Novi Sad, 2009

The aim of preoperative diagnosis

Radiological pathological correlation The get a minimum of sufficient material

in diagnosing breast carcinoma: the role
To motivate proper therapeutic
of pathology in the multimodality era
interventions
To not harm the patient
Tibor Tot MD, PhD
Department of Pathology
Central Hospital Falun
Sweden

Preoperative interdisciplinary
Proper interventions
consensus diagnosis
Benign or malignant (suspicious)
suspicious)
Preoperative therapy ? In situ or invasive
Proper surgical intervention, breast Tumor size
Proper intervention, axilla Unifocal,
Unifocal, multifocal or diffuse
Extensive or of limited extent
Position within the breast

Lobular invasive, high-grade invasive,

associated high - grade in situ component

The preoperative needle

Needling artifacts in biopsies are necessery but
>80% of cases not totally free of risk.

Angulated empty
spaces in >60%

Needle track in >20% Use the

thinest
Pseudotumor effective
needle !!!
Epithelial
displacement in <10%

Limit the number

of biopsier/case !!

1
 FNAB - categories
Preoperative diagnosis: planning
1. unsatisfactory I not performed
2. benign II insufficient material
Mammografic pathologic correlation 3. atypia. probably III benign
The experience with different biopsy benign IV suspicious
modalities (advantages and 4. suspicious for V malignant
disadvantages) malignancy
5. malignant
The clinical situation and the radiologic
image unsatisfactory
benign
European guidelines...
suspicious.

II insufficient material III benign

IV suspicious V malignant

2
 Cytological criteria Diagnostic accuracy of FNAB in
240 breast cancers
Benign Malignant % 100
90

cellularity - + 80
70 all cases
myoepithelium + - 60
50
40
cochesivenes + - 30
s 20
10
atypia - + 0
GIII Med Muc GII GI Lob DCIS Tub

Tot, Tabr, Gere: The role of core needle biopsy of breast lesions when fine needle biopsy is inconclusive Acta Cytol 1999;43(4)

FNAB : CORE
accuracy/tumor type
%
100
90
80
70
60
50 FNAB
40 CORE
30
20
10
0
ductal med muc lob tub

Tot, Tabr, Gere: The role of core needle biopsy of breast lesions when fine needle biopsy is inconclusive
Acta Cytol 1999;43(4)

Preoperative diagnosis
in 141 cases of fibroadenoma
80
70
60
Non - malignant FNAB
50
40 cyt.
core
=
30
20
10
anything
0
uns ben FA susp mal
Tot, unpublished results

3
 Diagnostic accuracy of FNAB and FNAB and CORE biopsy in
Core biopsy, Falun 1996-2003 2500 breast carcinoma cases (Falun, 1996-2008)
100%
90% 100%
91%
80% 90%
80%
70%
65% 70%
60%
60%
50% FNAB FNAB
50%
40% Core CORE
40%
30% 30%
20% 20%
10% 10%
0% 0%
II III IV V 1996 1998 2000 2002 2004 2006 2008

Vacuum biopsy Intact biopsy, Falun 2006-2008

3-4 mm thick cores

May include in toto an enlarged TDLU 115 cases
May include a transsection of a distended
38 Malignant
duct
10 ADH
May represent an alternative to open 67 Benign
surgical intervention in some cases

Preoperative diagnosis Preoperative diagnosis

FNAB CORE
- to prove malignancy in clinically and/or - to prove malignancy
radiologically malignant lesions ( lobular, tubular carcinomas )
- cystic lesions - to prove invasion
- axillary lymph nodes - to prove the benign character of solid
lesions

4
 Preoperative diagnosis
Vacuum biopsi microcalcifications
(diff dg DCIS gr I och II)
MRI
MRI adds valuable information to
Mammography / Ultrasound DG in 20% of
the cases (Duerloo EE et al. Eur Radiol 2006)
MRI detects multifocality in 38% of breast
cancer cases (Duerloo EE et al. Eur Radiol 2006)
MRI modifies the surgical approach in at
least 13% of cases (Martinez et al. EJC Suppl.
European Breast cancer conference abstract 2008)
Pathology is expected to be at least as accurate
as the radiology methods as it is based on direct
examination of the tissue and the lesions and
not on analysis of their images.
The traditional histopathology method based on
fragmentation and sampling of macroscopically
suspicious lesion(s)
lesion(s) is clearly insufficient for
modern postoperative radiological-
radiological-pathological
correlation.
Interdisciplinary diagnosis and treatment of breast
diseases is slowly but irrevocably becoming accepted
as the new gold standard for patient care. It requires
an additional investment in time and effort, which is
soon repaid by smoother delivery of care and far fewer
iatrogenic complications.
Tot T, Tabr L, Dean PB: Practical Breast Pathology,
Thieme Stuttgart New York, 2002
MRI
MRI detects previously occult but
suspicious lesions which require additional
evaluation (second look US, biopsy etc)
etc) in
25% of cases
In 75% confirms the index lesions and
justifies the planned therapy
Modifies the surgical approach in at least
13% of cases (mastectomy based on
multifocality
Crowe JP, et al. The Breast Journal, 15(1):52-60, 2009
Preoperative tumor board
The preoperative diagnosis determines
the need for neo-
neo-adjuvant therapy and the
type of the initial surgery
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 Preoperative tumor board Postoperative tumor board
Benign or malignant (R / P) The postoperative radiological-
radiological-
In situ or invasive (R / P) pathological correlation serves as quality
High grade (R / P) control of the preoperative judgement, and
Lobular (R / P) also may indicate the need for additional
Tumor size (RR / P) surgical intervention and adjuvant therapy.
Extent (R
R / )
Distribution (RR / )
Heterogeneity (R / P)

Conditions for successful Pitfalls in determining the real extent

radio-
radio-pathologic correlation
The pathologist is familiar with the
capabilties and limitations of the used
radiological methods
Preoperative findings
Specimen radiogram
(Macroscopic examination of the tissue)
tissue)
Large histological sections
Postoperative tumor board
and the distribution of the disease
Non - adequate methodology
Failure in radiological pathological
correlation
Invasive lobular carcinoma
Micropapillary DCIS
Low-
Low-grade in situ lesions

Conclusion 1.
Conventional histopathology is far
insufficient in defining tumor size,
distribution and disease extent in breast
cancer in a considerable number of cases
Modern breast imaging, especially in
multimodality approach, is very accurate
in assessing these parameters and
represents a real challenge for pathology,
Conclusion 2.
Using multiple large-
large-format histology
sections represents a prerequisite and
detailed radiological-
radiological-pathological
correlation the only proper way in
adequate demonstration and evaluation of
morphological findings in modern breast
pathology,

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 Conclusion 3.
Low-
Low-grade in situ lesions, micropapillary
DCIS and invasive lobular carcinoma are
the most frequent causes of discrepancies
in radiological versus pathological
assessment of these parameters, in
addition to failure in radio-
radio-pathologic
correlation,
Final conclusion
As all the imaging methods may
underestimate or overestimate the key
parameters in breast carcinomas, there is
a clear need for correct pathology
background in validating these methods.
The role of breast pathology has never
been as central and important as in the
era of rapidly developing modern breast
imaging.