患者56岁，乳腺穿刺诊断查到癌细胞，化疗几个疗程后做手术，手术后标本未找到肿物

病理报告:乳腺癌化疗后反应。

是否化疗能把肿物消除？穿刺诊断是否可以直接发？

请各位老师指点

 千百合您好！给您一点补救建议

1.不要轻易说“没有癌细胞”！

2. 肉眼仔细查，找癌床部位多取材

3.镜下全面仔细找，癌消失的足丝马迹

4.此例曾穿刺会引起反应性病变，化疗会造成化疗改变，要能识别

5.标本全部取材切片可能是明智的选择

6.如果工作到家了，找不到癌是可以的，新辅助化疗有10%-15%的病例癌可完全消失，前题是化疗前的诊断准确无误，经的起专家会诊！

千百合您能上几张图，显示一下化疗改变吗？

 Dr. Shen:  FNA cannot differentiate between in situ and invasive carcinoma.  The hospital where i was trained with cytopathology can do ER,PR with FNA specimens with excellent quality and accuracy (compared with later on biopsy specimens).  There are 2 ways to do it: de-stain the H&E FNA smear slides and re-stain with antibodies; make cell block from syringe rinse (we always do 3 passes and rinse one pass into preservative fluid Cytolyte or RPMI) and then do immunostains.

I did anatomic pathology residency and surgical pathology fellowship first, then a cytopathology fellowship.  I feel interpreting cytopath specimens requires very comprehensive understanding of pathology including the consequences of any diagnosis and treatment options, don't mention a pair of eagle's eyes. After all these training, during my first year of practice, i felt quite shaky and often needed backup whenever i render a positive diagnosis.  In our group, positive diagnosis needs manditory secondary review, except easy cases like SCC and BCC or recently diagnosed malignancy.

It is very nice to have a forum like here to exchange ideas.  Thanks.

两条个人意见：

1 不满意标本一不直接报“癌”，最多报到“可疑癌细胞伴退变”；

2 细胞学诊断如果直接报癌，一律加备注“细胞学诊断不应作为手术或进一步治疗的依据，建议进一步检查”。

病理金标准是指“活检”，不要试图用细胞学替代活检，即是简便。

用细胞学确诊，风险很大，教训深刻。

学习了。

 长见识了，谢谢各位老师。

 Thank you very much for all the great discussions.  I appreciate Dr. Yu's response to my questions. I will try to summarize what I learned from this case and hope this summary is accurate.  I welcome and appreciate any comments from colleagues from China or USA.

1. FNA diagnosis of breast can make a pretty accurate diagnosis of 癌(carcinoma), may be 95%以上 according to 七彩虹, but cannot reliably differentiate DCIS (in situ ductal 癌) from invasive carcinoma. There might be clues as 197 suggested, this could be invasive carcinoma (not sure how likely). Based on cytology image provided here, there are even different opinions as whether it is sufficient for a diagnosis of 癌 (malignant cells) among the expert cytopathologist (Dr. Yu and others).

2. If one cannot make a definitive diagnosis of invasive carcinoma 癌, I know that cytotoxic (not include tomoxifen) chemotherapy is not the right choice for this patient. On history, patient had some enlarged axillary lymph nodes before therapy. If FNA cytology was done for lymph node and proved that there is metastatic carcinoma, then I would think the neoadjuvant therapy might be reasonable.

3. For breast FNA cytology, it can provide an initial diagnosis of 癌. But report has to be clearly indicate that it can be either in-situ 癌 or invasive 癌. I agree with yangsi that 病理金标准是指“活检" for breast carcinoma.

4. I would also agree with Professor Ding (dhy) regarding how to deal with the case...We can only try to do the best afterwards and hope to find the "癌".  Even though it is possible that all the "癌 cell" might be melted away by chemotherapy, I would not feel satisfied with this result without knowing that the patient had "invasive carcinoma".  I think pathologist and surgeon should not feel good that we did a good job and cure the patient with a questionable "癌".  We may harm this or future patients by “over-treatment” with toxic chemotherapy they might not need.   In the situations described by fyshan, I think it is quite different.  It is not uncommon, but still rare that one cannot find DCIS after core biopsies in the excisional or lumpectomy specimens.   

I know this is a very long note and hope they are helpful. 

 Agree with most people that this is a positive case. Breast FNA can have definite dx of malilignant, but it cannot differentiate DCIS and invasive carcinoma even though there are many features suggestive. Always mention the triple test in your report that the FNA result needs to have correlation with clinicaln examination and  imaging study result. It is not uncommon that the tumor cells disappear after chemotherapy--called complete pathologic response to chemotherapy. It is true most surgens will do a core biopsy for the evaluation of ER. PR and Her2/neu and for the confirmation of invasion before further treatment (chemotherapy/radiation or surgery.

 非妇科细胞学可以作为临床治疗的依据，甲状腺细针穿刺诊断了乳头状癌的也可以不用做冰冻，胸腹水影像学检查没有占位性病变的即使没有细胞块也一样可以报腺癌，现在总是有人唱衰细胞学，说细胞学这也不行那也不行，我看就是他自己不行，细胞病理学有一定局限性，这一点我们必须的承认，组织病理学难道就不受取材的影响？组织病理学难道就没有过诊断低诊断的？冰冻难道就没有假阳性假阴性的？就拿支气管刷片来说，细胞学阳性组织学阴性时有发生，难道此时还要看你组织学的脸呢？细胞学阳性组织学阴性，组织病理医师还跑过来向细胞病理医师请教呢，这在进修时都是亲眼所见，为什么有的医院临床医师只相信组织学不相信细胞学？因为这些医院病理科的所谓细胞病理医师就没有干过让临床医师相信的事，有时候还将临床往沟里带呢，这让人家怎么相信你？我进修时外院的胸腹水、细针穿刺样本都还往我所进修的医院送呢，这些医院有病理科为什么临床还让家属将样本送往我所进修的医院呢？大家想想看，就是因为这些医院看细胞的病理医师不行，得不到临床的信任，自己不行能怨谁呢？有生意尽让别人做了，我所在进修的医院病理科细胞室人家就是强，阳性率就是高，难怪外院的样本都往这里送呢，有些检验科看细胞学的都比一些所谓的病理医师强，人家细胞学还搞得有声有色，还有的人总是认为细胞学很简单，看看就会了，这种人必定做不了一个好的细胞病理医师，细胞学很有用处，细胞学是三维的组织学是二维的，如果有一天你能真正从三维的角度看细胞，这说明你细胞学入门了。