PART TWO
Diagnostic Cytology
Fig. 25.77 (A) Aspirated carcinoma consisting exclusively of necrotic
cells and background debris with no viable diagnostic tumor cells
(Papanicolaou x HP). (B) Reaspiration of the peripheral portion of the mass,
demonstrating diagnostic malignant cells (Diff-Quik x MP).
nonpalpable breast masses, as w e ll as tra in in g and credentialing,
biopsy technique, diagnostic term inolog y, ancillary studies, and
post-FN A fo llo w -u p recom m endations, were discussed. The
conference proposed classifying the cytologic finding s in to the
fo llo w in g general categories: benign, atypical/indeterm inate, sus-
p icious/indeterm inate, suspicious/probably m alig nant, m alig -
nant, and unsatisfactory, along w ith a detailed explanation o f the
m icroscopic finding s th a t are diagnostically specific fo r each cat-
egory. A n im p o rta n t recom m end ation was to report the adequacy
o f the specimen and to note th a t an unsatisfactory specim en is
present i f the fo llo w in g cond itions are present: (1) scant cellular-
ity, (2) a ir drying (fo r those pathologists using fixed smears) o r
d isto rtio n artifact, a n d /o r (3) obscuring blood , in fla m m a tio n , o r
o the r factors. The prim e im portance o f the last recom m endation
is to classify these types o f specimen as inadequate o r unsatisfac-
to ry rather than negative. This avoids falsely labeling these lesions
as benign w h en the aspirated target was in fact n o t adequately
sampled. Besides these general categories, a specific diagnosis can
also be reported. This conference also recom m ended the use o f
cytologic nuclear grading corresponding to the grading system
em ployed w h en evaluating a histolog ic specimen. W e strongly
support the principles outlines b y this conference, along w ith the
need to standardize the reporting o f breast FNA.
Fig. 25.78 Immunoperoxidase stain for estrogen receptor protein
demonstrating intense nuclear staining of the malignant cells (immunocyto-
chemistry x MP).
Nipple Discharge Cytology *
1
8
N ip p le discharge, a lth ou g h re la tiv e ly u n c o m m o n , is th e sec-
o nd m ost c o m m o n breast sign after th e presence o f a lu m p .458
N ip p le discharge can be the resu lt o f e ith e r p hysiolog ic o r
p atholog ic causes.459 Drugs,
m eta b o lic c o n d itio n s such as
hyper- and h yp o th y ro id is m , p itu ita ry adenom a w ith elevated
p ro la c tin levels, and h o rm o n a l flu c tu a tio n resu ltin g fro m preg-
nancy o r lac tatio n are am ong the p hysiolog ic causes o f n ip p le
discharge.459 A p p ro x im a te ly 3% o f m a lig n a n t breast lesions are
associated w ith an a b no rm a l n ip p le discharge.460-462 In a large
stud y in v o lv in g 2037 w o m e n , Takeda et al. diagnosed o n ly
18 o u t o f 61 cancer cases b y n ip p le discharge cytology, in d i-
cating its lo w se n sitivity.460 T he n ip p le discharge s h o u ld raise
suspicion w h e n it is p in k o r b lood y, w h e n it is accom panied
b y a u n ila te ra l lu m p o r a p ositive m am m o g ram , o r w h e n the
p a tie n t is over 50 years o ld .459,461-463 C ia tto and colleagues rec-
o m m end ed th a t cytologic e xa m in a tio n sh o u ld be p erform ed
o n ly o n b lo o d y discharges, a lth o u g h others have cautioned
th a t carcinom a can also be associated w ith a n o n b lo o d y
discharge.458,464
Physiologic n ip p le discharge is generally paucicellular to
acellular, consisting a lm ost exclusively o f proteinaceous back-
g round m aterial. Som etim es, p re d o m in a n tly foam cells having
coarsely vacuolated cytoplasm together w ith occasional benign
ductal cells can be seen.465 T he o rig in o f these fo a m y cells has
been controversial.466,476 The ductal cells are u su a lly arranged in
tig h tly cohesive, u n ifo rm groups, and the cells show m in im a l
to n o va ria tio n in size. A lth o u g h the cells m ay have hig h N /C
ratios, hyperchrom asia w ith coarse c h ro m a tin is n o t present.
O ccasionally, apocrine cells can present. In fla m m a to ry and
infectious con d itio ns can also result in a nip p le discharge
w ith the expected in fla m m a to ry cell exudate. Tuberculosis can
be suspected w h en the cytologic e xa m in ation reveals e p ith e lio id
histiocytes and g iant cells. However, the d e fin itive diagnosis
needs to be confirm ed b y the presence o f acid-fast b a cilli. Galac-
torrhea is characterized b y num erous foam cells set in a p ro m i-
n en t lip op roteinaceous sm ear background.
760
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