Critical clinicopathologic analysis of 23 cases of fine-needle breast sampling initially recorded as false-positive. The 44-year experience of the Institut Curie.

BACKGROUND: Because false-positive cytologic diagnoses in breast tumors are rare, few cases have been reported, although their consequences may be highly detrimental to the patient. The authors report the Institut Curie's experience, by using a multidisciplinary approach. METHODS: Of 9334 benign breast tumors examined preoperatively for cytologic diagnosis by fine-needle sampling (FNS), the 23 (0.25%) FNS cases considered to be false-positive were retrospectively reviewed and analyzed. RESULTS: Tumors were situated close to the nipple in 7 cases and away from the nipple in 16 cases. Tumor stage was T0 for 1 case, T1 for 18 cases, and T2 for 4 cases. Radiologically, six tumors were classified as malignant, seven as indeterminate or suspicious, and nine as benign. Three of six tumors studied by flow cytometry were DNA aneuploid. Based on a multidisciplinary clinicopathologic review, 20 FNS cases were finally classified as false-positive, and the remaining 3 tumors with malignant FNS and subsequent benign histology were classified as true-positive, because local and/or metastatic progression was observed in the short term. CONCLUSIONS: The authors' review suggests two categories of false-positive cases: the first in which cytologic benign patterns are overdiagnosed, and the second in which atypical morphologic criteria were present. Nevertheless, as shown by the malignant course in three cases, patients with malignant preoperative FNS and corresponding benign histology always require close clinical follow-up. Finally, surgical overtreatment rate could be decreased if all radiologically benign tumors with positive/suspicious FNS were subject to intraoperative frozen section examination.

Prognostic value of the S-phase fraction of breast cancers treated by primary radiotherapy or neoadjuvant chemotherapy.

Neoadjuvant chemotherapy for large operable breast cancers is being increasingly used for the purpose of "downstaging," so that the lesions become accessible to conservative treatment. Since tumor proliferative activity has been shown to be a major prognostic factor for breast cancers, we have studied the value of S-phase fractions established by flow cytometry on cytological samples at diagnosis, in 184 stage II or IIIa patients entered in a randomized trial comparing neoadjuvant to adjuvant chemotherapy. All patients were pre- or perimenopausal, and the median follow-up was for 43 months (24-64). Using the median value (5%) as cutoff, a high SPF was found to be associated with relapse (p < 0.0008), locoregional recurrence (p < 0.02), or metastasis (p < 0.003). However, when the patients were analyzed according to the type of treatment, significance was maintained for the patients in the primary radiotherapy arm (p < 0.003) but not for those in the neoadjuvant chemotherapy arm (p < 0.06). The overall rate of response to neoadjuvant chemotherapy was significantly lower for tumors with low SPF (56.5%), compared to tumors with high SPF (85.6%). Thus, SPF was no longer predictive of outcome when the tumors regressed by more than 50% after chemotherapy (p = 0.66), whereas it was highly predictive in the nonresponding patients (p < 0.0001). Our study has revealed that patients with low-SPF tumors, irrespective of response or treatment schedule, had similar prognosis (around 70% free of disease at 45 months), while the high-SPF nonresponders had a dismal prognosis, with less than 25% free of disease at 24 months. If our results are confirmed with a longer follow-up, proliferative activity of breast cancers should prove to be instrumental for the initial therapeutic decision of stage II or IIIa patients.

Leydig cell tumor of the testis: a case diagnosed by fine-needle sampling without aspiration with histologic, immunohistologic, and electron microscopic analysis.

Fine-needle sampling without aspiration was performed in a patient with a testicular mass. The cytologic diagnosis was consistent with Leydig cell tumor. Cytologic features included abundant grey-blue cytoplasms with spherical or oval nuclei in May-Grünwald-Giemsa-stained smears. Intranuclear inclusions were observed but no Reinke's crystals were detected. Histologic findings confirmed the diagnosis and tumor cells were positive for vimentin. Electron microscopic analysis of the tumor showed abundant smooth endoplasmic reticulum and mitochondria with tubulovesicular cristae but no Reinke's crystals.

Fine-needle cytology of 292 palpable orbital and eyelid tumors.

Fine-needle cytology (FNC) of 292 palpable orbital and eyelid tumors was performed with a 25-gauge (0.5-mm), 3-cm needle and compared with the histopathologic findings in 286 cases. Among these 286 cases, a concordant diagnosis of malignancy and type was achieved in 249 cases (87%). False positive diagnoses were made in four cases (1.6%) and false negative diagnoses in five cases (1.8%). No complications were encountered. These results led to the conclusion that FNC is an accurate tool in the diagnosis of orbital and eyelid tumors, especially when sampling and interpretation are performed by an experienced pathologist.

Correlation of pretreatment proliferative activity of breast cancer with the response to cytotoxic chemotherapy.

That most cytotoxic agents act specifically against actively proliferating cells is well-recognized. In this study, we attempted to correlate pretreatment S-phase fractions (SPF) measured on DNA histograms with regression of the tumor mass after the administration of neoadjuvant chemotherapy. Tumor cells were obtained from 60 previously untreated, premenopausal patients with no metastases and with noninflammatory disease by fine needle sampling without aspiration. We could evaluate DNA ploidy in all patients and SPF in 50 or 83% of them. Tumor responsiveness was significantly related to SPF. The 12 patients who had SPF of 10% or more showed demonstrable regression; six had complete responses. None of the other parameters tested, i.e., DNA ploidy, histopathologic grade, or hormone receptor content, correlated with response. We believe this information may prove valuable for clinicians as they make their decisions regarding patient therapy.

DNA flow cytometry applied to fine needle sampling of human breast cancer.

Breast cancer cells can be obtained directly from the patient with minimal trauma by fine needle sampling (FNS). A method was developed that enabled us to prepare tumor cell nuclei for ploidy determination by flow cytometry (FCM). Fine needle sampling was performed on 235 patients with clinically suspected malignancy. Two hundred sixteen specimens (92%) produced enough material for assessment; 206 were diagnosed as cytologically malignant. In 41 patients surgical specimens from the same tumors were available. Thirty-eight of these specimens (93%) were classified according to ploidy. No significant correlation was found between aneuploidy and clinical stage (size and lymph node involvement). The comparison of DNA histograms from 21 primary breast tumors and homolateral axillary lymph nodes showed mostly similar patterns. On the contrary, eight of nine synchronous bilateral cancers were shown to have different ploidy. Flow-cytometry-derived DNA histograms of fine needle samples could be a valuable tool in the management of breast cancer.

Estrogen and progestin receptor assay in fine needle aspirates of breast cancer: methodological aspects.

A methodology, originally built up in our laboratory, for the simultaneous determination of estrogen (ER) and progesterone (PR) receptors on small samples of tumor tissues, has been adapted to fine needle aspirates (FNA) of breast tumors. The method is based on a simultaneous incubation of aliquots of high-salt (0.4 M KCl) cytosols with tritiated estrogen and progestin tags. The mixture of receptor-bound ligands is isolated by dextran-coated charcoal and extracted by ethanol. The extracted ligands are separated quantitatively by HPLC and counted by liquid scintillation. FNA provides sufficient cellular material for ER and/or PR assay by single point (5 nM) dextran-coated charcoal (DCC) assay. FNA samples, being contaminated by blood, [3H] R 2858 and [3H] O 2058 are appropriate tags for ER and PR respectively, giving lowest non-specific binding. Sixty-five simultaneous estrogen and progestin receptor determinations on FNA at time of diagnosis were compared to the individual assays performed on the surgical sample obtained from the same patients a few weeks after diagnosis. The correlation between the 2 sets of determinations is excellent in 60 cases with sufficient FNA cellularity. This correlation validates the reliability of estrogen and progestin receptor determination on FNA in the majority of clinical cases.

Cytological diagnosis by fine needle sampling without aspiration.

The merits of a simplified cytological method of fine needle sampling without aspiration are compared to those of the classical fine needle aspiration techniques in a series of benign and malignant mammary tumors which were subsequently proved histologically. A comparable cellular yield was obtained by both techniques. In a series of 635 benign and malignant breast tumors examined in 1981 with fine needle alone, insufficient cellular yield was recorded in 5.5% of the lesion. The same incidence (6%) was recorded with aspiration techniques in 7877 benign and malignant mammary tumors examined from 1954 to 1980. With the new technique, trauma is reduced and a better perception of the tumor and of its consistency is directly obtained.

Enzyme immunoassay of estrogen receptors in fine needle aspirates of breast tumors.

Enzyme immunoassay of estrogen receptors (ER-EIA) was compared to radioligand assay (ER-RLA) in fine needle aspirates of breast tumors. Fine needle aspiration is a relatively atraumatic means of harvesting malignant cells from breast tumors. Fine needle aspiration provides a homogeneous suspension (about 90% malignant cells) with a sufficient amount of cellular material (10 to 50 micrograms DNA per sample) for single point radioligand assays of extractable estrogen (ER) and/or progesterone receptor (PR) in about 85% of primary adenocarcinomas at the time of diagnosis. Sixty-one different samples of malignant mammary cells were obtained by fine needle aspiration from 43 adenocarcinomas, 11 metastatic axillary nodes or 7 cutaneous nodules. Thirteen patients were under antiestrogen therapy (tamoxifen). ER-EIA was performed with Abbott's reagents, following the manufacturer's protocol. ER-RLA was a single saturation (5 nM) dextran-charcoal assay with [3H]R2858 as the labeled estrogen. The sensitivity of ER-EIA allowed dilution of the sample up to 10 times (according to sample cellularity and ER level) with less than 20% deviation from undiluted samples. Three levels of dilution of the samples (1/1, 1/2, and 1/10) allowed them to fall at least once into the range of the ER-EIA standard curve. Quantitative correlation between ER-EIA and ER-RLA was high (r = 0.86), and highest (r = 0.97) when samples from patients undergoing tamoxifen treatment were excluded. Major discrepancies between ER-EIA and ER-RLA appeared in those patients undergoing tamoxifen therapy; much higher values were obtained by ER-EIA. Eight of 13 of these patients were ER negative by ER-RLA but ER positive by ER-EIA. This preliminary observation indicates that in vivo ER modulation by hormones and antihormones should be reevaluated.

[Breast cancer. Development of the concentration of hormonal receptors under cytotoxic chemotherapy]. / Cancer du sein. Evolution de la concentration en récepteurs hormonaux sous chimiothérapie cytotoxique.

38 patients with locally advanced breast cancer, were treated with a program of cytotoxic chemotherapy including Adriamycin, Cyclophosphamide, 5 Fluoro-uracile and Prednisone. The concentration of hormonal receptors (Estrogen ER and Progesterone receptor PR) in the tumor were studied before starting the chemotherapy and after one to 9 courses of chemotherapy. This therapeutic response rate was not related to the initial level of ER and PR. After chemotherapy, we observed an increase of ER level in 14 cases out of 29 (59%), of PR level in 17 out of 32 cases (53%); A therapeutic response is observed in 11 cases out of 17 when the PR concentration is increased and in 3 cases out of 15 when the PR concentration was either stable or decreased. These observations let us to suppose a selective initial activity of chemotherapy on lesser differentiated tumor cells.

Cytologic diagnosis of orbital and periorbital palpable tumors using fine-needle sampling without aspiration.

Sixty-two cases of orbital and periorbital palpable neoplasms were analyzed cytologically. The material was obtained by our technique of simply introducing a fine injection needle in the tumor mass without aspiration. Fifty-six of these tumors had a subsequent histologic diagnosis by surgical procedure or biopsy. Forty-nine of the 56 cytologic diagnoses (87%) were concordant with the histologic findings with regard to malignancy and its variety. In three other cases the diagnosis of malignancy was only achieved by surgical procedure or biopsy (5%). In two cases, there were false-malignant results (4%), one corresponding to a meningioma and the other related to a reactive lymphoid hyperplasia. There was one false-benign (2%) result in a case of non-Hodgkin's lymphoma. In one patient, the cytologic material was insufficient for diagnosis (2%). In six other cases, the initial cytologic examination was ultimately confirmed either by biochemical studies or by biopsies of nodal metastases. No orbital hemorrhage was observed after fine-needle sampling. This outpatient technique is highly accurate and permits diagnosis in a few minutes.

Comparison between the nuclear diameters of primary and metastatic breast cancer cells obtained by cytologic aspiration.

In order to determine if there are morphologically identifiable characteristics between malignant cells obtained from a primary cancer and its metastasis the nuclear diameter was used as an indicator of the degree of malignancy, since there is good correlation between nuclear size, DNA content, and chromosome numbers. The nuclear diameter of primary and metastatic mammary carcinoma cells, obtained by cytologic aspirates, was measured by ocular micrometry. The purpose was to investigate whether a cell population at the primary site developed, at the metastatic sites, a population with the same nuclear size or one having larger and more anaplastic nuclei. One hundred eighty-five patients with infiltrating ductal carcinoma of the common variety were examined. The primary cancer and axillary nodal metastasis were examined in 97 patients before treatment. Thirty had cytologic examination of the breast cancer, as well as of the metastasis, which developed 1 to 14 years after treatment. Eleven were examined before radical breast irradiation and again at the time of relapse in the breast. Forty-seven had bilateral synchronous mammary carcinoma and both primary cancers were studied. The data presented indicate that there is extreme similarity between the nuclear diameters of the primary tumor and its metastasis. This similarity persists for several years regardless of both the location of the recurrence or radical irradiation. These results support the view that the majority of tumors are monoclonal in origin. The clone that invades the metastatic site appears to be the same as the one that initiated the primary cancer. In contrast, the nuclear diameters of cell populations obtained from synchronous bilateral breast cancer were dissimilar, indicating that they arose from separate clones of malignant cells.

[Metastatic breast cancer: a comparative study of the efficacy of tamoxifen and the sequential administration of tamoxifen and medroxyprogesterone acetate]. / Cancer du sein métastasé: étude comparée de l'efficacité du tamoxifène et d'une administration séquentielle de tamoxifène et d'acétate de médroxyprogestérone.

Seventy-nine patients with an histologically proven disseminated breast cancer, never treated before with additive hormonal therapy, entered into a randomized trial between june 1981 and december 1982. In the first group 44 patients were given continually a daily dose of tamoxifen (TAM) of 20 mg/m2. In the 2nd group 35 patients were given a daily dose of TAM of 20 mg/m2 for 15 days and then an oral daily dose of medroxyprogesterone acetate of 350 mg/m2 for the next 15 days. In both groups I and II, the treatment was stopped at the first manifestation of progression of the disease. The hormonal receptor status was determined in 30 patients of the group I and 23 patients of the group II. An objective response to treatment was observed in 48 per cent of the patients of the group I and 60 per cent of the group II. This difference is not significant (X2 = 1,05). However, the mean duration of therapeutic response is significantly higher in the group II (p = 0,01).

Release of estrogen-induced glycoprotein with a molecular weight of 52,000 by breast cancer cells in primary culture.

In an attempt to find estrogen-specific responses in breast cancer, we have established primary cell culture from metastatic pleural effusions of breast cancer and have analyzed the proteins labeled by [35S]methionine and released into the culture medium using sodium dodecyl sulfate-polyacrylamide gel electrophoresis. We show that the synthesis of a Mr 52,000 glycoprotein which is released by metastatic breast cancer cells in primary cultures is stimulated by estradiol in four of six patients. This protein is similar to the Mr 52,000 protein of MCF7 cells on the basis of its mobility in one- and two-dimensional gel electrophoresis [the molecular weight of this protein was originally found to be 46,000; it is closer to 52,000 using labeled proteins from New England Nuclear as molecular weight markers], its immunoprecipitation by antisera raised against the Mr 52,000 protein, and its binding to concanavalin A. We conclude that, similar to some breast cancer cell lines, some metastatic breast cancers synthesize a Mr 52,000 glycoprotein which is regulated by estrogens and exported from the cells into the medium. This study also shows that some primary cultures established from metastatic breast cancer remain responsive to estradiol in vitro for the synthesis of specific proteins. More clinical studies are needed to prove the interest of the Mr 52,000 secreted protein as an additional marker of the hormone responsiveness of breast cancer.

[Fine-needle aspiration biopsy and analysis of estrogen receptors in breast cancer]. / Ponction-aspiration à l'aiguille fine et dosage des récepteurs d'oestrogènes dans le cancer du sein.

Estrogen receptor concentration was measured in fine needle aspirates from 98 human mammary carcinomas. We performed a biochemical radiolabeled assay by the Charcoal-Dextran procedure on cytosols obtained after homogenization in a saline hypertonic buffer (0,4 M KCl) and centrifugation at 105,000 g. DNA content of the pellets was measured by fluorimetry. A sample of about 10(6) cells, containing at least 10 micrograms of DNA, was needed to obtain a reliable result. In this report, 74 samples were over 10 micrograms of DNA each. The analysis of these samples showed that, in 39 cases (52,8%), the estrogen receptor level was over the limit of 500 fmol/mg of DNA. In 5 cases (6,7%), the range was between 500 to 600 fmol/mg DNA and, in 30 cases (40,5%), it was under 500 fmol/mg DNA and was considered as negative. For 15 patients, estrogen receptors were determined on the same tumor, as removed by fine needle aspiration and by a surgical procedure (6 cases) or drill-biopsy (9 cases). There was a good correlation between the receptor content in needle aspirates and in tissue specimens for 13 cases out of 15.