Ackerman breast carcinoma diagnosis

Clinical Examination 

• extremely useful and  practical technique, 

• carried out by the physician or by the  patient herself.

•  However, both its 👎sensitivity and discriminatory power are limited. 

• majority of breast cancers are detected through imaging studies,

 

• with only 10% of the tumors being detected solely  by palpation.

• The clinical impression is incorrect in approximately 15% of the cases thought to be benign and approximately 10% of  those thought to be malignant. 

 

• clinical evaluation of axillary lymph nodes is also fraught with error; determination of lymph  node status requires microscopic examination.

 

Mammography 

use of screening mammography has led to an increase  in the detection of breast cancers at an earlier stage and of smaller  size, 

primarily based on the presence of 

1. microcalcifications, 

2. nonpalpable masses, or 

3. architectural distortion.

The incidence of  calcification

•  in breast carcinoma is 50%–60%, and  the 

•  in benign breast disease is 20%.

qualitative differences in the appearance of the microcalcifications, 

 frequently predictive of malignant disease histology

pleomorphic or heterogeneous calcifications that  are 

1. fine, 

2. linear, 

3. branching, or 

4. casting (conforming to the pattern of  a duct)

 In a study of 2545 women enrolled in a breast screening  program found to have microcalcifications alone on imaging, 47.9%  were subsequently shown to be associated with malignancy (31.8%  DCIS and 16.1% invasive carcinoma, mostly with associated DCIS)  and 52.1% of cases were associated with nonmalignant lesions.315  

In the United States, mammographic findings are universally reported  using the Breast Imaging Reporting and Data System (BI-RADS),  

Breast imaging studies are assigned one of seven assessment categories:

BI-RADS 0:	incomplete	need additional imaging evaluation (additional mammographic views or ultrasound) and/or for mammography, obtaining previous images not available at the time of reading
BI-RADS 1	negative	symmetrical and ❌🚫no masses, architectural distortion, or suspicious calcifications
BI-RADS 2	benign	0% probability of malignancy
BI-RADS 3	probably benign	<2% probability of malignancy short interval follow-up suggested
BI-RADS 4	suspicious for malignancy	2-94% probability of malignancy for mammography and ultrasound, these can be further divided: BI-RADS 4A: low suspicion for malignancy (2-9%) BI-RADS 4B: moderate suspicion for malignancy (10-49%) BI-RADS 4C: high suspicion for malignancy (50-94%) biopsy should be considered
BI-RADS 5	highly suggestive of malignancy	>95% probability of malignancy appropriate action should be taken
BI-RADS 6	known biopsy-proven malignancy

The majority of core biopsy samples will be from patients with  BI-RADS category 4 lesions.

• negative mammogram does not rule out carcinoma, since  

• approximately 15% of palpable tumors are not detectable with this technique.

Ultrasound  may be the better modality for palpable  masses. 

• Mammographically detected nonpalpable lesions usually require preoperative wire localization, if excision is necessary, to guide the surgeon to the suspicious area within the  breast. 

• Today, most patients have undergone a core needle biopsy  procedure prior to excision with placement of a radio-opaque  clip, and it is this clip, along with tissue landmarks, that is used to guide wire-localization by the radiologist. 

Tagging the specimen 

In excised specimen the margins should be marked by the surgeon  with sutures (typically superior and lateral margins, short and long  sutures, respectively by convention) and an

 

x-ray study of the specimen performed to confirm removal of the target area and biopsy  clip. 

If❌🚫 no lesion/calcification or clip is seen, the surgeon should  obtain additional tissue, if feasible. 

 the specimen should be inked with six different colored inks according to the orientation given by the surgeon and  the 

specimen sliced and processed in the pathology laboratory. 

As  mentioned above, the vast majority of patients have undergone a  core needle biopsy procedure prior to definitive surgery; therefore  the pathologic diagnosis from that earlier procedure can be used to  guide tissue processing.  

The highest yield is obtained from histologic examination of the areas with radiographic calcification and fibrous parenchyma.318 

paraffin block X-ray studies can be taken to document the fact that the microcalcifications seen in the mammogram have  been embedded (Fig. 36.69).

 An important source of discrepancy  between mammographic targeting of calcifications and microscopic  findings are calcium oxalate crystals, which can be easily identified  radiographically but may be missed on histologic examination.319  Every attempt should be made to identify, in the microscopic sections,  the imaging target regarded by the radiologist as “suspicious” for  carcinoma. 

Breast ultrasonography 

benignity	malignant diagnosis
circumscribed and  “wider than tall,”	hypoechoic with irregular  borders  “taller than wide” and has posterior shadowing
whether a mass lesion is cystic or solid,

 MRI

 is unlikely to replace mammography as the imaging modality  of choice, although contrast-enhanced techniques have rendered it more informative and potentially more useful. 

• It is more sensitive  but has

•  lower specificity, resulting in greater numbers of false-positive  call backs and unnecessary biopsies. 

• use MRI in patients at high risk (>20% lifetime risk) for the development of breast cancer.

 

Where adopted for screening purposes, the National Cancer  Institute has traditionally recommended 

• mammography be done on an annual basis from the age of 40 years onwards. 

• revised recommendations from  the US Preventive Services Task Force, which calls for mammograms  to be done biennially from the ages of 50 to 74, with the decision  to begin screening at 40 years being an individual one depending on a woman’s risk factors

Cytology 

The two methods to obtain cytologic material from breast lesions are 

1. collection of nipple discharge (often directly  onto a glass slide) and 

2. Fn aspiration of a palpable lesion 

Nipple secretion cytology is of limited use, 

•  carcinomas may be  found

•  often bloody, degenerated specimens, rendering  this technique of only marginal value.

 The situation with FNA is  different, as shown in the pioneer attempts at Memorial Sloan  Kettering Cancer Center in the 1930s. In experienced hands the  technique is highly reliable (Fig. 36.70).323,324 The average sensitivity  is approximately 87%, the specificity close to 100%, the predictive  value of a positive diagnosis nearly 100%, and the predictive value  of a negative diagnosis between 60% and 90%.323,325

 

Fna 

1. Most benign lesions misinterpreted as malignant are usually 

• fibroadenomas or intraductal papillomas with marked epithelial  proliferation.

2. ❌🚫 not possible to distinguish between in situ and invasive carcinoma  on FNA cytology,

 for these reasons core needle biopsy has largely  superseded FNA cytology as the diagnostic procedure of choice in  the United States. 

 

3.There remains a role in the evaluation of clinically positive axillary lymph nodes, particularly in the neoadjuvant setting to document lymph node metastasis prior to initiation of  chemotherapy. 

Core Needle Biopsy 

core needle biopsy (image-guided and with or without vacuum assistance) has become the gold standard for the diagnosis of image-detected nonpalpable and palpable breast lesions. 

• Allows for evaluation of both cytologic and architectural features, 

•  thereby permitting definitive diagnosis of invasive carcinoma when present. a benign lesion, such as fibroadenoma, can be  readily recognized, and 

• core needle biopsy allows for easier sampling and 

• identification of microcalcifications.

• core biopsy specimens should  be x-rayed and the 

• cores with calcifications submitted separately  from those without, in the event additional levels are needed

• it reduces the number of inadequate samples and does not require cytopathology expertise.

In order to obtain maximum information from the  procedure, the pathologist should be provided with a complete clinical  history, including radiographic signs and the site of the biopsies.  In cases with microcalcifications, the.328  The use of site-marking devices at the time of the core biopsy is  helpful for the radiologist, to guide placement of a localization  wire should an excision be required, and in determining whether  the subsequent surgical specimen includes the radiographically abnormal area

American Society of Clinical Oncology (ASCO)/ College of  American Pathologists (CAP) guidelines, 

1. breast specimens  should be fixed for a 

2. minimum of 6 hours and a 

3. maximum of  72 hours to permit accurate biomarker testing, should that be  required

4. minimum of three levels should be obtained initially on all core needle biopsy specimens, 

5. with additional levels and  immunostains performed when necessary.

 

definitive diagnosis  on the basis of a core biopsy and triage for patient management  is possible in the majority of cases.331 However, there are some  diagnoses that are not malignant that have warranted surgical excision because of the frequency with which a worse lesion has been  found upon excision of the area of concern (i.e., the “upgrade”  or “underestimation” rate). Unfortunately, many of these recommendations for excision were based on data from small studies,  often with radiologic-pathologic discordance and selection bias  with regard to which patients underwent excision. Newer studies  have taken care to address the imaging findings, ensure radiologicpathologic correlation, and provide data on upgrade rates for  incidental cases of atypia.

 standard management  algorithm: 

DCIS or invasive carcinoma	undergo excision
ADH or atypical ductal proliferations with features bordering on DCIS	undergo excision
management of LCIS and ALH is evolving	past, most authors recommended surgical excision lobular neoplasia is determined to be incidental to the  targeted lesion, are recommending observation over excision (if  targeted lesion is benign and does not itself require excision),   exception of cases of nonclassical or pleomorphic  LCIS
Columnar cell lesions without atypia	do not require excision.
FEA identified on core needle	excision in patients  in whom there are  residual calcifications on a post-biopsy mammogram or for  whom there is radiologic-pathologic  discordance
papillary  carcinoma or papilloma with atypia	warrants excisional biopsy
papilloma	clinical  follow-up if imaging findings are concordant many centers  still excise radiologically targeted papillomas
stromal pools of mucin associated with mucocele	surgical excision because  of the concern for undersampled mucinous carcinoma

Complications of the core needle biopsy  

1. hemorrhage,

2. reactive spindle cell nodules, and 

3. epidermal inclusion cysts.

4. procedural artifact and not  to mistake for invasive carcinoma : mechanical displacement of epithelial cells into the stroma or even inside vessel lumina (also seen in connection with the  FNA) (see Fig. 36.54).

• more common with both benign and malignant papillary lesions, due to greater friability.

• displaced epithelial cells may appear as small nests or single cells with atypical, “squamoid,” or degenerated features. 

Identification of biopsy site changes such as 

granulation tissue and 

hemosiderin-laden  macrophages will help prevent an erroneous diagnosis. 

Note that  myoepithelial cells are often absent, as such IHC is not helpful.

 

Frozen Section 

• Intraoperative by frozen section has limited applicability  in current practice. 

• Some centers perform intraoperative evaluation  of the specimen margins with a view to immediate re excision of  involved margins. 

•  technically challenging to freeze because they are often composed entirely of adipose tissue and they can be challenging to interpret, resulting in well-documented  false-positive and false-negative rates.

 

intraoperative frozen section evaluation  of sentinel lymph nodes. The need for this is largely obsolete343  given the results of the American College of Surgeons Oncology  Group (ACSOG) Z0011 randomized clinical trial demonstrating an  absence of clinical benefit for completion axillary dissection even  in patients with 1–3 positive sentinel lymph nodes.

 for frozen section in the setting of mastectomy,  where completion dissection may be performed if the sentinel lymph  node is positive