The cytopathology of ductal carcinoma in situ of the breast. A detailed analysis of fine needle aspiration cytology of 58 cases compared with 101 invasive ductal carcinomas

Elite VABB 13G: A New Ultrasound-Guided Wireless Biopsy System for Breast Lesions. Technical Characteristics and Comparison with Respect to Traditional Core-Biopsy 14-16G Systems

The typification of breast lumps with fine-needle biopsies is often affected by inconclusive results that extend diagnostic time. Many breast centers have progressively substituted cytology with micro-histology. The aim of this study is to assess the performance of a 13G-needle biopsy using cable-free vacuum-assisted breast biopsy (VABB) technology. Two of our operators carried out 200 micro-histological biopsies using the Elite 13G-needle VABB and 1314 14–16G-needle core biopsies (CBs) on BI-RADS 3, 4, and 5 lesions. Thirty-one of the procedures were repeated following CB, eighteen following cytological biopsy, and three after undergoing both procedures. The VABB Elite procedure showed high diagnostic performance with an accuracy of 94.00%, a sensitivity of 92.30%, and a specificity of 100%, while the diagnostic underestimation was 11.00%, all significantly comparable to of the CB procedure. The VABB Elite 13G system has been shown to be a simple, rapid, reliable, and well-tolerated biopsy procedure, without any significant complications and with a diagnostic performance comparable to traditional CB procedures. The histological class change in an extremely high number of samples would suggest the use of this procedure as a second-line biopsy for suspect cases or those with indeterminate cyto-histological results.

The International Academy of Cytology Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy Cytopathology

The International Academy of Cytology (IAC) gathered together a group of cytopathologists expert in breast cytology who, working with clinicians expert in breast diagnostics and management, have developed the IAC Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy (FNAB) Cytology. The project was initiated with the first cytopathology group meeting in Yokohama at the 2016 International Congress of Cytology. This IAC Yokohama System defines five categories for reporting breast cytology, each with a clear descriptive term for the category, a definition, a risk of malignancy (ROM) and a suggested management algorithm. The key diagnostic cytopathology features of each of the lesions within each category will be presented more fully in a subsequent atlas. The System emphasizes that the crucial requirements for diagnostic breast FNAB cytology are a high standard for the performance of the FNAB and for the making of direct smears, and well-trained experienced cytopathologists to interpret the material. The performance indicators of breast FNAB, including specificity and sensitivity, negative predictive value, positive predictive value and ROM stated in this article have been derived from the recent literature. The current practice of breast FNAB has evolved with the increasing use of ultrasound guidance and rapid on-site evaluation. Two recent publications have shown a range of ROM for the insufficient/inadequate category of 2.6-4.8%, benign 1.4-2.3%, atypical 13-15.7%, suspicious of malignancy 84.6-97.1%, and malignant 99.0-100%. The management algorithm in the System provides options because there are variations in the management of breast lesions using FNAB and core-needle biopsy in those countries utilizing the "triple test" of clinical, imaging, and FNAB assessment, and also variations in the availability of CNB and imaging in low- and middle-income countries. The System will stimulate further discussion and research, particularly in the cytological diagnostic features of specific lesions within each category and in management recommendations. This will lead to continuing improvements in the care of patients with breast lesions and possible modifications to the IAC Yokohama System.

Feasibility of Masood's cytological index for screening breast lesions in low resource setting

Fine needle aspiration cytology has long been an accepted diagnostic modality in combination with physical examination and mammography to investigate breast lesions. In the present era, more proficient methods such as stereotactic mammographically guided breast biopsy is the preferred choice, however, in low resource setting, FNAC still remains the most cost effective and sampling modality to diagnose breast cancer. With the intention to evaluate the efficacy and limitations of FNAC in evaluation of breast lesions in low resource setting, we employed the Masood's cytological staging system to stratify the breast lesions and correlate them with histopathology wherever possible. All breast lesions aspirates were analyzed and classified according to the Masood's cytological scoring system and correlated with histopathological findings wherever adequate material was available. A total of 776 patients were studied of which 23 aspirates were unsatisfactory, 120 aspirates were categorized as inflammatory breast disease. Six hundred and thirty-three cases were classified according to Masood's cytological system. Nonproliferative breast diseases (Group I) encompassed maximum cases with 55% followed by carcinoma in situ and invasive cancers (Group IV) with 39% and proliferative breast disease without atypia (Group II) and with atypia (Group III) which had equal number of cases constituting 2.4% each. Cyto-histopathological correlation done in 102 cases revealed 100% concordance in group IV and 75% concordance in group III while it could not be performed in Group I and II as no histopathological specimen was available in those patients. Masood Cytological grading for breast aspirates is a reliable and an easily reproducible system which can be used to formulate appropriate treatment protocols in cases presenting with breast lesions.

Fine needle aspiration cytology of lobular breast carcinoma and its variants

OBJECTIVE

To identify associations between cytological criteria in fine needle aspiration (FNA) specimens and histological subtypes of lobular breast carcinoma (classical and other types).

STUDY DESIGN

FNA cytology and mastectomy specimens from 72 cases of invasive lobular breast carcinoma were consecutively retrieved from the files of the Amaral de Carvalho Hospital, Jaú-São Paulo, Brazil. All cases were reviewed regarding five cytological criteria: cellularity, cellular cohesion, presence of inflammation, nucleoli and nuclear atypia. The χ2 test or Fisher's exact tests with 95% confidence intervals (CI) were used.

RESULTS

The classical type showed lower initial cytological diagnosis of malignancy compared to the other variants (p=0.017; odds ratio (OR) 0.26, 95% CI 0.89-0.80). Moderate/intense cellular cohesion (p=0.011; OR 0.18, 95% CI 0.04-0.73) and mild atypia (p=0.000; OR 16.15, 95% CI 3.20-81.48) were significantly associated with the classical type of lobular breast carcinoma, while the absence of inflammation (p=0.082; OR 0.36, 95% CI 0.12-1.15) was marginally associated with the classical type.

CONCLUSIONS

In cytology, the characterization of lobular carcinoma as malignant is difficult, especially the classical type. The association between cell cohesion and the classical type of lobular breast carcinoma may be one of the factors that complicate this diagnosis.

The microscopic complexities of C3 in breast cytology

BACKGROUND

Fine-needle aspiration (FNA) of difficult breast lesions often results in an atypical (C3) report. The assortment of outcomes generated by C3 reports varies widely, and this has given rise to different clinical management pathways.

OBJECTIVE

To identify and objectively assess microscopic features associated with atypical/C3 breast FNA cases.

MATERIALS AND METHODS

A total of 230 atypical breast FNAs were subjected to a blind microscopic rescreen using a range of robust qualitative and quantitative cytological criteria including cellularity, architectural qualities, cytomorphology and background features. A logistic regression with a receiver operating characteristic (ROC) curve and the resultant forward stepwise analysis were conducted to assess the results. This statistical testing was measured against malignant, benign proliferative and benign non-proliferative outcomes.

RESULTS

The malignant and benign proliferative outcomes showed a mixture of opposing protective and predictive individual cytological criteria. The stepwise analysis produced models demonstrating the best combination of individual cytological criteria for malignancy, proliferative and benign non-proliferative entities. In the malignancy model, discohesion, nuclear crowding within sheets, diminished numbers of bare bipolar nuclei and myoepithelial cells, the presence of tubules or necrosis and the absence of a cystic background were important features. The benign proliferative model suggested the same criteria but with the opposite implication and with the addition of several others, such as the presence of apocrine metaplasia, retained polarity and a speckled or coarse chromatin pattern. Age was a significant factor in malignant and proliferative outcomes. The benign non-proliferative stepwise analysis produced a model with fewer criteria (complex sheets, bare bipolar nuclei and a cystic background) limiting clinical application.

CONCLUSION

Atypical/C3 breast cytology remains a legitimate reporting category. However, it is associated with a number of different histological outcomes. The incidence of the C3 category can be significantly reduced by controlling extrinsic factors and understanding the associated microscopic features.

Recognizing breast ductal carcinoma in situ on fine-needle aspiration: a diagnostic dilemma

In this study, we evaluated cytomorphologic features of different subgroups of ductal carcinoma in situ (DCIS); we compared seven cytologic features between DCIS and invasive ductal carcinoma (IDC) aspirates to determine whether diagnosis of stromal invasion can be made based on fine-needle aspiration (FNA) findings. There were 142 cases of DCIS and 1,978 cases of IDC enrolled in our study. FNA analysis revealed 80.3% sensitivity for DCIS and 94.7% sensitivity for IDC. High and intermediate grade DCIS exhibited marked nuclear abnormality (92.1% vs. 35.7%, 30.0%; P1 < 0.001, P2 < 0.001) and necrosis (69.7% vs. 0%, 10.0%; P1 < 0.001, P2 = 0.001) in a higher percentage of cases compared to low grade DCIS and intraductal/intracystic papillary carcinoma. The rates of background macrophages (71.3% for DCIS and 21.9% for IDC, P < 0.001) and extensive necrosis (54.0% for DCIS and 16.7% for IDC, P < 0.001) were significantly higher in DCIS compared to IDC. Lymphocytes were observed in conjunction with tumor cells more frequently in IDC (81.3%) compared to DCIS (36.8%, P < 0.001). Stromal fragments associated with tumor cells were only observed in invasive lesions (11.9% micro-invasive DCIS and 52.1% IDC). Tubular structures were found exclusively in IDC (11.5%). Cytologic criteria for diagnosis of high and low grade DCIS are different. The suspicion of DCIS is raised when background macrophages and extensive necrosis are observed. Stromal invasion is suggested by FNA if lymphocytes are entwined around tumor cells or if stromal fragments associated with tumor cells or tubular structures are observed.

Quality Appraisal of Diagnostic Accuracy Studies in Fine-Needle Aspiration Cytology: A Survey of Risk of Bias and Comparability

Context.—The quality of diagnostic accuracy studies is determined by 2 key factors: risk of bias and comparability. Bias can distort accuracy estimates and poor reporting impairs comparability. While diagnostic accuracy studies for fine-needle aspiration cytology (FNAC) are frequently published, the methodologic issues associated with this body of literature have never been reviewed.

Objective.—To assess the quality of design and reporting of diagnostic test accuracy studies in FNAC.

Data Sources.—Diagnostic accuracy studies were identified by a Medline (US National Library of Medicine) search. Sixty-four FNAC diagnostic test accuracy studies were randomly selected for structured review with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) survey. Studies were divided between 2 time periods: 2000-2001 and 2009-2011.

Conclusions.—Diagnostic test accuracy studies of FNAC suffer from numerous deficiencies in study design, which negatively affect the reliability of accuracy estimates.

Fine-needle aspiration cytology of the breast

Fine-needle aspiration cytology (FNAC) is an established, highly accurate, and cost-effective method for diagnosing lesions in different organs, including the breast. The method is minimally invasive without unwanted side effects. FNAC forms part of the triple assessment of breast lesions. Despite some shortcomings of the reporting categories, FNAC as part of the triple assessment has proved its value in describing the findings most accurately. The diagnostic impact depends on experience of the operator, quality of preparation, and diagnostic skills of the cytopathologist. The highest accuracy is achieved at centers with a multidisciplinary approach. FNAC is often palpation guided from palpable breast masses, whereas ultrasonography guidance is more widely used on nonpalpable lesions. Inadequate sampling with FNAC is particularly seen in collagenous lesions and in submitted specimens sampled by physicians lacking experience with the FNAC procedure. A diagnostic biopsy is recommended when FNAC provides scant material. FNAC is considered to be a safe method for screening purposes, although moderately less sensitive than core needle biopsy. FNAC is most accurate when experienced cytopathologists are available to assess the adequacy of the aspirated material and advise on additional aspirations for ancillary tests when needed.

Cancer size, histotype, and cellular grade may limit the success of fine-needle aspiration cytology for screen-detected breast carcinoma

BACKGROUND

Fine-needle aspiration cytology (FNAC) was adopted as the first-line method to assess breast lesions in the Verona Breast Cancer Screening Program. The radiological and pathological factors relating to the success of FNAC in breast cancer series were evaluated.

METHODS

Between July 1999 and June 2004, 418 breast cancers were submitted to FNAC in the Verona Breast Cancer Screening Program. The results of FNAC diagnoses were compared with final histology. The FNAC sensitivity rate, underestimation of malignancy rate, and inadequacy rate were correlated with histotype, size, grading, and radiologic imaging.

RESULTS

Of the 418 cancers, 95 were in situ, and 323 were invasive. The sensitivity rate was higher in invasive cancers (P < .001), and the underestimation of malignancy rate was greater in in situ cancers (P = .002). Lobular type cancers had a lower sensitivity rate in invasive and in situ cancers. The sensitivity rate was 100% in medullary, mucinous, and papillary cancers, and no case had inadequate sampling. The underestimation of malignancy rate was higher in tubular carcinoma (18.2%); lobular carcinoma showed a higher inadequacy rate (10.4%). The sensitivity rate was lower and the underestimation of malignancy rate was higher in low-grade carcinomas and in lesions <1 cm (P < .001). The performance of FNAC was not significantly influenced by mammographic imaging of lesions.

CONCLUSIONS

Low-grade cancer histotype, cancer size <1 cm, and lobular and tubular histotypes limit the possibility of obtaining positive results by FNAC. Operator experience and multidisciplinary consultation may help in overcoming these limitations. Pathologists must be aware of the limits of FNAC; results must be critically evaluated in light of the triple assessment.

Imprint cytology of needle core-biopsy specimens of breast lesions: Is it a useful adjunt to rapid assessment breast clinics?

This study aimed at assessing the practicability of imprint cytology (IC) of core biopsy (CB) specimens in order to achieve one-stop diagnosis of breast lesions. In total, 199 symptomatic patients underwent free-hand CB of the suspected breast lesions. The slides were stained by Diff-QuikO and reported independently of histological reporting. For practical reasons cytology specimens were graded as follows: C1=inadequate, as less than 4 groups of epithelial cells were seen, C2=benign, C3=probably benign, C4=probably malignant and C5=positive for malignancy. The results of IC were correlated with CB histology. Absolute sensitivity of the IC was 85.0% and complete sensitivity was 89.2% when correlated with CB. Specificity (biopsy cases only) of IC was 53.1% while full specificity was 53.1%. Positive predictive value of C5 was 99.3%, C4 55.6 % and C3 was 100%. Overall suspicious rate was 5.5%. It was concluded that IC is a reliable way of diagnosing symptomatic breast lesions in one-stop breast clinic and retains the advantage of pre-operative availability of detailed pathological characteristics of tumours for treatment planning.

Cell blocks of breast FNAs frequently allow diagnosis of invasion or histological classification of proliferative changes

Two major limitations of breast fine needle aspiration (FNA) compared with core needle biopsies (CNB) are the inability to determine whether a cancer is invasive and to classify proliferative lesions. We studied 40 consecutive "rapid cell blocks" from breast FNAs with surgical pathology follow-up to test whether cell blocks can overcome these limitations. Of 25 carcinomas, invasion could be identified in the cell block sections in 11 (44%). One cystosarcoma phyllodes was suspected based on the cell block sections. Cell blocks from 12 of 14 benign breast FNAs showed sufficient cells to assign a histologic diagnosis of no hyperplasia (1 case, confirmed on follow-up) and usual hyperplasia (11 cases; confirmed in eight of 11 on follow-up). Specific histologic diagnoses included intraductal papilloma (2 cases), and in situ lobular neoplasia (2 cases). Cell blocks complement smears and monolayers and appear to overcome major limitations of breast FNA.

Cytomorphology of Common Malignant Tumors of the Breast

A definitive cytologic diagnosis of breast cancer is usually possible when using the six major criteria of malignancy (cellularity, dyshesion, monomorphism, anisonucleosis, irregular nuclear membranes, prominent nucleoli) as part of the triple test. Carcinomas of special type have unique clinical and cytologic features that pathologists need to consider, because these may confuse interpretation. Complete subtyping of carcinomas may not always be possible by fine needle aspiration. Diagnostic accuracy for breast carcinoma is excellent. False-negative diagnoses are infrequent and chiefly due to sampling issues. False-positive diagnoses are extremely rare. Uniform report terminology should be used to ensure that diagnostic information is conveyed appropriately and consistently to guide the next diagnostic or treatment step.

Cytologic features of ductal carcinoma in situ in fine-needle aspiration of the breast mirror the histopathologic growth pattern heterogeneity and grading

BACKGROUND

Approximately 20% of the breast carcinoma cases detected on mammography screening represent ductal carcinoma in situ (DCIS). Cytopathologists are exposed to cytologic material from DCIS when nonpalpable, mammographic lesions are aspirated during the workup of organized and opportunistic mammography screening.

METHODS

The material in the current study was comprised of 225 representative fine-needle aspiration cytology (FNAC) smears from histologically confirmed DCIS of the breast that were diagnosed between 1990-2003. Smears were rescreened to search for the following features: nuclear size (grading), monolayer sheets, solid and cribriform epithelial aggregates, micropapillary and true papillary structures, comedo-type necrosis, microcalcifications, myoepithelial cells, and discohesion.

RESULTS

There were 174 high-grade lesions (77% were Grade 3) and 51 nonhigh-grade lesions (Grades 1 and 2). The concordance between the cytologic and histologic grading was 97% in the Grade 3 lesions and 94% in the Grade 1/2 lesions. Smears from Grade 3 DCIS contained solid and/or cribriform epithelial aggregates in > 93%% of the cases, whereas smears from Grade 1/2 lesions were found to contain cribriform aggregates in 94% of the cases. Pure subtypes were virtually nonexistent. Monolayer sheets were found in 49% of nonhigh-grade DCIS and in 16% of high-grade DCIS. Myoepithelial cells were demonstrated in 51% of the nonhigh-grade DCIS lesions and 27% of the Grade 3 lesions. Microcalcifications were found on the smears from 96% of nonhigh-grade lesions and 84% of high-grade lesions. Approximately 47% of high-grade DCIS and 31% of nonhigh-grade DCIS were found to harbor a distinct single cell population.

CONCLUSIONS

The findings on FNAC from DCIS of the breast completely mirror the histologic heterogeneity of growth pattern subtypes. Primary cytologic grading can effectively separate the high-grade lesions from the nonhigh-grade lesions.

Fine-needle aspiration cytology in nonpalpable mammographic abnormalities in breast cancer screening: results from the breast cancer screening programme in Oslo 1996-2001

Fine-needle aspiration cytology (FNAC) of nonpalpable mammographic lesions has been under attack from two sides for some years. There has been much discussion and controversy as to the ability to differentiate between in situ and invasive carcinomas in cytological material. A further issue is that of optimal sampling to obtain adequate cell material in sufficient quantity. We present the results of FNAC from 832 nonpalpable mammographic abnormalities detected in the course of the breast cancer screening programme in Oslo during 1996-2001. In 11.6% of cases the smears were inadequate, and there were 7% false negatives (FN) and 1.3% false positives. Of the FN, 64% represented microcalcifications and 86% were due to sampling errors. Absolute sensitivity was 74%, complete sensitivity 88% and specificity 88%. In 255 carcinomas a cytological diagnosis of them as in situ or invasive was made. In 93% of the invasive cases (190/205) these had been correctly identified as invasive on FNAC. In 78% of cases proper follow-up could be resolved by cytology/radiology alone. Suboptimal sampling and localization remains the main cause of FN FNAC results. Problems in differentiating between in situ and invasive breast carcinomas can be significantly reduced by applying strict criteria for in situ lesions.

Cytological criteria for the diagnosis of intraductal hyperplasia, ductal carcinoma in situ, and invasive carcinoma of the breast

The advent of mammography screening presents a diagnostic challenge to the cytopathologist as an increasing proportion of breast lesions requiring investigation will be nonpalpable and up to 40% will be accounted for by atypical intraductal hyperplasia and ductal carcinoma in situ, as opposed to previously, when these lesions represented less than 10% of palpable tumors. We studied 133 fine-needle aspirates from breast tumors and found that nuclear morphology, myoepithelial cells, signs of invasion, and degree of cellular dissociation are among the most potent factors discriminating between benign epithelial proliferations, atypical intraductal hyperplasia, ductal carcinoma in situ, and invasive carcinoma.

Cytoplasmic vacuolation, intracytoplasmic lumina, and DPAS staining in ductal carcinoma of the breast

A retrospective study was carried out on 30 cases of histologically proven invasive ductal carcinoma of the breast with a prior fine-needle aspiration (FNA) cytology. On evaluating the May-Grünwald-Giemsa (MGG) FNA smears, cytoplasmic vacuolation was observed in 70% cases. Positivity with periodic acid Schiff-positive, diastase-resistant (DPAS) staining was observed in 90% of cases. The chi(2) value on a McNemar test was 4.16. Thus, DPAS staining was significantly superior to MGG staining for picking up cytoplasmic vacuoles (P < 0.05). In 56.67% cases, DPAS staining showed an improvement in score as compared to MGG smears. This was highly significant (P < 0.001) on Wilcoxon matched-pairs signed-ranks test. Applying the strict criteria of thick-walled cytoplasmic vacuoles with a central darkly stained dot, none of our cases revealed true intracytoplasmic lumina. Larger studies are required to establish a role for DPAS staining in separating borderline, in situ, and invasive breast lesions, and to see if such positvity can be incorporated into the grading systems for breast carcinoma.