Management of breast papillary lesions diagnosed in ultrasound-guided vacuum-assisted and core needle biopsies.

AIMS: To assess the outcome of breast papillary lesions diagnosed by ultrasound-guided core needle biopsy (CB) or vacuum-assisted 'mammotome' biopsy (MT), the accuracy of these diagnoses, and whether it is justified not to undertake surgical excision of non-malignant papillary lesions so diagnosed. METHODS AND RESULTS: Among 3219 (MT, 2195; CB, 1024) breast biopsies spanning 5 years, 185 (5.7%) papillary lesions [MT, 162 (88%); CB, 23 (12%)] were identified. Of these, 142 cases (77%; MT/CB, 125/17) were benign, 24 (13%, 23/1) were atypical, and 19 (10%; 14/5) were malignant. Of the 142 benign cases, 114 had imaging follow-up (FU) (FU period 2-81 months); 17 of 114 cases were excised, and four were malignant (3.5%) (FU period 4-57 months). Of the 24 atypical cases (23 had FU), 19 were excised: six were benign (32%) and 13 malignant (68%). The remaining four cases were considered to be non-malignant (FU period 7-54 months). CONCLUSIONS: Benign papillary lesions diagnosed by MT or CB might not require immediate excision, but should receive imaging FU for at least 5 years. Excision should be performed in cases showing changes in imaging features, as the possibilities of carcinoma coexisting with papilloma or carcinoma developing from papilloma cannot be excluded, as illustrated by the 4% upgrade rate at excision in this study.

Evaluation of inadequate, indeterminate, false-negative and false-positive cases in cytological examination for breast cancer according to histological type.

BACKGROUND: We previously investigated the current status of breast cytology cancer screening at seven institutes in our area of southern Fukuoka Prefecture, and found some differences in diagnostic accuracy among the institutions. In the present study, we evaluated the cases involved and noted possible reasons for their original cytological classification as inadequate, indeterminate, false-negative and false-positive according to histological type. METHODS: We evaluated the histological findings in 5693 individuals who underwent cytological examination for breast cancer (including inadequate, indeterminate, false-negative and false-positive cases), to determine the most common histological types and/or features in these settings and the usefulness/limitations of cytological examination for the diagnosis of breast cancer. RESULTS: Among 1152 cytologically inadequate cases, histology revealed that 75/173 (43.6%) cases were benign, including mastopathy (fibrocystic disease) in 38.6%, fibroadenoma in 24.0% and papilloma in 5.3%. Ninety-five of 173 (54.9%) cases were histologically malignant, with scirrhous growing type, invasive ductal carcinoma (SIDC) being significantly more frequent (49.5%) than papillotubular growing type (Papi-tub) (P < 0.0001), solid-tubular growing type (P = 0.0001) and ductal carcinoma in situ (DCIS) (P = 0.0001). Among 458 indeterminate cases, 54/139 (38.8%) were histologically benign (mastopathy, 30.0%; fibroadenoma, 27.8%; papilloma, 26.0%) and 73/139 (52.5%) were malignant, with SIDC being the most frequent malignant tumor (37.0%). Among 52 false-negative cases, SIDC was significantly more frequent (42.3%) than DCIS (P = 0.0049) and Papi-tub (P = 0.001). There were three false-positive cases, with one each of fibroadenoma, epidermal cyst and papilloma. CONCLUSIONS: The inadequate, indeterminate, false-negative and false-positive cases showed similar histological types, notably SIDC for malignant tumors, and mastopathy, fibroadenoma and papilloma for benign cases. We need to pay particular attention to the collection and assessment of aspirates for these histological types of breast disease. In particular, several inadequate, indeterminate and false-negative cases with samples collected by aspiration were diagnosed as SIDC. These findings should encourage the use of needle biopsy rather than aspiration when this histological type is identified on imaging. Namely, good communication between clinicians and pathological staff, and triple assessment (i.e., clinical, pathological and radiological assessment), are important for accurate diagnosis of aspiration samples. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/7349809170055423.

Comparison of the accuracy of breast cytological diagnosis at seven institutions in southern Fukuoka Prefecture, Japan.

OBJECTIVE: Cytological examination is inexpensive and relatively simple to carry out and deserves utilization in breast cancer screening. We investigated the status of cytological diagnosis at seven facilities in southern Fukuoka Prefecture, Japan. METHODS: We collected data on the criteria for cytological judgments and status of breast cytological diagnosis at seven different facilities in this region. RESULTS: Among 5693 individuals who underwent breast cytological examination, analyses were conducted on 1250 individuals (22.0%) in whom cytological diagnoses were confirmed by histological diagnoses. Among these patients, cytological diagnosis had an absolute sensitivity of 71.9%, a specificity of 76.0%, a false-negative value of 6.7% and a false-positive value of 0.08%. At three facilities with relatively large numbers of cases (>300), excluding a facility for specialized breast disease, similar trends of high complete sensitivity (94.3, 95.6 and 97.1%, respectively) and low absolute sensitivity (60.4, 74.8 and 57.2%, respectively) were found. No false-negative or false-positive cases were seen in individual facilities with relatively low numbers of cases (<150). CONCLUSIONS: The accuracy of cytological diagnosis at the facilities we surveyed was relatively high compared with the goals of assessment of diagnostic accuracy. However, the performance was dependent on the facility type, i.e. number of cases, staff involved and whether it was specialized or not, making the diagnosis specific for this region. We recommend that management of the accuracy of cytological diagnosis be undertaken jointly by multiple facilities to establish systems in Japan that lead to more useful diagnostic tools.

Cytological features of myxomatous fibroadenoma of the breast.

Fibroadenoma (FA) is a benign tumor that must be differentiated from carcinomas. FAs often exhibit myxedematous changes (myxomatous FA, M-FA). We previously reported on the clinical significance of M-FA. M-FA and (mucinous) carcinoma share clinical findings, rapid growth and a relatively large size, a high-depth/width (D/W) ratio, a relatively round shape, and posterior echo enhancement with internal hyperechogenicity on ultrasonography (US). Next, a biopsy is required for differential diagnosis. In this study, we evaluated the diagnostic significance of the cytological findings of M-FA with US findings. Among 13 FAs that were diagnosed by cytology, we compared (i) a group of six mucinous carcinomas with acellular mucin and a D/W ratio ≥ 0.7 (a suspicious factor for malignancy) with a group with a D/W ratio of <0.7, and (ii) the frequency of metachromasia on Giemsa stain between M-FAs and non-M-FAs among eight FA cases confirmed by histology. (i) FA lesions (7 of 13) showed metachromasia with Giemsa staining significantly more frequently than did mucinous carcinoma (0/6) (Fisher's exact test, P < 0.044). FA lesions with a D/W ratio ≥ 0.7 (6/7) showed metachromasia significantly more frequently than did FA with a D/W ratio <0.7 (1/6) (Fisher's exact test, P < 0.029). Among eight FA cases confirmed by histology, M-FA cases (6/6) demonstrated metachromasia significantly more frequently than non-M-FA cases (0/2) (P < 0.036). M-FA cytologically exhibits marked metachromasia on Giemsa staining. Combining cytological examination and understanding the clinical features of M-FA may allow us to choose cytological examination as a first-line diagnostic method for tumor-forming lesions.

Myxomatous fibroadenoma of the breast: correlation with clinicopathologic and radiologic features.

Fibroadenoma is a frequently encountered benign tumor that must be differentiated from carcinoma. Fibroadenomas often exhibit myxedematous changes (myxomatous fibroadenoma). We focused on myxomatous fibroadenomas and evaluated their diagnostic imaging and clinicopathologic findings. We examined the (1) clinicopathologic findings of myxomatous fibroadenomas out of 113 fibroadenomas among 592 needle biopsy cases and (2) clinical findings of 27 patients with fibroadenoma who underwent surgical resection. One hundred thirteen (19%) of 592 cases were fibroadenoma, of which 45 cases (40%) were myxomatous fibroadenoma. Based on ultrasonography findings, the depth to width ratio was significantly higher in the myxomatous fibroadenoma group (0.79 ± 0.26) compared with the non-myxomatous fibroadenoma group (0.64 ± 0.26) (P < .01). Forty-two patients were subjected to needle biopsy to differentiate fibroadenoma from carcinomas based on ultrasonography and clinical findings, of which 13 cases (31%) were myxomatous fibroadenoma. These lesions showed a relatively round shape and increased posterior echo enhancement with internal hyperechogenicity on ultrasonography. Among 17 resected cases suspected of malignancy that showed rapid growth and/or size greater than 3 cm, 16 cases were myxomatous fibroadenoma. Tumors showing rapid growth and a relatively large size, a high depth to width ratio, a relatively round shape, and posterior echo enhancement with internal hyperechogenicity on ultrasonography require differentiation from (mucinous) carcinoma but are histologically more likely to be myxomatous fibroadenoma. Understanding the histologic features and combining the ultrasonography findings of myxomatous fibroadenomas may permit reduction in the number of unnecessary needle biopsies for tumor-forming lesions.

Clinicocytopathology of breast cancers with a ring-like appearance on ultrasonography and/or magnetic resonance imaging.

On breast cancer imaging some cancers have an anechoic or high-echoic zone in the tumor on ultrasonography and ring-shaped enhancement on contrast-enhanced magnetic resonance imaging (MRI) with high intensity in the central area of the tumor on T2-weighted imaging, necessitating their differentiation from benign disease. Thus, nine breast cancers with a ring-like appearance on imaging were analyzed on cytopathology. Histologically the cancer cells of these lesions showing a ring-like appearance were located in the periphery of the tumor, with a central hypocellular zone. Five such lesions with a thick, doughnut-like appearance were identified as cancers with acellular zones (CAC), and four lesions with a thinner, rim-like appearance as matrix-producing carcinomas (MPC). The percentage ratio of the cancer-zone width to the tumor diameter was 26.4 +/- 7.8 and 8.0 +/- 3.2 (mean +/- SD), respectively (P= 0.003). Cytologically, highly atypical, naked-nucleus cells were observed in eight of the nine cancers. In two MPC and three CAC, cartilage matrix and amorphous material, respectively, were observed in the background. In summary, the present series of breast cancers having a ring appearance on imaging did not have uniform cytopathological features. They were classified as MPC or CAC, and cytology was useful in their diagnosis and differentiation in some cases.