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A presentation about breast health, diagnosis of breast disease and risk factors associated with breast cancer in the United States.
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It’s not always cancer: Biopsies, Breast Health and
PreventionTeresa Alasio, MD
Director, Cytodiagnostic CenterCairo Diagnostics, LLC
www.cairodiagnostics.com
MD from Mount Sinai Internship in General Surgery Residency in Anatomic Pathology Fellowship in Cytopathology Past:
Director of Cytology, SUNY Downstate Cytopathologist, Private Laboratory
Current: Director, Cytology and Cytodiagnostic Center, Cairo Diagnostics
About Me
Cytodiagnostic Center Ultrasound guided Fine Needle Aspiration
biopsies Head and neck, thyroid, breast
Immediate assessment Preliminary results to patient Final report within 24 hours
Current Practice
Screening Mammogram Ultrasound Breast Self Exam (BSE)
Testing Biopsies
Fine Needle Aspiration Core biopsy
What else could it be? Risk Factors
What we will talk about
Mammogram (film mammography) USPSTF recommends screening women starting at age 50
every 2 years Routine mammogram in women 40-49 not recommended
Controversial Insufficient evidence to recommend screening mammogram
in women >75 years and older
Ultrasound Recommended as additional test for women who have dense
breast tissue Not a primary screening tool
Breast Cancer Screening
Multidisciplinary Breast Cancer Symposium, 2011 Records of >5000 women diagnosed with early
stage breast cancer Cancers found on screening mammography were:
More likely to be lower stage (0 or 1) than higher stage (2 or 3)
41% less likely to be treated with mastectomy (compared to lumpectomy)
31% less likely to require chemotherapy (and generally required less aggressive treatment overall)
Mammogram
Clinical Breast Examination (CBE) Helps detect a significant portion of breast cancers if the only
test available May produce false positive results, increasing patient anxiety
and unnecessary biopsies Breast Self Examination (BSE)
Controversial 2008 study May do more harm than good 20% of breast cancers detected on BSE
Does not reduce breast cancer mortality Should be used in conjunction with mammography and CBE
Recommendation from Breastcancer.org
Breast Exam – Clinical and BSE
Breast Self Exam
1. 2, 3.
Breast Self Exam
4. 5.
Ultrasound Guided Fine Needle Aspiration Biopsy (USFNA)
Core Needle Biopsy (CNB)
Testing
Increasing use of core needle biopsy (CNB) for breast lesions has led to diminished use of FNA in recent years
BUT….there is still a place for FNA in the evaluation of both palpable and mammographically identified breast abnormalities
The Case for Breast Cytology
Cost Minimally invasive procedure Spares patient open biopsy, especially if benign Complications are rare
Bleeding Infarction
Adequacy Are you in the lesion?
Triage Markers, lymph node assessment
Rapid diagnosis allows for pre-operative/pre-treatment discussion of therapeutic options
Advantages of Breast FNA
Nipple discharge cytology Benign vs. malignant nipple secretions Patient usually does not have a palpable or
mammographic abnormality FNA
Some limitations Accuracy of FNA is highly operator dependent IDC vs. invasive carcinoma Papilloma vs. papillary carcinoma (“papillary lesion”)
Specimen Types
If it’s not cancer,what else could it be?
15-25 lactiferous ducts Begin at nipple, branch and then end in
terminal duct lobular unit (TDLU) Lobule
Terminal duct and many small ductules (acini)
All ducts are lined by a double layer of cells Epithelial and myoepithelial cells
Normal Breast
Fibrocystic changes Non-proliferative Proliferative
Fibroadenoma Pregnancy and lactational changes Fat necrosis Radiation change Mastitis Subareolar abscess Gynecomastia
Benign Conditions of Breast
Most common Cysts of varying size Apocrine metaplasia Fibrosis Adenosis
Fibrocystic Changes
Significant intraductal hyperplasia is not present
Lesion is predominantly fibrous Apocrine cells Foam cells Small ductal cells
Non-proliferative FCC
Non-proliferative FCC
Variable in severity and degree of atypia Moderate and florid ductal hyperplasia, ADH,
ALH Histologic criteria, not cytologic
Crowding and nuclear atypia give clues to cytologic diagnosis of ductal proliferative lesions
Proliferative FCC
Proliferative FCC
Without atypiaSheets and tight
clusters of cells without significant overlapRegular cellular
spacingFinely granular
chromatin patternInconspicuous to
small nucleoli
With atypiaSheets and tight
clusters of cells with significant nuclear overlapRegular to irregular
cellular spacingFinely to coarsely
granular chromatinProminent to multiple
nucleoli
Proliferative FCC
Without atypia With atypia
Most common benign tumor of female breast Seen in women of any age Circumscribed, freely movable, rubbery
masses that result from both stromal and glandular proliferation
Fibroadenoma
Fibroadenoma
Pregnancy Associated Changes
Uniform cells Granular vacuolated cytoplasm Prominent nucleoli Proteinaceous background
Lactating Adenoma
Cytoplasm easily strips away
Foamy proteinaceous backgroundMany naked nuclei
Occasional small ductal cell clusters and portions of lobules
Do not confuse with invasive lobular carcinoma which can look similar (also NHL can look similar!)
Galactocele
Abundant foamy macrophages Benign epithelial cells
Can mimic carcinoma both clinically and mammographically
History very important Many patients have had previous surgery or
trauma to the breast
Fat Necrosis
Fat Necrosis
Increasing frequency due to widespread use of lumpectomy and radiation to treat patients with breast cancer
Often seen in conjunction with fat necrosis
Radiation Change
Radiation Change
Hypocellular aspirate Nuclear and cellular
enlargement Low N/C ratio Hyperchromatic nuclei
with round, regular outline and prominent nucleoli
Coarse cytoplasmic vacuoles, some containing inflammatory cells
Binucleation and multinucleation
Acute mastitis = bacterial infection Lactating women
Chronic mastitis can be a sequel to acute mastitis or associated with duct ectasia Dilatation of large and intermediate-size ducts with
surrounding inflammatory infiltrate of lymphocytes and plasma cells with or without a mass
Granulomatous mastitis Infectious (tb or fungal) Presents as a firm mass
Mastitis
Mastitis – Cytomorphology
Acute mastitisAbundant
neutrophilsOccasional groups
of reactive ductal cells with enlarged nuclei and prominent nuceloli
Chronic Mastitis
Abundant, amorphous, granular debris from inspissated ducts
Inflammatory infiltrate composed of lymphocytes and plasma cells
Granulomatous Mastitis
Clustered epithelioid histiocytes
Abundant vacuolated cytoplasm
Round or folded nuclei Dispersed chromatin
texture Large nucleoli Giant cells,
lymphocytes, plasma cells and eosinophils
Rare clusters of benign ductal cells
“recurring subareolar abscess” Inflammatory condition Arises in the areola
squamous metaplasia of lactiferous ducts subsequent keratin plugging and rupture of the
ducts Can recur and form sinus tracts
Subareolar Abscess
Subareolar Abscess
Numerous anucleate squames admixed with neutrophilsHistiocytes and MNGsOccasional groups of atypical reactive ductal cellsFragments of granulation tissue
Gynecomastia
Resembles fibroadenoma
Low, moderate or high cellularity
Groups of ductal cells with small oval nuclei, scant cytoplasm and little variation in size and shape
Isolated bipolar cells Naked nuclei
Intraductal papillomas (IDP) usually solitary Arise in subareolar lactiferous ducts
Bloody nipple discharge Can present with subareolar mass requiring
FNA
Papillary Neoplasms
1-2% of breast carcinomas Predominant growth pattern is frond-like Invasive or non-invasive Cystic or solid Favorable prognosis
Papillary Carcinoma
Impossible to establish by FNA Call it a “papillary lesion” and leave it Recommend excisional biopsy
Papilloma vs. Papillary Carcinoma
Papillary Neoplasms
Papillary lesion on cytologyPapilloma on excision
Papillary Neoplasm
Papillary lesion on cytologyDCIS, papillary type on excision
Breast Cancer Risks
Non-modifiable Female Age Family History Genetics Personal history Menstrual history Radiation Race Dense breasts
Modifiable Obesity Pregnancy Breastfeeding Alcohol use HRT Lack of Exercise Smoking
Breast Cancer Risks Cont’d
Emerging Risks Lack of Vitamin D Light Exposure at Night DES exposure Processed food Methods of cooking
Hetrocyclic Amines (HCA) Grilling
Polycyclic Aromatic Hydrocarbons (PAH) Smoking foods
Chemical Exposure Cosmetics Food Water Sunscreen Plastic