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The Role of Pathology in Diagnosis

A patient referred to hospital with a breast lump is seen in a dedicated breast clinic and assessed by a team of breast specialists.  

Triple Assessment
Triple Assessment  is the standard approach to the investigation of a patient presenting with a breast lump in the UK.

Such a patient referred by a GP to the Royal Free Hospital is seen in a dedicated breast clinic.  At the clinic the patient is assessed by a team of breast specialists.

This involves:
Clinical examination by a breast surgeon
Radiological assessment - mammography and ultrasound
Pathological assessment - fine needle aspiration and needle core biopsy
    

Below, Dr Nuala McDermott MB BCh BAO FRCPath, Consultant Histo/Cytopathologist at the Royal Free Hospital, explains the role of pathology in  this assessment.     

Pathological Assessment
Fine Needle Aspiration (Cytology)
A fine needle with a syringe attached is inserted into the lump and cells are drawn out into the syringe.  The cells are then spread on a thin piece of glass which is called a slide.  They are subsequently stained with dye in the cytology laboratory and the stained slide is ready to be examined under a microscope by a cytologist.   

stained slide ready for examination

a group of cells from a benign lump seen under a microscope

cells from a cancer seen under a microscope

In the majority of cases, an experienced cytologist is able to provide the information required from this test. 
It is a minimally invasive and cost effective procedure.

Needle Core Biopsy 
In a proportion of cases a fine needle aspiration is either not appropriate or not informative.  In these cases a needle core biopsy is carried out.

Under local anaesthetic a slightly larger, hollow needle is inserted into the lump and a small core of tissue is removed.  This is sent to the laboratory where it undergoes processing.  The processed tissue is then embedded in a wax block.

wax block containing tissue

Very thin slices are cut from the wax and applied to glass slides.  These thin sections are then stained with dye. The slide containing the stained sections is then examined by a histopathologist.

wax block and stained sections (left)	normal breast tissue

A well differentiated cancer

Whether the patient has had a fine needle aspiration or a needle core biopsy, the resulting report forms the pathology element of the triple assessment process.

The information from the: 

• Clinical examination
• Radiological assessment
• Pathological evaluation

is then reviewed by a team of specialists at a weekly multi-disciplinary meeting where appropriate treatment is agreed.