FNAC OF BREAST CANCER

DR SAURAV

NORMAL BREAST FNAC

• Usually yields scanty cellularity.

• Following cells can be seen in FNAC of a non-neoplastic breast

DUCTAL CELLS – Cells are small round with monomorphic nuclei. nuclear membrane is regular with homogeneous

chromatin.

MYOEPITHELIAL CELLS – These are elongated spindle-shaped naked cells. presence of such cells is hallmark of benign nature of lesion.

APOCRINE CELLS – These are large cells having abundant granular cytoplasm with central

to eccentric monomorphic round nuclei. These cells are usually present in fibrocystic disease or fibroadenoma.

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FOAM CELLS – These cells have abundant vacuolated cytoplasm

and centrally placed monomorphic round nucleus. phagocytosed material may be found in the

cytoplasm presence of foam cells usually indicates cystic

degeneration.

DUCTAL CARCINOMA

FNAC FINDINGSMore or less cell rich smearsSingle population of epithelial cells; no

myoepithelial cells, no single bare bipolar nucleiVariable loss of cell cohesion-irregular clusters and

single cellsSingle epithelial cells with intact cytoplasm

Moderate to severe nuclear atypia;enlargement,pleomorphism,irregular nuclear membrane and chromatin

Fibroblasts and fragments of collagen associated with atypical cells

Intracytoplasmic neolumina in some casesNecrosis unusual, more suggestive of DCIS.

Problems and differential diagnosis

Representative sampling Smearing artifacts Carcinoma with small cells Fibrosclerotic lesionsIn situ and low grade carcinomaNuclear atypia in other lesionsGynaecomastiaMetastatic carcinoma

Ductal carcinoma NOS,low grade

Ductal carcinoma NOS,intermediate grade

Invasive duct carcinoma NOS,high grade

LOBULAR CARCINOMA

Usual findingsA variable, often poor cell yield Cells single and in small clusters, single files

characteristicScanty cytoplasm; many naked nuclei; nuclear

moulding in cell clustersSmall hyperchromatic nuclei of relatively uniform

size.

Irregularity of nuclear shapeIntracytoplasmic lumina/mucin vacuoles/signet

ring cellsFew if any naked bipolar nucleiTraumatised cell pattern

Problems and differential diagnosis

Sparse cellularityResemblance to non-neoplastic breast tissue in

low powerComponent of benign epitheliumLobular hyperplasia in pregnancy and lactationDistinction from low-grade ductal carcinomaIntracytoplasmic lumina in other lesions

Lobular carcinoma (classic type)

Infiltrating lobular carcinoma,classic type

Lobular carcinoma,alveolar type

MEDULLARY CARCINOMA

– Abundant dissociated cells along with syncytial clusters of malignant cells

– Round to oval large cells with moderate nuclear pleomorphism

– Large prominent nucleoli– Lymphocytes and plasma cells

Problems and differential diagnosis

Metastatic malignancy to axillary nodesMalignant lymphomaHigh grade DCIS (comedocarcinoma)

Medullary carcinoma

MUCINOUS CARCINOMALarge amount of mucinous materialFloating malignant cells in the pool of mucinCells with abundant cytoplasm Mild to moderately pleomorphic nucleiBland nuclear chromatin“Chicken wire” blood vessels are often present in

smears of mucinous carcinoma

Problems and differential diagnosis

Lack of nuclear pleomorphismMucinous DCIS Mucinous fibroadenomaMyxoid stromal matrix resembling mucinMetastatic carcinomaHemorrhage and necrosis induced by FNBUltrasound gel

Colloid carcinoma

Colloid carcinoma

TUBULAR CARCINOMA• Usual findings: Moderately cellular smears Cells predominantly in cohesive clusters Epithelial fragments with an angular or tubular shape Relatively uniform, mildly to moderately atypical

epithelial cells Single bipolar nuclei of benign type often present in

small numbers Fibroblastic cells; fragments of fibromyxoid or elastotic

stroma.

Problems and differential diagnosisMinor deviation from the benign patternMixed tubular and usual ductal carcinomaComplex sclerosing lesion/radial scar,adenosisFibroadenoma

Tubular carcinoma

Tubular carcinoma

METAPLASIC CARCINOMA

– Predominant cell component is other than glandular or epithelial

– Population of spindle cells, multinucleated giant cells or squamous cells may be seen.

Scarff-Bloom-Richardson (SBR) Grade in Breast Cancer

– Histologic grading system for breast cancer– The cells and tissue structure of the breast cancer

are examined histopathologically to determine how aggressive the cancer is

– Correlates well with prognosis– Adopted by World Health Organization in 1968– Also referred to as Nottingham modification

Scarff-Bloom-Richardson (SBR) Grading

• Tubule Formation– Majority of tumor (>75%) – 1 point– Moderate degree (10-75%) – 2 points– Little or none (<10%) – 3 points

• Nuclear pleomorphism (compare to adjacent normal epithelium)– Small, regular uniform cells – 1 point– Moderately increased size and variability – 2 points– Marked variation – 3 points

• Mitotic Count (must adjust for microscope field)– Low – 1 point– Moderate – 2 points– High – 3 point

Scarff-Bloom-Richardson (SBR) Grade

TubuleFormation

Nuclear Pleomorphism

MitoticCount

Grade 1 Grade 2 Grade 3

Overall Grade is Sum of Scores

Grade 1 – well differentiated – 3 to 5 points

Grade 2 – moderately differentiated – 6 to 7 points

Grade 3 – poorly differentiated – 8 to 9 points