Some common lesion leading to false positive diagnosis in FNA of breast are listed with Keys to differentiate them.
Artifactual Atypia
Most common of these is disruption of cell aggregates by too vigorous smearing, which can mimic the loss of cohesion characteristic of malignant epithelial cells .
Excessive smearing pressure can also cause smudging of nuclei, giving a false impression of nuclear enlargement and pleomorphism.
Dying artifacts in alcohol-fixed Pap smears have a similar effect.
Hormonal Stimulation and Physiologic :Hyperplasia in Pregnancy and Lactation
Physiologic hyperplasia of acinar epithelial cells in late pregnancy and lactation can look worrying in FNA smears.
Key: The recognition of milky secretion is the main clue to a correct diagnosis to be correlated with clinical information.
Reactive Atypia
This is seen in mastitis fat necrosis, postoperative repair, and post radiation.
Key: Correct clinical information is important. A history of previous tissue injury and the presence of acute inflammatory cells (not just lymphocytes) rarely seen in breast cancer call for caution and careful evaluation of the nuclear structure of atypical cells.
Fibroadenoma
Epithelial atypia, most likely hormone related, can be prominent in smears of fibroadenoma. This is the most frequent cause of false positive diagnosis in breast FNA.
Key: In most cases, the atypical cells constitute only a minor part of the cell population. The presence of benign components is a safeguard against an erroneous malignant diagnosis.
Papillary Lesions
The combination of high cellularity, loss of cell cohesion, and variable nuclear atypia sometimes seen in smears from benign papillary lesions may raise a suspicion of malignancy. A false positive diagnosis is possible, particularly if a papillary microarchitecture is notidentified.
Key: In general, the presence of background apocrine cells, foam cells, and single bipolar nuclei suggest a benign papilloma.
REFERENCES
1. Franze´n S, Zajicek J. Aspiration biopsy in diagnosis of palpable lesions of the breast. Acta Radiol. 1968;7:241–262.
2. Zajdela A, Ghossein NA, Pilleron JP, et al. The value of aspiration cytology in the diagnosis of breast cancer: experience at the Foundation Curie. Cancer. 1975;35:499–506.
3. Greenberg M. Diagnostic pitfalls in the cytological interpretation of breast cancer. Pathology. 1996;28:113–121.
9 comments:
This is true that false atypia can be quite worrisome, but in cases where dilemma is not resolvd, what should be the followup investigation protocol??
Very useful & practical information
did you encounter epithelial malignancy (DCIS/Invasive ductal carcinoma)in a case of phyllodes tumor?
Hello,
Yes, I have encountered cases of frbroadenoma with DCIS.
Howevere they are not very common.
Common things first!!!
Thanks.
i am posting a dilemma that i encountered recently. although not related exactly to this current topic. i got a case of fibroblastic lesion on anterior abdominal wall of a 40 yr old male. it was recurrent and m/s 5.0 cm in diameter. though cells were uniform looking but in focal areas there was high mitotic activity amounting to 3-4 MF/ hpf. how can we separate a desmoid from fibrosarcoma in this case, without IHC? what should be the other features which should be looked. in such cases what should be the comment in report.
Dear Dr.Anshu,
Thanks for your email.
At Low power :
Fibrosarcoma will show spindle cells arranged in fascicles that intersect each other at acute straight angles with a herringbone appearance
Fibromatosis will show Longitudinally oriented fascicles of spindle cells in a prominent collagenous background, with a infiltrative growth pattern Thick walled vessels and a perivascular lymphocytic infiltrate may be seen
On High Power :
Fibrosarcoma : Mitotic activity is generally present, but variable Spindle cells resemble fibroblasts, with hyperchromatic nuclei Less differentiated tumors may have more hyperchromasia and foci of round cells but pleomorphism and numerous giants cells favor a diagnosis of MFH Fibromatosis :Spindle cells are benign-looking, with oval nuclei and one or more nucleoli with low mitotic activity
Anshu has left a new comment on your post "False positive diagnosis in breast FNAC.":
This is true that false atypia can be quite worrisome, but in cases where dilemma is not resolvd, what should be the followup investigation protocol??
Dear Dr. Anshu,
The protocol for unresolved FNA with worrisome features is as follows;
1) Review the clinical history and radiological findings carefully.
2) review slides with a colleague
3) Examine cell block of the remaining cells in the FNAC container.
4) Recommend biopsy for definitive diagnosis.
I hope this helps you.
Keep well.
regards
Dr.Prashant A. Jani.
MD,FRCP(C)
Nice post as for me. I'd like to read something more about that matter. Thanx for posting that information.
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We could stand to gather a second or even a third opinion over this one. I have read cases wherein this happens to women who had undergone breast implantation procedure.
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