant tumor combine features
of carcinoma with that of well differentiated
sarcoma(lipoma,oste or chondroSa,fibrosarcoma)
• Diagnostic: two or more population of malignant
cells
• Spindle cell variant resembles soft tissue sarcoma,
difficult to distinguish from phyllodes
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80. Smears cell rich composed of dispersed small &
relatively uniform cells with coarse granular nuclear
chromatin resembling carcinoid
Mistaken for lymphoma,look for possibility of
metatstatic neuroendocrine ca
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82. • Aspiration : plenty of blood, few tumor cells(low
grade)
• Tumor cells spindly, attenuated basophilic cytoplasm
without distinct borders& have dark pleomorphic,
elongated or plump spindle nuclei(High grade )
mistaken for sarcoma
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84. Gynecomastia
Smears similar to fibroadenoma
Sheets of cuboidal ductal cells & fragments of loose
connective tissue stroma
Bipolar, spindly myoepithelial cells & oncocytes
Fragments of fibrous stroma & adipose tissue
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86. Bloody nipple secretions are more likely to be
malignant
Two subtypes in spontaneous nipple secretions:
1.Solid/papillary ductal carcinoma
2.Ductal carcinoma with paget`s disease
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87. • Cancer cells desquamate singly or in clusters
• Clusters may be loosely structured, and are
sometimes thick or spherical, but may show a
relatively orderly arrangement of cancer cells in
papillary clusters
• Necrosis is common comedo type DCIS
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88. Background of keratin, squamous cells, inflammatory
cells & debris(scrape smears from nipple)
Large malignant cells, single and in small groups, closely
associated with squamous & inflammatory cells
Abundant pale cytoplasm with distinct borders
Obvious nuclear features of malignancy
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91. • If cytological pattern does not fit any of the
recognised types of primary breast cancer,then
possibility of metastasis need to be considered
• Mets are common from melanoma, SCC of cervix,
bronchogenic carcinoma, mucin secreting
adenocarcinoma stomach, ovarian adenoca,
alveolar RMS, soft tissue sarcoma
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93. False positive
1. Papillary lesions
2. Epithelial hyperplasia with nuclear atypia
3. Radial scar/complex sclerosing lesion
4. Fibroadenoma
5. Regenerative epithelial atypia
6. Pregnancy & lactation
7. Skin adnexal tumor
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94. False negative
1. Tumors with central necrosis/sclerosis
2. Small carcinoma next to a dominant benign lesion
3. Complex proliferative lesion
4. Low grade ductal carcinoma
5. Lobular carcinoma Ca and small cell ductal Ca
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97. • As the prognosis and thereby the line of
management of each group of breast lesions varies,
it is important to recognize the spectrum of
morphological changes seen and separate them into
benign, premalignant and malignant categories.
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98.
Masood et al, cytological grading system based on
Cellular arrangement (relationship of cells to one another in
a sheet of ductal epithelial cells),
The degree of cellular pleomorphism (the variation in cell
size of the ductal epithelial cells),
Anisonucleosis,
The presence of myoepithelial cells,
Nucleoli
The status of chromatin pattern like clumping of chromatin
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