Breast
Cytopathology Competency Assessment
Breast Cancer

Author: Gordon H. Yu, M.D. (see Authors page)

Revised: 15 June 2016, last major update September 2012

Copyright: (c) 2012-2016, PathologyOutlines.com, Inc.

Cite this page: Cytology/Competency Assessment - Breast Cancer. PathologyOutlines.com website. http://pathologyoutlines.com/topic/breastcytcompbreastcancer.html. Accessed November 21st, 2017.
Medical Knowledge, Practice Based Learning and Systems Based Practice
  1. Recognize breast cancer as the most common cancer of women in the US
  2. Become familiar with historic trends in breast cancer incidence and mortality
  3. Risk Factors
    1. Identify risk factors for the development of breast cancer, including genetic factors and estrogen exposure
    2. Become familiar with the increased relative risk of breast cancer based on other breast disease, including epithelial hyperplasia with and without atypia and DCIS
  4. Prognosis – Systems Based Practice
    1. Become familiar with factors which impact prognosis and survival of patients with breast cancer
    2. Grading of Breast Cancer
      1. Identify the nuclear features which determine grading of breast carcinoma
    3. Other Prognostic Factors
      1. Understand the impact of primary tumor size and stage of disease on survival
      2. Hormone Receptors
        • Appreciate the importance of testing for estrogen and progesterone receptor status, methods by which hormone receptor status is determined, and its impact on clinical behavior
      3. Her2/Neu
        • Recognize the importance of Her2/neu testing and its impact on prognosis and response to therapy
      4. Other Prognostic Markers
        • Recognize the prognostic potential of other markers, including markers of proliferative activity
  5. FNA Biopsy of Breast Cancer – Practice Based Learning
    1. Become familiar with the cytomorphologic features of breast carcinoma
    2. Become aware of lesions which may lead to diagnostic difficulty in FNA specimens (i.e. benign lesions which yield hypercellular aspirates and malignant lesions which yield limited cellularity)
    3. The Gray Zone in FNA Biopsy of the Breast
      1. Become familiar with lesions which most commonly lead to "atypical" or "suspicious" diagnoses
  6. Breast Cancer Classification and Diagnosis
    1. Infiltrating Ductal Carcinoma
      1. Recognize that the majority of breast carcinomas are ductal carcinoma and become familiar with the cytomorphologic features of FNA of this common subtype
      2. Recognize variants of ductal carcinoma which may be encountered
      3. Carcinoma In Situ (DCIS)
        • Become familiar with the clinical and histologic features of DCIS
        • Recognize that the distinction of DCIS from invasive carcinoma cannot be definitively made on the basis of FNA cytology alone
    2. Lobular Carcinoma
      1. Become familiar with the clinical features of lobular carcinoma
      2. Become familiar with the typical cytomorphologic features of lobular carcinoma, while noting that the distinction of lobular and ductal carcinoma is often not possible via FNA cytology alone
      3. Appreciate the fact that lobular carcinoma is associated with a higher false-negative rate on FNA than any other breast malignancy, due to its frequent hypocellularity and minimal cytologic atypia
      4. Lobular Neoplasia (ALH and LCIS)
        • Recognize that although these entities exist and are described in the histology literature, they do not represent distinct diagnoses made on FNA cytology
    3. Tubular Carcinoma
      1. Learn the clinical and mammographic features of tubular carcinoma
      2. Become familiar with the histologic features of tubular carcinoma and correlate with the cytologic features of this neoplasm seen upon FNA
    4. Invasive Cribriform Carcinoma
      1. Become familiar with the cytomorphologic features of this tumor and its differential diagnoses
    5. Medullary Carcinoma
      1. Become familiar with the clinical characteristics of medullary carcinoma
      2. Become familiar with the typical cytomorphologic features of medullary carcinoma and the differential diagnosis of this pleomorphic tumor
      3. Recognize that the definitive diagnosis of this tumor is not possible on the basis of FNA cytology alone, due to the need to assess characteristics of the tumor margin histologically
    6. Mucinous (Colloid) Carcinoma
      1. Recognize the favorable prognosis for this tumor subtype
      2. Become familiar with the cytomorphologic features of colloid carcinoma, including the differential diagnosis of this mucin-rich lesion
      3. Recognize that the definitive diagnosis of colloid carcinoma is not possible on FNA cytology, due to the need to exclude the presence of ordinary ductal carcinoma on histologic examination
    7. Signet Ring Cell Carcinoma
      1. Become familiar with the cytomorphologic features of this subtype and recognize that this may be a morphologic variant of either ductal or lobular carcinoma
    8. Neuroendocrine Carcinoma
      1. Become familiar with the clinical and cytomorphologic features of neuroendocrine carcinoma as well as the need to exclude the possibility of metastasis to the breast from another site
      2. Recognize that neuroendocrine carcinoma encompasses a range of morphologic variants (as in other organ systems), including:
        • Low-Grade (Carcinoid-like) Neuroendocrine Tumors
        • Small Cell (Neuroendocrine) Carcinoma
        • Large Cell Neuroendocrine Carcinoma
    9. Invasive Micropapillary Carcinoma
      1. Become familiar with the cytomorphologic features of this subtype and its differential diagnosis
    10. Apocrine Carcinoma
      1. Learn the definition of apocrine carcinoma and appreciate the fact that focal apocrine change may be seen in a relatively large number of ductal, lobular and other breast tumor subtypes
      2. Appreciate the importance of distinguishing apocrine carcinoma from atypical apocrine metaplasia in benign conditions, including the importance of considering other aspirate components and pertinent clinical features
    11. Metaplastic Carcinoma
      1. Identify the basic subtypes of metaplastic carcinoma and the expected cytomorphologic features seen in each
        • Adenosquamous Carcinoma
        • Spindle Cell Carcinoma
        • Carcinosarcoma
        • Squamous Cell Carcinoma
    12. Lipid-Rich Carcinoma
      1. Become familiar with the cytomorphologic features of this rare breast carcinoma variant, including its differential diagnosis
    13. Glycogen-Rich Carcinoma
      1. Become familiar with the cytomorphologic features of this rare tumor
    14. Secretory (Juvenile) Carcinoma
      1. Become familiar with the clinical features of this rare tumor with excellent prognosis in children
      2. Be aware of a potentially more aggressive clinical course in adults, as well as its typical cytomorphologic features
    15. Cystic Hypersecretory Duct Carcinoma
      1. Become familiar with the cytomorphologic features which may be noted in this rare variant of breast carcinoma
  7. Papillary Neoplasms
    1. Become familiar with the subtypes of papillary neoplasms (papilloma, papillary carcinoma), including the expected patient age and tumor size for each subtype
    2. Become familiar with the typical cytomorphologic features of these lesions, particularly the presence of three-dimensional papillary tissue fragments with fibrovascular cores
    3. Identify the cytologic features which favor papilloma, and those which favor papillary carcinoma
    4. Recognize the need for excisional biopsy for definitive classification when a papillary neoplasm is suspected upon FNA
  8. Miscellaneous Breast Tumors
    1. Paget Disease of Nipple
      1. Recognize the clinical appearance of Paget Disease and its association with in situ and invasive carcinoma
    2. Inflammatory Carcinoma
      1. Recall the clinical appearance of inflammatory carcinoma and its correlation with histologic findings (tumor involvement of dermal lymphatics)
    3. Cystic Breast Cancer
      1. Appreciate the difficulty of the diagnosis of cystic breast cancer by FNA
      2. Recognize that greater than 50% of cystic breast cancers represent papillary carcinoma
      3. Become familiar with the cytomorphologic features of these lesions, with particular attention to the background findings
  9. Myoepithelial Neoplasms
    1. Pleomorphic Adenoma
      1. Recognize the possibility of this neoplasm in the breast and understand that the cytomorphologic features are similar to those seen in more common locations (salivary gland)
    2. Adenoid Cystic Carcinoma
      1. Recognize that this tumor subtype may rarely appear in the breast and that its cytologic appearance is identical to that seen when encountered in the salivary gland
    3. Adenomyoepithelioma
      1. Become familiar with the cytomorphologic features of this neoplasm and identify immunocytochemical stains which may be useful in its diagnosis
    4. Myoepithelioma
      1. Become familiar with the cytomorphologic features of this rare tumor and its differential diagnosis
  10. Soft Tissue Tumors of the Breast
    1. Recognize the low incidence of these tumors in the breast (<1% of all breast cancer)
    2. Be aware that virtually any soft tissue tumor may occur in the breast and become familiar with the cytomorphologic features of each, including the utility of specific immunocytochemical stains in their diagnosis:
      1. Myofibroblastoma
      2. Pseudoangiomatous Stromal Hyperplasia
      3. Angiosarcoma
      4. Stromal Sarcoma
      5. Granular Cell Tumor
  11. Malignant Lymphoma/Leukemia
    1. Recognize the possibility of lymphoma, both as a primary lesion of the breast, as well as secondary involvement of the breast in patients with an established history
    2. Become familiar with the cytomorphologic features of lymphoma and leukemia
  12. Metastatic Malignancy
    1. Identify the extramammary tumors which are most commonly encountered as metastatic lesions in the breast
    2. Appreciate the different tumor subtypes most likely to occur in women, men and children
    3. Become familiar with the cytomorphologic features of commonly-encountered metastatic lesions and the utility of immunocytochemical stains in their diagnosis
  13. Posttherapy Breast Masses – Practice Based Learning and Systems Based Practice
    1. Recognize the rare possibility of post-therapy neoplasms in the breast (i.e. post-radiation sarcoma)
    2. Appreciate the utility of FNA in the exclusion of post-therapy malignancies
    3. Radiation-Induced Lesions
      1. Appreciate the cytomorphologic features of fat necrosis, scarring and epithelial atypia which may be induced by radiation therapy of the breast
      2. Be aware of the possibility of false-positive diagnoses in this setting and the importance of caution when interpreting FNA specimens in patients with a history of radiation
  14. Breast Masses in Children, Adolescents
    1. Become familiar with the most frequent causes of breast masses in this age group:
      1. Gynecomastia
      2. Breast Button (Thelarche)
      3. Ectopic or Supernumerary Breast
      4. Fibroadenoma
      5. Juvenile (Virginal) Hypertrophy
      6. Inflammatory Lesions
      7. Lymph Node
      8. Fibrocystic Disease
      9. Juvenile Papillomatosis
      10. Cancer
        • Become familiar with the possible tumor subtypes that may rarely occur
        • Recognize that malignancy in the pediatric population is more likely to be secondary (metastasis) rather than a primary malignant lesion