Success in FNAC Service minded - availability Sampling by trained cytopathologist Quick staining to avoid insufficient material Application of ancilla

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2 Success in FNAC Service minded - availability Sampling by trained cytopathologist Quick staining to avoid insufficient material Application of ancillary technique Close contact with clinicians Triple diagnosis Multidisciplinary meetings pre-post operative and therapy conferences

3 Breast FNAC FNAC is a widely accepted technique in the diagnosis and management of palpable and non-palpable breast lesions due to its simplicity, accuracy and utility for avoidance more invasive procedures.

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6 Most countries adopted a triple assessment approach. FNAC is the first-line pathological investigation in both screening and symptomatic populations, with the exception of microcalcifications. Cytopathologists are best qualified to collect and interpret FNA samples.

7 The majority of European countries use similar reporting systems for breast FNA (C1-C5) in keeping with European Guidelines for QA in Breast Cancer Screening and Diagnosis, although some still prefer descriptive reporting only. The use of CNB has increased, although not always for evidence-based reasons. CNB and FNAC are not mutually exclusive. FNAC should be used in diagnosis of benign, symptomatic lesions and CNB in microcalcifications, suspicious FNAC findings and malignancies where radiology cannot guarantee stromal invasion.

8 Pre-operative diagnostic procedure The choice of sampling method in any centre should be determined by: the sensitivity and specificity of the technique in the centre. the diagnostic information required for malignant lesions. patient comfort and costs. the availability of staff skilled and experienced in using the procedures, particularly FNAC sampling and interpretation.

9 Breast FNAC How not to be washed away? Doing the technique with quality Coupled with image. Solving specific problems

10 Accuracy of FNAC The accuracy of FNAC depends on three main factors: a sample that is adequate and representative of the lesion. suitable processing and staining without artifact. accurate interpretation of the cytological material with a clear report conveyed to the rest of the clinical team.

11 FNAC Multistep technique Clinical examination Image-guided (US) Aspiration Slide preparation Fixation and staining Cytological interpretation

12 Breast FNAC It would be difficult to think of a contemporary medical procedure that is less HIGH TECH than Fine Needle Aspiration Cytology

13 Breast FNAC A successful marriage of low tech and high tech occurs when modern radiographic techniques are used to guide a needle to a non-palpable lesion

14 TRIPLE ASSESSMENT APPROACH Clinical Imaging BBB: 98% benign follow up MMM: 1% error surgery Other: biopsy Cytology

15 FNAC Clinic IPATIMUP Material 23Gx30mm 25Gx16mm 10 ml

16 FNAC Clinic IPATIMUP US-Guided Needle

17 Aspiration

18 Slide preparation Material obtained with a fine needle is expelled onto appropriately labelled glass slide. This is usually performed by using a 10-ml syringe filled with air, attaching the needle to do it and pushing the contents out of the needle.

19 Slide preparation Sometimes, if the hub of the needle is full, it is possible to tap the hub against the glass and obtain the material directly from there.

20 Smears: one step

21 Smears: two steps

22 Quality of the smear

23 CYTOLOGICAL INTERPRETATION

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25 BREAST FNAC: solving problems

26 CYTOLOGICAL CRITERIA OF BENIGN LESIONS BENIGN* Low to moderate cellularity Cohesive epithelial groups without or with mild nuclear overlapping and presence of myoepithelial cells Background: naked nuclei * Adequate sample without evidence of malignancy.

27 CYTOLOGICAL CRITERIA OF MALIGNANCY MALIGNANT* High cellularity Loss of cohesiveness Nuclear pleomorphism Dirty background Absence of naked nuclei * Adequate smear containing cells with unequivocal characteristics of malignancy.

28 BREAST FNAC: solving problems Current evidence indicates that the use of nonoperative diagnosis substantially reduces the number of unnecessary operations performed both for benign disease and for malignancy, with reduced discomfort and inconvenience to the patient. What is the role of breast FNAC in benign lesions, malignant lesions and gray zone lesions?

29 BREAST FNAC: solving problems Benign Lesions 35-year old female presented with a 25 mm well-defined nodule in the right breast. Mammography and US are compatible with fibroadenoma. There is no family history of breast cancer.

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31 BREAST FNAC: solving problems Benign Lesions FNAC is a useful and reliable tool in the evaluation and management of benign breast lesions, such as: Inflammatory conditions Cysts Fibroadenoma

32 CYTOLOGICAL INTERPRETATION Inflammatory diseases BENIGN SUBAREOLAR ABSCESS A high yield of inflammatory cells and multinucleated giant cells. Keratin and squamous metaplastic cells. The identification of giant cells with keratin at cytoplasm is an important clue for the diagnosis. Reactive epithelial cells.

33 CYTOLOGICAL INTERPRETATION Inflammatory diseases BENIGN FAT NECROSIS Moderate to high cellularity. Foam cells (always present), sometimes multinucleated. Collapsed fat cells. Inflammatory cells. Sometimes, presence of worrisome nuclei atypical

34 CYTOLOGICAL INTERPRETATION Inflammatory diseases BENIGN GRANULOMATOUS MASTITIS

35 CYTOLOGICAL INTERPRETATION BENIGN - CYSTS

36 RULES TO EVALUATE CYSTS After complete aspiration of the cyst, it is especially important to re-evaluate the area (US) to determine if a residual breast mass is present. If a residual mass is found, a second aspiration should be performed. Be careful with apocrine changes

37 CYTOLOGICAL INTERPRETATION Fibroadenoma It is the most common benign tumour of the breast. Solitary nodule (most), sometimes multifocal and/or bilateral. Usually are non-tender wellcircumscribed nodules. Biphasic proliferative lesion (epithelial and stromal elements) is similar to the structures of the terminal lobular-ductal unit (TLDU).

38 CYTOLOGICAL INTERPRETATION Fibroadenoma A high cell yield. The three characteristic components are: large branching, monolayered sheets of uniform epithelial cells; numerous single, bare bipolar nuclei (myoepithelial cells) fragments of fibromyxoid stroma.

39 CYTOLOGICAL INTERPRETATION Benign epithelial proliferative lesion Moderate to high cellularity. Cohesive epithelial groups without or with mild nuclear overlapping and presence of myoepithelial cells. Heterogeneous cell population: mild variation in the size and shape of the nuclei (oval, round or spindle). Bipolar naked nuclei in the background. Apocrine and foam cells.

40 BREAST FNAC: solving problems Malignant Lesions 33-year old female presented with a 15 mm ill-defined nodule in the right breast. Mammography and US are compatible with carcinoma.

41 Benign Granular cell tumour Imaging typically shows a dense mass with stellate margin, simulating malignancy. High cellular yield. Cells showing moderate atypia with intact, abundant and granular cytoplasm.

42 BREAST FNAC: solving problems Malignant Lesions Definitive surgery for carcinoma can be planned preoperatively using the triple approach or radiological imaging, clinical examination and FNAC (or CNB). This permits treatment for many malignant lesions in a one-stage operation.

43 CYTOLOGICAL INTERPRETATION Invasive ductal carcinoma Cellular smear Variable cell pattern, sometimes plasmocytoid appearance Nuclear pleomorphism Loss of cohesion

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45 Diagnostic Cytopathology, 2009

46 CYTOLOGICAL INTERPRETATION Invasive lobular carcinoma Variable cellularity (moderate to intense). In some cases very poor cell yield. Cells single and in small clusters, short single files common. Epithelial cells have small dark nuclei with scanty cytoplasm. The lack of pleomorphism can be cause of a falsenegative diagnosis. Intracytoplasmic lumina/vacuoles.

47 CYTOLOGICAL INTERPRETATION Invasive lobular carcinoma A most valuable clue on ILC is the tendency to form small chains of cells in the aspirates

48 CYTOLOGICAL INTERPRETATION Mucinous carcinoma Well defined and circumscribed tumour (similar to fibroadenoma). Abundant background mucinous, atypical cells in small solid aggregates, single files or isolated. The mucin stains violet to blue with MGG or pink on HE staining.

49 CYTOLOGICAL INTERPRETATION Tubular carcinoma Variable cellularity (moderate to intense). At low magnification a pattern somewhat similar to fibroadenoma. Cells arranged mostly in tubular structures with comma-like pattern. Epithelial cells are uniform and bland. The lack of pleomorphism can be cause of a false-negative diagnosis. Bare nuclei are present in rare cases.

50 CYTOLOGICAL INTERPRETATION Medullary carcinoma Well-circumscribed mass (similar to fibroadenoma) with fibro-elastic consistency. Highly cellular smears with irregular cell groups and single atypical cells. The neoplastic cells are large, pleomorphic with prominent nucleoli. Background rich in lymphocytes. Definitive diagnosis requires the demonstration of well defined borders. They are frequently associated with germinal mutation of BRCA-1.

51 CYTOLOGICAL INTERPRETATION Apocrine carcinoma Malignant cells have a large dense eosinophilic granular cytoplasm with large nuclei with prominent nucleoli. Neoplastic cells are isolated, sometimes without cytoplasm and in small aggregates. Necrosis is frequent.

52 CYTOLOGICAL INTERPRETATION Metaplastic carcinoma Is an invasive ductal carcinoma with metaplastic changes: squamous cells, spindle cells, osteoid or chondroid. Smears can show different cell types: ductal epithelial, spindle or squamous. Sometimes we can observe multinucleated giant cells and myxoid material. Can be cystic at aspiration and with necrotic material.

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54 P63 expression in sarcomatoid/metaplastic carcinomas of the breast Reis Filho JS & Schmitt FC. Histopathology 42: 92-99, 2003

55 CYTOLOGICAL INTERPRETATION Invasive micropapillary carcinoma Highly cellular smears composed by angulated small groups of cohesive cells with papillary configurations without fibro vascular cores. Cells showing nuclear atypical, irregular nuclear contours and prominent nucleoli. Cytoplasm vacuoles are rarely seen. Background is clean with rare isolated neoplastic cells.

56 CYTOLOGICAL INTERPRETATION Breast carcinoma with osteoclast-like giant cells Cellular smears composed by cohesive groups of epithelial cells, with low grade of atypia. Groups of plump spindle cells as well as isolated atypical epithelial cells. Presence of osteoclast-like multinucleated cells at periphery of the epithelial cells or in the background of the smears.

57 CYTOLOGICAL INTERPRETATION Adenoid cystic carcinoma Highly cellular Pattern of large tissue fragments, consisting of sheets of cells with poorly defined cytoplasm with minimal cytological atypia and myoepithelial cells, or crowded atypical cells without biphasic appearance and moderate nuclear atypia Background may have dispersed bare nuclei and/or dispersed intact atypical cells Hyaline spherules, varying from mucinous to collagenous Invagination of collagenous material into invasive epithelial sheets Scattered true lumens within epithelial proliferation

58 CYTOLOGICAL INTERPRETATION Breast carcinoma with signet-ring cells

59 CYTOLOGICAL INTERPRETATION Other special subtypes of breast carcinoma SECRETORY CARCINOMA ACINIC CELL CARCINOMA

60 CYTOLOGICAL INTERPRETATION Metastatic malignancy METASTATIC MELANOMA

61 CYTOLOGICAL INTERPRETATION Other malignancy NON-HODGKIN LYMPHOMA

62 CYTOLOGICAL INTERPRETATION Inflammatory diseases BENIGN INTRAMAMMARY LYMPH NODE

63 BREAST FNAC: solving problems Gray zone Conditions in which there is a risk of making a false-positive diagnosis Papillary lesions Atypical hyperplasia Complex sclerosing lesion Fibroadenoma Regenerative epithelial atypia Pregnancy and lactation Skin adnexal tumours Specific cytological problems Tubular and lobular carcinoma Low grade DCIS vs benign lesions High grade DCIS vs invasive ca Conditions in which there is a risk of a false-negative diagnosis Tumours with necrosis /fibrosis Small carcinomas associated with benign lesions Complex proliferative lesions with foci of carcinoma Low grade in situ or invasive carcinoma Lobular carcinoma

64 CYTOLOGICAL INTERPRETATION Papillary Lesions Cellular smears. Papillary three-dimensional arrangements. Complex folded and branching sheets of epithelial cells. Columnar cells in rows, palisades and single. Variable nuclear atypical Epithelial cells with cytoplasm vacuoles Others: macrophages, apocrine metaphase, bare oval nuclei.

65 CYTOLOGICAL INTERPRETATION Papillary carcinoma Is it possible to distinguish benign and malignant Papillary breast tumours on FNA? Cytological findings favouring malignant Higher cellularity Papillary three-dimensional arrangements without a central fibro vascular core (cell balls) Tall columnar cells are frequent. Isolated cells with cytoplasm. Absence of bare nuclei, apocrine metaplasia and rare macrophages.

66 PAPILLARY LESIONS: CNB helps?

67 European guidelines on breast cancer screening

68 CYTOLOGICAL INTERPRETATION Epithelial proliferative lesions Moderate to high cellularity. Epithelial cell groups with nuclear overlapping and without or with few myoepithelial cells. Bipolar naked nuclei in the background absent or in few numbers. Less cell cohesively in the borders of the cell groups with occasional isolated epithelial cells with preserved cytoplasm. 20% are malignant at biopsy

69 DCIS CCL RADIAL SCAR LOW GRADE INVASIVE CA

70 CYTOLOGICAL INTERPRETATION Fibroepithelial lesions PHYLLODES TUMOUR Biphasic proliferative lesion (epithelial and stromal elements) similar to fibroadenoma but with predominance of the stroma over the epithelium Fibromyxoid stromal fragments are larger than those seen in fibroadenomas and are highly cellular with fibroblastic spindle cells. The presence of isolated stromal cells with spindle nuclei and abundant pale cytoplasm is suggestive of PT.

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72 CYTOLOGICAL INTERPRETATION Fibroepithelial lesions Fibroadenoma Myxoid changes Atypia

73 Breast FNAC How not to be washed away? QUALITY QUALITY QUALITY

74 Accredited Laboratory of CAP in Pathology Certified Laboratory by ISO

75 NHSBSP, 2011

76 Technical factors False-positives Bad quality of smears Fixation artefacts False-negatives Operator dependent Characteristics of the lesion: Size of the lesion Size of the breast Location Histological type

77 Scanty material Inadequate smearing Artifacts of fixation Thick smear

78 BREAST FNAC X CNB

79 Core-needle biopsy Advantages More specific diagnosis of benign lesions Avoid the problem of atypias Allow to distinguish carcinoma in situ from invasive Diminish the inadequate rate Allow study of prognostic and predictive factors Needs less diagnostic expertise

80 Core-needle biopsy Advantages More specific diagnosis of benign lesions Avoid the problem of atypias Allow to distinguish carcinoma in situ from invasive Diminish the inadequate rate Allow study of prognostic and predictive factors Needs less diagnostic expertise

81 ATYPIA ON FNA 8.0 a 9.5% 60% are malignant ATYPIA ON CNB 3.6 a 9.0% 56% are malignant Connoly et al., USCAP 2002

82 Core-needle biopsy Advantages More specific diagnosis of benign lesions Avoid the problem of atypias Allow to distinguish carcinoma in situ from invasive Diminish the inadequate rate Allow study of prognostic and predictive factors Needs less diagnostic expertise

83 Core-needle biopsy Do not exclude invasion with only DCIS is present Until 30% of DCIS cases have invasion on the surgical specimen. Predicts invasion in 92% of the cases Connoly et al., USCAP 2002

84 Core-needle biopsy Advantages More specific diagnosis of benign lesions Avoid the problem of atypias Allow to distinguish carcinoma in situ from invasive Diminish the inadequate rate Allow study of prognostic and predictive factors Needs less diagnostic expertise

85 RATES OF UNSATISFACTORY MATERIAL ON FNA Type of lesion (microcalcification) Histological type (> benign lesion) Cytopathologist Type of system used to guide the needle. Variable on literature: 3 a 80%(!) Acceptable until 25%in non-palpable lesions

86 Core-needle biopsy Advantages More specific diagnosis of benign lesions Avoid the problem of atypias Allow to distinguish carcinoma in situ from invasive Diminish the inadequate rate Allow study of prognostic and predictive factors Needs less diagnostic expertise

87 ER/PR ASSESSMENT IN BREAST FNAs

88 Who should performs? The success of FNAC is directly related with the ability and experience of the aspirator. There is strong evidence that the procedure is better when performed by a well-trained staff.

89 Core-needle biopsy Disadvantages Sampling error (loss malignancy in complex benign lesions) Can not give immediate diagnosis. More expensive and traumatic than FNA Also have problematic lesions : papillary. mucinous, etc Dissemination of malignant cells?

90 Breast FNAC How not to be washed away? Aspiration should be direct to a define target. FNAC is a multi-step procedure and to obtain a good material is essential for the diagnosis. The cytological diagnosis should be done only with the knowledge of the clinical context and preferential in a multidisciplinary environment. Negative results can not solve the patient problem.

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93 FOUNDED IN BRUSSELS, Belgium 1957 AS SUPRANATIONAL ORGANIZATION: To encourage cooperation; To foster international exchange; To stimulate development; To encourage research.

94 The official journal of the International Academy of Cytology Editor-in-Chief Marluce Bibbo, Philadelphia Associate Editors R. Marshall Austin, Pittsburgh Thomas A. Bonfiglio, Rochester Lukas Bubendorf, Basel Yener S. Erozan, Baltimore David B. Kaminsky, Palm Springs Harubumi Kato, Tokyo Leopold G. Koss, New York, N.Y. Gladwyn Leiman, Burlington, Vt. Shahla Masood, Jacksonville, Fla. Robert Y. Osamura, Tokyo Ibrahim Ramzy, Irvine, Calif. Fernando C. Schmitt, Porto Volker Schneider, Freiburg Mark E. Sherman, Rockville Diane Solomon, Rockville Alain P. Verhest, Brussels Philippe Vielh, Villejuif

95 INTERNATIONAL CONGRESS OF CYTOLOGY SINCE 1961: Paris, May 26 30,2013

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98 INTERNATIONAL BOARD OF CYTOPATHOLOGY SINCE 1974: Comprehensive, one-day examination for medical members of the Academy to document proficiency in cytopathology

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