Cytologic features of 22 radial scar/complex sclerosing lesions of the breast, three of which associated with carcinoma: clinical, mammographic, and histologic correlation

Infiltrating Epitheliosis of the Breast: Fine Needle Aspiration Cytology

Epitheliosis (or usual duct hyperplasia) is a proliferation of epithelial and myoepithelial cells located within enlarged acini and small ducts, which is characterized by irregular and peripheral fenestration. Infiltrating epitheliosis (IE) is a specific lesion, characterized by classical epitheliosis flowing out into the adjacent stroma. The stroma is desmoplastic and shows keloid appearance with irregular elastosis. IE can mimic malignancy both on radiological and histological grounds. The aim of the present study is to describe the fine needle aspiration cytological features of 6 consecutive cases of IE, with histological correlation. IE cases presenting as screen detected lesions and preoperatively diagnosed on fine needle aspiration cytology (FNAC) were reviewed. All patients had radiologically breast lesions suspicious for malignancy that underwent FNAC followed by surgical resection. The FNAC smears presented some features that could lead to a misdiagnosis of malignancy, such as bloody background, high cellularity, and stromal fragments containing epithelial cells. Nevertheless, malignancy was excluded, due to the absence of atypia and the presence of myoepithelial cells in the cell clusters. IE presents a special FNAC pattern that can be misinterpreted as malignancy. Therefore, knowledge is necessary to avoid patient overtreatment.

Practical Considerations in Breast Papillary Lesions: A Review of the Literature

Context.—Diagnosis of papillary breast lesions, especially in core biopsies, is challenging for most pathologists, and these lesions pose problems for patient management. Distinction between benign, premalignant, and malignant components of papillary lesions is challenging, and the diagnosis of invasion is problematic in lesions that have circumscribed margins. Obtaining a balance between overtreatment and undertreatment of these lesions is also challenging.

Objectives.—To provide a classification and a description of the histologic and immunohistochemical features and the differential diagnosis of papillary breast lesions, to provide an update on the molecular pathology of papillary breast lesions, and to discuss the recommendations for further investigation and management of papillary breast lesions. This review provides a concise description of the histologic and immunohistochemical features of the different papillary lesions of the breast.

Data Sources.—The standard pathology text books on breast pathology and literature on papillary breast lesions were reviewed with the assistance of the PubMed database (http://www.ncbi.nlm.nih.gov/pubmed).

Conclusions.—Knowledge of the clinical presentation, histology, immunoprofile, and behavior of papillary breast lesions will assist pathologists with the diagnosis and optimal management of patients with papillary breast lesions.

Indeterminate and erroneous fine-needle aspirates of breast with focus on the 'true gray zone': a review

OBJECTIVE

To review our experience and the literature on inconclusive/erroneous fine-needle aspirates (FNAs) of breast with the focus on the 'true gray zone'. To describe the cytology, differential diagnosis, pitfalls and limitations of common and rare lesions.

STUDY DESIGN

We conducted a literature search focusing on breast FNAs with statistical data of C3 and C4 categories including false-positive and false-negative cases. Similar data from 2003 to 2009 was obtained from our institution.

RESULTS

C3 and C4 categories account for 3-17% of breast FNAs. Contributing factors are technical difficulties, inexperienced pathologists interpreting FNAs of breast and overlap of cytologic features of certain benign and malignant conditions; this last, 'true gray zone' accounts for 2% of cases. Fibroadenoma, proliferative breast lesions, gynecomastia, infiltrating and in situ low-grade adenocarcinomas and tubular, cribriform, lobular and mucinous carcinomas are the most common problematic lesions. Granular cell tumor, adenomyoepithelioma, pregnancy-related lesions, fat necrosis, inflammatory and radiation changes, adenoid cystic carcinoma, spindle-cell lesions and Phyllodes tumor are less common.

CONCLUSION

Inconclusive/erroneous FNAs of breast due to the 'true gray zone' are rare. Most are due to the overlapping cytologic features of some benign and malignant conditions. Practical features that may help arrive at the correct diagnoses are elucidated.

Role of core needle biopsy in the treatment of radial scar

Invasive tumor or ductal carcinoma in situ occur in radial sclerosing lesions in one third of the cases therefore, surgical excision is mandatory. Forty-five patients with radial scar morphology were examined. Ultrasound guided fine-needle aspiration biopsy (FNAB) and core biopsy (CB) were performed in all cases. The postoperative pathological findings were compared to the results of preoperative biopsies. Sensitivity of preoperative percutaneous biopsies (FNAB and CB) was 17.6% and 70.6%, false-negative rate was 82.4% with FNAB and 29.4% with CB. The negative predictive value was 48.1% and 84.8% respectively. Had we done preoperative cytology only, we would have had to perform a two-step procedure (sentinel lymph node biopsy) in 7 patients (15.6%), while with preoperative core biopsy it has decreased to 2 patients (4.4%). Preoperative CB in small radial stellate lesions is recommended to achieve accurate diagnosis in order to avoid a two-step surgical procedures.

The fine needle aspiration biopsy diagnostic criteria of proliferative breast lesions: A retrospective statistical analysis of criteria for papillomas and radial scar lesions

This study aimed to analyze statistically the accuracy of fine needle aspiration biopsy cytological criteria in diagnosing epithelial hyperplasia with atypia (EHA), papillary lesions (PAP), and radial scar/complex sclerosing lesions (RS/CSL). The 42 criteria studied were extracted from a literature review and those developed and used in our department. Cytological cases with diagnoses of EHA, PAP, and RS/CSL for the period of 1997-2001 were correlated with relevant histological follow-up and the positive predictive power of these diagnoses have been presented in an earlier publication. Some 77 cases with definite, specific histological diagnoses of atypia or a more severe lesion, PAP and RS/CSL, were reviewed and scored using 55 cytological criteria. As the group of EHA and RS/CSL yielded a smaller number of cases, these were grouped together in the statistical analysis and compared to PAP. The cytological features, which were most diagnostic for PAP, were stellate (Odds ratio 1.75) and meshwork (Odds ratio 3.29) tissue fragments, while the presence of tubular structures was inversely proportional to the histological outcome of PAP. True papillary fragments were uncommon and not statistically significant in diagnosing PAP of the breast.

A prospective study of the diagnostic accuracy of cytological criteria in the FNAB diagnosis of breast papillomas

Seventy-four fine needle aspiration biopsies (FNAB) of breast were selected from the 133 cases with surgical biopsy follow up, from a total of 1,154 consecutive breast FNAB received in a 6-month-period. These 74 cases were reviewed and scored using all relevant cytological criteria for proliferative breast lesions used in our recent retrospective study, without reference to the original cytological and surgical biopsy diagnoses. Of the 42 criteria scored, 13 had a statistically significant association between the cytology score and the presence or absence of a papilloma (PAP), and the sensitivities, specificities and positive predictive values (PPV) of these individual criteria, or a combination of criteria, were derived. It was found that stellate and meshwork tissue fragments and papillary fragments were all highly specific (0.98) for the diagnosis of PAP, with meshwork fragments having the highest PPV (0.93). Stellate fragments (0.41) and papillary fragments (0.24) were less sensitive not only because they occurred less often, but also because they were present in smaller numbers. The presence of a proteinaceous background with macrophages and siderophages or a moderate to marked number of apocrine sheets were useful indicators only when coexisting with at least one of the above three features.

Fine-needle aspiration cytology of apocrine adenosis of the breast: Report on three cases

Apocrine adenosis is a distinctive breast lesion, which can sometimes be misdiagnosed as malignant histologically. Although its histological characteristics have been well established, there are limited descriptions of its cytological features. We report fine-needle aspiration (FNA) cytology of three cases of apocrine adenosis. There were diverse cytological features between cases, and in two cases, FNA smears were highly cellular. Naked nuclei were present in all cases, and were numerous in one. Enlarged nucleoli and anisonucleosis were common. Apocrine metaplasia with nuclear atypia mimicking apocrine carcinoma was prominent in one case, whereas one case lacked definite apocrine features. Regardless of their various atypical FNA cytologies, the nuclei were consistently less hyperchromatic in all cases. Although FNA cytology of apocrine adenosis has the potential to be misinterpreted as malignant, the naked nuclei of background and less hyperchromatic nuclear features may be useful in distinguishing apocrine adenosis from carcinoma. Being familiar with these distinctive breast lesions is also important in decreasing false positives.

Positive predictive value of the breast FNAB diagnoses of epithelial hyperplasia with atypia, papilloma, and radial scar

Proliferative breast lesions are a spectrum of lesions that have overlapping cytological features and are difficult to subclassify in fine-needle aspiration biopsies (FNABs). This study of breast FNABs from the period of 1997-2001 aimed to correlate the cytological diagnoses of epithelial hyperplasia with atypia (EHA), papilloma (PAP), and radial scar/complexing sclerosing lesions with relevant histological follow-up, and to assess the positive predictive value (PPV) of the cytological diagnosis. The PPV for the three categories were found to be 0.16, 0.74, and 0.63 respectively. The low value observed in the cytological category of EHA was due to the heterogeneous nature of the group, which makes it difficult to correlate cytological appearances with the varying histological lesions. However, it was found that 70% of these EHA cases had benign histological diagnoses, matching the expected outcome. The PPV of 0.74 for the cytological diagnosis of PAP of the breast compares favorably to similar published studies, and we suggest that the specific diagnosis of PAP can be made reliably using cytological criteria.

Cytomorphology of Benign Breast Disease

Fine needle aspiration biopsy is a widely used technique for the initial diagnosis of mammary lesions. The majority of patients undergoing fine needle aspiration biopsy of a breast lesion will have a benign disease of the breast. This article provides a review of the cytomorphologic features in a variety of benign breast lesions,and discusses the commonly encountered differential diagnoses on aspiration biopsy. Topics discussed include inflammatory and reactive conditions, treatment-induced changes, pregnancy-related changes, benign proliferative lesions, and benign neoplasms of the breast.

Fine needle biopsy cytology of breast lesions: a review of interpretative difficulties

Screening mammography and greater community awareness of breast carcinoma have led to an increase in fine needle biopsies of the breast. As a consequence, a wide variety of cytologic patterns have been encountered and studied in benign, proliferative, and malignant breast lesions. We review the main reasons for diagnostic difficulties in breast cytology, the situations in which either a false positive or a false negative diagnosis is possible, as well as conditions whose incorrect typing can lead to inappropriate management.

Can sonography be used to help differentiate between radial scars and breast cancers?

The aim of this study was to determine whether sonography can help differentiate radial scars (RS) from breast cancers. Series of 75 consecutive mammographic screen-detected RS and carcinomas were reviewed: shape, orientation, echotexture, halo, acoustic attenuation and architectural distortion were compared for sonographic RS and cancers. RS were 43% sonopositive (25/58 examined) vs. 93% sonopositive carcinomas (68/73 examined); P<0.001. Of 22 RS and 66 cancers available for film review, findings were: echogenic halo in zero RS vs. 38 cancers (0% vs. 58%); tiny sonographic cysts in 3 RS vs. zero carcinomas (14% vs. 0%); assessment category malignant vs. indeterminate/suspicious (8% vs. 59%, P<0.001); breast architecture disruption (43% vs. 91%, P<0.001); sound attenuation (55% vs. 86%, P<0.005), taller-than-wide shape (36% vs. 56%, P=0.11). RS showed echogenic components more than cancers (32% vs. 9%, P=0.016). Jagged margins were equally seen (77% vs. 76%, P=0.89). The findings suggest that sonographic differences can help discriminate between RS and carcinomas.

Review of 125 SiteSelect stereotactic large-core breast biopsy procedures

Advances in stereotactic breast biopsies have introduced a variety of devices that yield different sizes of tissue samples. The choice of biopsy device should be based on which technique is most likely to yield a definitive diagnosis at the time of the initial biopsy. This is a prospective study of 104 patients who underwent a total of 125 stereotactic breast biopsies using the SiteSelect large-core biopsy device. From May 1999 to June 2001, 104 patients underwent 125 stereotactic breast biopsies with the SiteSelect large-core biopsy device. One hundred four 15 mm SiteSelect biopsies, eighteen 10 mm SiteSelect biopsies, and three 22 mm SiteSelect biopsies were performed. Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) were found in 15% of the biopsies and infiltrating cancer was found in another 15% of the biopsies. Seventy-eight percent of the ADH and 90% of the DCIS lesions were associated with indeterminate calcifications noted on mammogram. Two of the 22 mm SiteSelect excisions yielded a specimen that contained the entire cancer with clear surgical margins. All of the patients with DCIS or invasive carcinoma underwent definitive surgical and adjuvant therapy. The sensitivity and specificity of SiteSelect in this series of patients was 100%. The SiteSelect biopsy procedure is safe, well tolerated by patients, and can be performed under local anesthesia. SiteSelect is comparable to an open excisional biopsy in its ability to obtain adequate tissue for accurate diagnosis, but excises significantly less normal surrounding breast tissue. Based on the data, indications for primary use of SiteSelect are indeterminate calcifications on mammogram, rebiopsy of a vacuum-assisted biopsy site that yielded atypia on pathologic examination, and complete excision of a lesion suspicious for invasive carcinoma in order to assess actual size and margin status.

Cicatriz radial/lesão esclerosante complexa: aspectos radiológicos com correlação clínica, ultra-sonográfica e anatomopatológica

OBJETIVO: Estudar, retrospectivamente, as várias formas de apresentação da cicatriz radial/lesão esclerosante complexa (CR/LEC) na mamografia, correlacionando-as com o exame clínico e os achados ultra-sonográficos. Os achados histopatológicos e a associação da CR/LEC com hiperplasia atípica e carcinoma são discutidos. MATERIAIS E MÉTODOS: Foi realizado estudo retrospectivo de 926 lesões impalpáveis em 901 pacientes submetidas a biópsia excisional após localização pré-cirúrgica, do arquivo do Centro de Diagnóstico por Imagem e do Hospital Santa Rita, Vitória, ES, no período de outubro de 1993 a dezembro de 2001, nas quais 57 pacientes tiveram diagnóstico histopatológico de CR/LEC. RESULTADOS: A idade variou de 31 a 84 anos (média de 49 anos). As lesões foram palpáveis em dez casos. Na mamografia, 48 casos se apresentaram como distorção arquitetural, e com a mesma freqüência o nódulo espiculado e a densidade assimétrica, quatro casos cada. As microcalcificações foram detectadas na mamografia em 14 casos e em 20 quando o espécime cirúrgico foi avaliado. A ultra-sonografia foi realizada em 51 casos, tendo expressão em 17 como área hipoecóica irregular com atenuação acústica posterior. Houve 42 casos de CR/LEC sem ou com proliferação típica, nove casos com proliferação epitelial atípica e seis casos com carcinoma infiltrativo associado. CONCLUSÃO: Não é possível fazer diagnóstico diferencial de CR/LEC com câncer pelos métodos de imagem e a biópsia excisional deve ser realizada.

Three years of experience with advanced breast biopsy instrumentation (ABBI)

This article reports our experience using the advanced breast biopsy instrument (ABBI) system for excisional biopsy of mammographically visible nonpalpable breast lesions. Patients with nonpalpable mammographically detected breast lesions were evaluated as potential ABBI candidates. Selection criteria included noncystic lesions for which complete removal or large sampling was indicated, compressed thickness of the breast of more than 25 mm, and the patient's ability to lie prone for at least 1 hour. During the period August 1997-April 2000 (33 months), 284 patients were found to be potential ABBI candidates. Sixteen patients were subsequently excluded. Biopsies using the ABBI system were performed in 268 cases, yielding an overall technical success rate of 94.4%. The mammographic abnormalities included mass in 125 cases (46.6%), mass with calcifications in 63 cases (23.5%), and microcalcifications without a mass in 80 cases (29.8%). Histologically 56 specimens (20.9%) were malignant (mass in 30 cases, mass with calcifications in 12, and microcalcifications in 14) and 212 (79.1%) were benign. Carcinoma in situ was found in 17 cases (30.4%), invasive carcinoma in 35 cases (62.5%), tubular carcinoma in 2 cases (3.6%), metastatic intramammary lymph node of previously unknown malignant melanoma in 1 case, and malignant lymphoma in 1 case. Open reexcision was performed in 54 cases with primary breast cancer. The histologic investigation revealed that in 26 (48.15%) cases the mammographic lesion was completely excised and in 28 (51.85%) cases the margins involved malignant residue and/or other foci of carcinoma. There were complications in 17 cases: wound infection in 2, ecchymosis in 9, seroma in 5, and a large immediate hematoma in 1 patient. Only the latter patient required immediate revision and drainage; the remainder underwent successful conservative treatment. Most nonpalpable breast lesions, if selected properly, are accessible for ABBI procedure. The biopsy causes minimal complications and minimal distortion of the breast architecture. Should relumpectomy be needed after the ABBI procedure, the tunnel of the cannula path is easily recognized, leaving no need for needle localization.

New mammographic stromal deformity: what is the significance of this finding on screening mammograms?

Current practice within the NHS Breast Screening Programme recommends surgical excision of screen detected areas of stromal deformity as differentiating carcinomas from radial scars and excluding in situ malignancy in association with radial scars is unreliable. We retrospectively reviewed all cases recalled for assessment over a 4 year period, identified to have an area of persistent stromal deformity not associated with surgical scarring and without an associated mammographic mass. Thirty women were prevalent (first) round screens--17 cases proved to be malignant and 13 benign. The latter group included three cases of atypical ductal hyperplasia. Nineteen women were incident (subsequent) round screens--all 19 cases proved to be malignant. This study supports the practice of surgically removing all areas of stromal deformity, particularly new areas of stromal deformity detected in the incident round, as in this group the likelihood of malignancy is extremely high.

Comparison of mammographically guided breast biopsy techniques

OBJECTIVE

To determine which mammographically guided breast biopsy technique is the most efficient in making a diagnosis in women with suspicious mammograms.

SUMMARY BACKGROUND DATA

Mammographically guided biopsy techniques include stereotactic 14-gauge core-needle biopsy (SC bx), stereotactic 11-gauge suction-assisted core biopsy (Mammotome [Mbx]), stereotactic coring excisional biopsy (Advanced Breast Biopsy Instrument [ABBI]), and wire-localized biopsy (WL bx). Controversy exists over which technique is best.

METHODS

All patients undergoing any one of these biopsy methods over a 15-month period were reviewed, totaling 245 SC bx, 107 Mbx, 104 ABBI, and 520 WL bx. Information obtained included technical success, pathology, discordant pathology, and need for open biopsy.

RESULTS

Technical success was achieved in 94.3% of SC bx, 96.4% of Mbx, 92.5% of ABBI, and 98.7% of WL bx. The sensitivity and specificity were 87.5% and 98.6% for SC bx, 87.5% and 100% for Mbx, and 100% and 100% for ABBI. Discordant results or need for a repeat biopsy occurred in 25.7% of SC bx, 23.2% of Mbx, and 7.5% of ABBI biopsies. In 63.6% of ABBI and 50.9% of WL bx, positive margins required reexcision; of the cases with positive margins, 71.4% of ABBI and 70.4% of WL bx had residual tumor in the definitive treatment specimen.

CONCLUSION

Although sensitivities and specificities of SC bx and Mbx are good, 20% to 25% of patients will require an open biopsy because a definitive diagnosis could not be reached. This does not occur with the ABBI excisional biopsy specimen. The positive margin rates and residual tumor rates are comparable between the ABBI and WL bx. The ABBI avoids operating room and reexcision costs; therefore, in appropriately selected patients, this appears to be the most efficient method of biopsy.