Tony K.F. Ma

The Role of Conservative Treatment in Idiopathic Granulomatous Mastitis

Abstract:  Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory disease of the breast that mimics carcinoma of the breast. Its etiology and treatment remain unclear. A retrospective review of nine women with histopathologic diagnosis of IGM was performed. The women had a mean follow‐up of 18.7 months and a mean age of 45.7 years (range 32–83 years). The main presentation was breast mass (100%). Clinically and radiologically, 55.6% of the women were suspected to have malignancy. One patient was treated with lumpectomy without recurrence. Eight patients were treated with expectant management with close regular surveillance. No surgery was performed and no medications were given. Fifty percent of the patients had spontaneous complete resolution of disease after a mean interval of 14.5 months. These four patients had no recurrence. Fifty percent of patients had static disease. In conclusion, it is important to differentiate IGM from carcinoma of the breast. Tissue biopsy remains the gold standard to confirm the diagnosis. Expectant management with close regular surveillance is the treatment of choice.

Role of Radiologic Features in the Management of Papillary Lesions of the Breast

OBJECTIVE The purpose of our study was to assess the role of imaging and core biopsy in the management of patients with papillary lesions of the breast. MATERIALS AND METHODS Clinical records and mammographic and sonographic findings of 40 women with papillary lesions in the breast were retrieved. The imaging features and cytologic findings were correlated with histologic findings. RESULTS Fifty-six papillary lesions in 40 patients underwent either mastectomy, segmental duct resection, or excision biopsy. There were three papillary carcinomas, 13 papillaryal lesions with carcinoma in situ, one atypical papilloma, four sclerosed papillomata, and 35 papillomata. Of these lesions, 37.5% (21/56) and 82.1% (46/56) could be detected on mammography and sonography, respectively. Galactography and dilated ducts helped to suggest the papillary nature of the lesions. However, mammography and sonography were not able to predict malignancy (sensitivity, 69% and 56%, respectively; specificity, 25% and 90%; positive predictive value [PPV], 60% and 75%; and negative predictive value [NPV], 33% and 90%). Combined interpretation of mammography and sonography gave a sensitivity of 61%, specificity of 33%, PPV of 85%, and NPV of 13%. Fine-needle aspiration gave a sensitivity of 44%, specificity of 68%, PPV of 31%, and NPV of 79%, whereas core biopsy gave a sensitivity of 82%, specificity of 100%, PPV of 100%, and NPV of 83% in the diagnosis of malignancy. CONCLUSION Radiologic features are not sufficiently sensitive or specific to differentiate benign from malignant papillary lesions. Fine-needle aspiration and core biopsy have pitfalls, and the need for surgical excision of all papillary lesions should be revisited.

Hamartoma of the breast: a clinicopathological review

Aims: To review 25 cases of breast hamartoma and discuss the pathological criteria, and the usefulness of imaging modalities, fine needle aspiration cytology (FNAC), and needle core biopsy in the diagnosis. Methods: The hamartomas were assessed for interlobular fibrotic stroma, stromal adipose tissue content, pseudo-angiomatous stromal hyperplasia, and epithelial changes (hyperplasia, adenosis or apocrine metaplasia, and cyst formation). All imagings, previous FNACs, and biopsies were also reviewed. Results: Imaging (mammography, ultrasound, and magnetic resonance imaging) was performed in 18 cases, and mostly showed encapsulated masses with a heterogeneous appearance. Microscopically, all hamartomas demonstrated good demarcation with fibrous tissue condensation. Adipose tissue was noted in all cases (5–90%; mean, 31%), and interlobular fibrosis in 21 cases. Benign epithelial hyperplasia occurred in 10 cases, and pseudo-angiomatous stromal hyperplasia or cystic ducts in eight cases each. Apocrine metaplasia, calcification, stromal giant cells, and adenosis occurred in four cases or less. Two cases showed coexisting ductal carcinoma in situ limited to within the hamartoma. Needle core biopsies (four cases) and FNAC (14 cases) were largely insufficient, inconclusive, or non-specific. Conclusions: Hamartomas do not possess specific diagnostic histological features. The role of FNAC and needle core biopsy in making the diagnosis is limited, and requires clinical and radiological correlation to avoid underdiagnosis.

Granulomatous mastitis: a clinicopathological review of 26 cases

Aims: Twenty‐six cases of granulomatous mastitis were examined to determine the common histological and clinical features and the possible association with micro‐organisms. Methods: A retrospective review of the clinical and histological features of these cases was undertaken, including granuloma, inflammatory cell infiltrate, multinucleated giant cells, necrosis and lymphocytic lobulitis, as well as special stains for micro‐organisms including Mycobacterium, other bacteria and fungus. PCR for Mycobacterium tuberculosis DNA was also performed in 19 cases. Results: Granulomas were present in all cases (100%) while multinucleated giant cells were seen in 17 cases (65%), background inflammatory cell infiltrate in 23 cases (88%), predominantly lymphocytes in 18 cases (69%), significant lymphocytic lobulitis in 13 of 19 cases (68%) and necrosis in three cases (11%). Special stains and cultures for micro‐organisms were all negative. Clinically, four cases (15%) were associated with duct ectasia, eight (31%) with abscess, and there was no such association in 14 cases (54%). Of the 19 cases with PCR for tuberculosis, one case showed Mycobacterium DNA in the sample, raising the possibility of occult tuberculosis infection. Conclusions: Granulomatous mastitis is a heterogeneous group of diseases with a diverse clinical picture and association. Most idiopathic cases are not associated with specific micro‐organisms.

Fine needle aspiration cytology of granulomatous mastitis

Aims: Granulomatous mastitis (GM) is an uncommon breast lesion that mimics carcinoma. The fine needle aspiration cytological (FNAC) features of GM have rarely been discussed in the literature. These features are reported in eight histologically confirmed cases of GM. Methods: A retrospective study was undertaken in which a diagnosis of GM had been made on histopathology, and the FNAC slides were reviewed and assessed for the presence of granulomas, necrosis, multinucleated giant cells, and inflammatory background cells. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis was performed on the histological material to exclude tuberculosis. Results: All cases were confirmed histologically and PCR for mycobacterial DNA was negative. In the FNACs, varying numbers of granulomas composed of epithelioid histiocytes were present in four cases. The same four cases showed giant cells of either foreign body or Langhan’s type. No necrosis was noted. Six cases showed many histiocytes, some plump and others epithelioid, in the background. The number of epithelioid histiocytes corresponded to the presence of granulomas. Neutrophils were the predominant background inflammatory cells in most cases (six). Conclusions: The cytological diagnosis of GM is difficult because the features overlap with other aetiologies, including tuberculosis. Specific features are absent. The absence of necrosis and a predominantly neutrophilic infiltrate in the background favour a diagnosis of GM. This diagnosis should also be considered when abundant epithelioid histiocytes are seen in smears, even in the absence of granulomas. However, the definitive diagnosis of GM depends on histology from fine needle biopsies and negative microbiological investigations.

Tuberculosis of the Nasopharynx: A Rare Entity Revisited

Objectives Tuberculosis of the nasopharynx is uncommon. A large series of 17 cases is reported, and the clinical and pathological features are discussed.

Papillary lesions of the breast - Accuracy of core biopsy

Tse G M, Tan P‐H, Lacambra M D, Jara‐Lazaro A R, Chan S‐K, Lui P C, Ma T K F, Vong J S, Ng D C H, Shi H‐J & Lam W W
(2010) Histopathology56, 481–488

Fine needle aspiration cytologic features of mammary phyllodes tumors

OBJECTIVE To evaluate specific diagnostic fine needle aspiration cytologic (FNAC) features of phyllodes tumor (PT), particularly in the differentiation from fibroadenoma (FA). STUDY DESIGN Twenty-eight FNAC of PT were reviewed for smear cellularity, epithelial and stromal fragments, their size and atypia, epithelial/stromal area ratio, background single stromal cells (oval or columnar), multinucleated giant cells, and squamous and apocrine cells. Twenty-one FNAC of fibroadenoma were also assessed for comparison. RESULTS PT was significantly larger than FA. Epithelial fragments were found in all cases, with atypia present in PT. Stromal fragments were present in half the cases; there was no difference in stromal size, but the epithelial/stromal area ratio was significantly lower in PT than FA. Single columnar stromal cells with recognizable cytoplasm and multinucleated stromal giant cells were seen in some PT but not in FA. CONCLUSION Cytologic diagnosis of PT remains difficult, with significant overlap with FA. The presence of large size, low epithelial/stromal ratio, epithelial atypia, columnar stromal cells with visible cytoplasm and stromal giant cells favors a diagnosis of PT over FA.

Fine-needle aspiration cytology of breast carcinoma with endocrine differentiation.

The value of fine‐needle aspiration (FNA) in atypical proliferative to in situ to low grade invasive breast lesions remains limited due to the overlapping cytologic features of these entities. In the current study the authors review the FNA cytology of endocrine carcinoma and identify common cytologic features that allow for the diagnosis of this uncommon, low grade subtype of mammary malignancy.

Multinucleated stromal giant cells in mammary phyllodes tumours

Summary Mammary phyllodes tumour (PT) is an uncommon fibro‐epithelial neoplasm with a prominent stromal component. We report five cases of PT (one benign, three borderline, one malignant) with giant cells in the stroma. All occurred in adults and ranged from 1.8 to 4.0 cm in size. The overall cellularity, stromal cell pleomorphism and mitotic count was higher for the malignant and borderline than the benign PT. The giant cell number ranged from 18 to 35 cells per 10 high power fields, but there was no relationship between this number and the grade of the PT. Most giant cells were subepithelial, with multiple nuclei arranged in a linear or irregular pattern, and moderate amount of cytoplasm. The immunohistochemical profile of the giant cells was similar to the stromal cells. In all cases, both giant cells and stromal cells expressed vimentin strongly but not desmin; in two cases, both cell populations expressed actin weakly. The respective percentage of giant cells and stromal cells expressing MIB1 was also similar. This suggests that these giant cells do not represent a different, more active stromal population, despite the more bizarre appearance. In view of the small number of cases, the significance of such giant cells on the prognosis of PT remains uncertain.