Difference between revisions of "Breast pathology"

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==Phyllodes tumour==
==Phyllodes tumour==
*Previously ''cystosarcoma phyllodes''.
*Previously ''cystosarcoma phyllodes''.
 
{{Main|Phyllodes tumour}}
===General===
*The name comes from the word "leaf".
**With imagination or psychotropic drugs, it may look like one: the epithelial component = the veins of the leaf.
*Wide excision -- this differs from fibroadenoma (just local excision).
*Approximately 6% are malignant.<ref name=pmid12689668>{{cite journal |author=Guerrero MA, Ballard BR, Grau AM |title=Malignant phyllodes tumor of the breast: review of the literature and case report of stromal overgrowth |journal=Surg Oncol |volume=12 |issue=1 |pages=27–37 |year=2003 |month=July |pmid=12689668 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0960740403000057}}</ref>
 
Notes:
*There are case reports of ''phyllodes tumours'' in the [[prostate gland]].<ref name=pmid20069045>{{Cite journal  | last1 = Bannowsky | first1 = A. | last2 = Probst | first2 = A. | last3 = Dunker | first3 = H. | last4 = Loch | first4 = T. | title = Rare and challenging tumor entity: phyllodes tumor of the prostate. | journal = J Oncol | volume = 2009 | issue =  | pages = 241270 | month =  | year = 2009 | doi = 10.1155/2009/241270 | PMID = 20069045 }}</ref>
* Outside of the breast a phyllodes-like histomorphology may represent an ''[[adenosarcoma]]''.<ref name=pmid20179434>{{Cite journal  | last1 = McCluggage | first1 = WG. | title = Mullerian adenosarcoma of the female genital tract. | journal = Adv Anat Pathol | volume = 17 | issue = 2 | pages = 122-9 | month = Mar | year = 2010 | doi = 10.1097/PAP.0b013e3181cfe732 | PMID = 20179434 }}</ref>
 
===Gross===
*Clefts/leaf-like structures.
*Friable - especially vis-à-vis a [[fibroadenoma]].
 
Image:
*[http://radiographics.rsna.org/content/29/3/907/F48.expansion.html Benign phyllodes tumour (rsna.org)].
 
===Microscopic===
Features - either 1, 2 or both of the following:
#Large slit-like spaces - '''key feature'''. †
#Cellular stroma  - '''key feature'''. †
#*May be [[myxoid stroma|myxoid]].
*+/-Infiltrative border.
*+/-Mitoses.
*+/-Nuclear atypia.
*+/-"Stromal overgrowth" ~ stroma fills microscopic field.
 
Notes:
* † Large slit-like spaces are required for a benign phyllodes tumour.
*# Slit-like spaces may absent in a borderline phyllodes ''or'' a malignant phyllodes.
*# A cellular tumour without features suggestive of malignancy and without slit-like spaces is a ''[[cellular fibroadenoma]]''.
*#*Some pathologists don't believe in ''cellular fibroadenoma'' - they call everything with stromal cellularity a ''phyllodes tumour''.<ref>URL: [http://www.breastpathologyconsults.com/blog/wp-content/uploads/2011/03/FEL_poster.pdf http://www.breastpathologyconsults.com/blog/wp-content/uploads/2011/03/FEL_poster.pdf]. Accessed on: 23 February 2012.</ref>
 
DDx:
*[[Fibroadenoma]].
*[[Metaplastic breast carcinoma]].
*Primary breast sarcoma.
*Other [[sarcoma]]s.
 
====Images====
<gallery>
Image:Phyllodes_tumour_-_very_low_mag.jpg | Phyllodes tumour - very low mag. (WC/Nephron)
Image:Phyllodes_tumour_-_low_mag.jpg | Phyllodes tumour - low mag. (WC/Nephron)
</gallery>
 
====Grading====
Phyllodes tumours are graded:
*Benign.
*Borderline.
*Malignant.
 
Grading phyllodes tumours - based on WMSP:<ref name=Ref_WMSP263>{{Ref WMSP|263}}</ref>
{| class="wikitable sortable"
! Feature
! Benign phyllodes
! Borderline phyllodes
! Malignant phyllodes
|-
| Circumscription
| Well
| Well
| Poor
|-
| Stromal overgrowth †
| none
| none
| may be present
|-
| Nuclear atypia
| mild
| mild-to-moderate
| moderate-to-marked
|-
| Mitoses per 10 [[HPF]]s ‡
| < 5
| 5-10
| >10
|-
| Heterologous elements
| +/- benign
| +/- benign
| +/- malignant
|-
| DDx
| [[fibroadenoma]]
| benign phyllodes, malignant phyllodes
| [[metaplastic breast carcinoma]], sarcoma
|-
|}
 
Notes:
* † Stromal overgrowth = epithelial elements absent in one low power field (LPF), defined as x40;<ref name=pmid17932112>{{cite journal |author=Taira N, Takabatake D, Aogi K, ''et al'' |title=Phyllodes tumor of the breast: stromal overgrowth and histological classification are useful prognosis-predictive factors for local recurrence in patients with a positive surgical margin |journal=Jpn. J. Clin. Oncol. |volume=37 |issue=10 |pages=730-6 |year=2007 |month=October |pmid=17932112 |doi=10.1093/jjco/hym099 |url=http://jjco.oxfordjournals.org/cgi/reprint/37/10/730}}</ref> ''LPF'' is not adequately defined - see [[LPFitis]].
* ‡ ''HPF'' is not adequately defined - see [[HPFitis]].


==Pseudoangiomatous stromal hyperplasia==
==Pseudoangiomatous stromal hyperplasia==

Revision as of 04:44, 15 February 2014

The breast is an important organ for the continuance of the species and one that pathologists see quite often because it is often afflicted by cancer. Before women started smoking in large numbers, it was the number one cause of cancer death in women (in Canada).

Fortunately, breast cancer, these days, has a relatively good prognosis if it is detected early... and this is why there are week-ends to end breast cancer -- there are large numbers of breast cancer survivors that are well, wealthy and can advocate for better care and research into breast cancer.

Clinical

Classic presentation:

  • Nipple discharge.
  • Pain.
  • Breast lump/mass.
  • New nipple inversion.
  • Skin changes, e.g. peau d'orange.

Most common presentation:

  • Abnormal/suspicious screening mammogram - suspicious microcalcifications and/or suspicious mass.

Breast cancer screening

Breast cancer screening, for normal risk individuals, starts at age 50 in Canada. In the USA, breast screening starts at age 40.

Radiologic screening is less effective in younger individual as:

  1. The breast is more dense and thus radiologically more difficult to interpret, and
  2. The incidence of breast cancer is lower.

Breast radiology

BI-RADS = Breast Imaging Reporting And Data System:[1]

  • 0: Incomplete - come back for more imaging (radiologist cha-ching).
  • 1: Negative.
  • 2: Benign finding(s).
  • 3: Probably benign -- often short follow-up.
  • 4: Suspicious abnormality -- needs biopsy.
  • 5: Highly suggestive of malignancy.
  • 6: Pathologist says there is a malignancy.

Specimens

Breast comes in three main flavours:

  1. Core needle biopsy (CNB).
  2. Lumpectomy.
  3. Modified radical mastectomy.

Note:

Core needle biopsy

Work-up of CNBs is dependent on the clinical abnormality:[2]

  1. Mass lesion - usu. obvious what is going on; typically 3 levels.
  2. Calcifications - abnormality may be very small; typically 10 levels.

Lumpectomy

Lumpectomies are usually oriented with short and long suture; short is typically superior (aspect) and long is typically lateral (aspect).

Modified radical mastectomy

  • Usually done with sentinel lymph node biopsy - as one cannot go back later to do this.

Normal

Resting

  • Glands -- normally has two cell layers (like the prostate).
    • Myoepithelial cells
      • Frequently spindle-like, often hard to see.
    • Secretory cells.
  • Stroma:
    • Not cellular.
    • Not myxoid.

May be present:

  • Calcification:
    • Purple globs (with concentric rings) on H&E = calcium phosphate.
      • Q. How to remember? A. Purple = Phosphate.
    • Calcium oxalate visible with (light) polarization - not assoc. with malignancy.
    • Often in the lumen of a gland, may be in the stroma.
    • Calcific material typically has a well-demarcated border +/- "sharp corners".
    • Radiologists can pick-up calcs (calcifications) that are approximately 100 micrometers; if "calcs" is on the requisition one needs to find calcs this size.[3]
      • The large calcs seen on radiology are approximately 1/5 - 1/6 the size of a HPF, if the field of view (FOV) is ~0.55 mm (as is the case with 22 mm-10x eye pieces and a 40x objective).

Image:

Notes:

  • The architecture is more important than the cytologic features in the diagnosis of malignancy in the breast;[4] low grade tumours have distorted architecture but normal/near normal cytology.

Lactational changes

  • AKA secretory change, AKA lactational adenoma.[5]

General

  • May be present focally in non-pregnant females.

ASIDE:

  • Some believe lactational change and secretory change aren't the same...
    • Lactational change = only in lactation.
    • Secretory change = other times.
  • This hair splitting is clinically irrelevant-- both are benign. Also, experts use the terms interchangeably.[6]

Microscopic

Features:[7]

  • Glands dilated.
  • Increased number of lobules.
    • Relative decrease in intralobular and extralobular stroma.
  • Luminal cells enlarged.
    • Vacuolated cytoplasm.
    • Hobnail morphology - hang into the lumen.
  • Myoepithelial cells indistinct - after second trimester.

DDx:

Images

  • Lactational change - low mag. (WC/Nephron)

  • Lactational change - high mag. (WC/Nephron)

www:

Where to start

Main articles: Short_power_list#Breast_pathology and Long_power_list#Breast_pathology

The following entities are a starting point for understanding routine breast pathology & some of challenges in breast pathology:

  1. Apocrine change.
    • Pink benign cells.
  2. Columnar cell change.
    • Columnar cells with blebs ("snouts") - often have calcifications (purple).
  3. Fibroadenoma.
    • Abundant myxoid (light/blanched) stroma - very common.
  4. Florid epithelial hyperplasia.
    • Too many cells in a duct, cells overlap & form slit-like spaces.
  5. Ductal carcinoma in situ (DCIS).
    • Too many cells in a duct, nuclei do not touch - "cells are spaced".
    • Cells line-up around ovoid/circular spaces - "punch-out" appearance/"cookie cutter" look.
    • Myoepithelial cells present.
  6. Invasive ductal carcinoma.
    • Bread & butter cancer - in sheets or glands.
  7. Lobular carcinoma.
    • Dyscohesive cells - can easily be missed.
  8. Tubular carcinoma.
    • Glands have one cell layer... but near normal appearance.

The key to breast pathology is... seeing the two cell layers (at low power). The myoepithelial layer is hard to see at times and that is the challenge.

Common diagnoses - overview

  • Normal.
  • Benign.
    • Columnar cell change.
      • Calcification often in lumen.
  • Neoplastic.
    • Benign neoplastic:
    • Malignant neoplastic:
      • Epithelial/myoepithelial - most common, e.g. ductal carcinoma, lobular carcinoma.
      • Breast stroma - malignant phyllodes tumour.
      • Stromal, e.g. angiosarcoma - quite rare.

A tree diagram (overview)

General classification

 
 
 
 
 
 
 
 
 
 
Breast pathology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stromal
pathology
 
 
 
 
Miscellaneous
 
 
 
 
Glandular
pathology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Myxoid
 
 
 
Long slit-like
spaces
 
 
 
 
Simple
epithelium
 
Dilated
 
Cellular lesions
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fibroadenoma
 
Malignant
features
 
Benign features
 
 
Tubular
carcinoma
 
FEA, FCC,
CCC
 
FEHUT, Neoplastic,
Malignant
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Malignant
phyllodes
 
Benign phyllodes
 
 
 
 
 
 
 
 
 
 
 
 
 

Notes:

  • The challenges in breast pathology are in: the Simple epithelium category and the Cellular lesions category.
  • Neoplastic includes: ADH and LDH.
  • Malignant includes: DCIS, LCIS, ductal carcinoma (DC) and lobular carcinoma (LC), some papillary lesions.
  • Lobular carcinoma (a pitfall) may appear to be a stromal problem, i.e. the stroma looks too cellular.
  • Miscellaneous includes rare tumours of the breast that do not fit into another category, i.e. metastases, lymphomas, melanoma, sarcomas. Skin-related pathology is dealt within the dermatologic neoplasms article. Paget disease of the breast, which may be seen in the context of malignant breast lesions, is discussed in its own article.

Cellular lesions

 
 
 
 
 
 
 
 
 
 
 
 
Cellular lesions
(Glandular)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Equal spacing,
punched-out
 
Streaming, periph.
slit-like spaces.
 
Discohesive cells,
expanded gl.
 
Single cells
or single file
 
Fibrovascular
cores
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ductal lesion
 
FEHUT
 
Lobular lesion
 
Lobular carcinoma
 
Papillary lesions
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Two cell layers
 
One cell layer
 
<50% of gl.
 
>50% of gl.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ductal non-inv.
neoplasm
 
Ductal carcinoma
 
ALH
 
LCIS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Large extent
 
Small extent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DCIS
 
ADH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Notes:

  • The largest challenge is: differentiating between the first two categories on level 2, i.e. equal spacing' vs. streaming.
  • The fibrovascular cores must arise from a tuft, i.e. if they are arising directly from the wall of glands only it is likely papillary DCIS.

Papillary lesions

 
 
 
 
 
 
 
 
 
 
Papillary lesions
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Myoepithelial cells
present
 
 
 
 
 
 
 
 
 
Myoepithelial cells
absent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unremarkable
papillae
 
 
 
 
 
Atypia or arch. abnorm.
or cellular proliferation
 
 
 
 
 
Neoplastic cells
present
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Benign
intraductal
papilloma
 
High grade atypia
 
Low grade atypia
or abnorm. arch.
 
Only cellular
proliferation
 
Intracystic
(encapsulated)
papillary ca.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DCIS in
papilloma
 
 
 
 
 
 
FEHUT in
papilloma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
>3 mm extent
 
<3 mm extent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DCIS in
papilloma
 
ADH in
papilloma
 
 
 
 
 
 

Notes:

  • Adapted from Mulligan & O'Malley.[8]
  • The most important decision is the first one: myoepithelial cells present vs. absent.
  • abnorm. arch. = abnormal architecture present.
  • DCIS = ductal carcinoma in situ.
  • FEHUT = florid epithelial hyperplasia of the usual type.
  • extent refers to the size of the abnormal cell population within the papillary lesion.

Malignant lesions

Non-invasive breast cancer

Main article: Non-invasive breast cancer

This includes the in situ lesions - DCIS and LCIS.

Invasive breast cancer

Main article: Invasive breast cancer

This is includes descriptions of the usual types... and the not so common ones.

Common benign lesions

The breast has lots of benign things. Unlike the prostate, the where benign is called benign, everything has a name. It is more common among breast pathologists to sign-out things like: apocrine metaplasia (benign), columnar cell change (benign), and florid epithelial hyperplasia of the usual type (FEHUT) - instead of - benign breast tissue.

Mild epithelial hyperplasia

General

Microscopic

Features:[9]

  • Breast glands with three or four cell layers above the basement membrane.
  • Variable cells.

Note:

  • No nuclear atypia.

DDx:

Apocrine metaplasia

General

  • Benign/not significant. Can be considered to be pretty wallpaper in the house of breast pathology.

Etiology

Microscopic

Features:

  • Eosinophilic cytoplasm - key feature.

Note:

  • Apocrine changes, i.e. cytoplasmic eosinophilia, can appear in malignant tumours; eosinophilia doesn't make something benign.
  • Apocrine snouts may be present. (???)
    • Small globules at the apical aspect of the cell (composed of cytoplasm and plasma membrane).

Images

  • FCC with apocrine metaplasia (right bottom of image) - high mag. (WC/Nephron).

Fibrocystic change

  • Abbreviated FCC.
  • AKA fibrocystic changes.

General

  • Really common.
  • Benign.

Microscopic

Features:

  • Dilated glands - key change.
    • Glands normal: two cell layers present.
  • Often seen together with apocrine metaplasia.

Images

  • FCC - intermed. mag. (WC/Nephron)

  • FCC - high mag. (WC/Nephron)

  • FCC - left of image - and a phyllodes tumour - very low mag. (WC/Nephron)

Columnar cell change

  • Abbreviated CCC.
  • AKA blunt duct adenosis.

General

  • Columnar cell change is associated with (benign) calcification - key point.

Microscopic

Features:

  • Secretory cells (line gland lumen) have columnar morphology.
  • May have "apical snouts".
    • Blebs or round balls eosinophilic material appear to be adjacent to the cell at their luminal surface.
    • The snouts are attached to the cell-- appear as round ball only in the plane of section.
  • Cytoplasm +/-eosinophilia.

DDx:

Image:

Gynecomastoid hyperplasia

  • AKA gynecomastia.

General

  • Benign enlargement of breasts in males.
    • Histologic changes may be seen in females.[10]

May be seen in the context of:

Microscopic

Features:[10]

  • Moderate hyperplasia.
    • Glands have more than 2 cell layers.
  • "Budding" - individual cells jut into the lumen - key feature.
    • Buds may be multicellular; however, narrower toward the centre of the lumen.
  • Stromal palor.[11]

DDx:

Images

  • Gynecomastoid hyperplasia - intermed. mag. (WC/Nephron)

  • Gynecomastoid hyperplasia - very high mag. (WC/Nephron)

  • Gynecomastoid hyperplasia - 2 - intermed. mag. (WC/Nephron)

www:

Lesions with increased risk of malignancy

Florid epithelial hyperplasia

  • AKA florid epithelial hyperplasia, abbreviated FEH.
  • AKA florid epithelial hyperplasia of the usual type, abbreviated FEHUT.
  • AKA epithelial hyperplasia - term should be avoid as it could lead to confusion with mild epithelial hyperplasia.

General

Note:

  • Moderate epithelial hyperplasia redirects to this section.
    • It is generally not separated from FEH, as the prognosis is thought to be the same.

Microscopic

Features:[13]

  • Breast glands with more than four cell layers above the basement membrane - key feature.
  • Irregular cell spacing; streaming.
  • Slit-like lumina, esp. at the periphery of the duct.
  • No DCIS-like architecture (not cribriform, not papillary, not micropapillary, not solid).
  • No nuclear atypia - usually no nucleoli.

Memory device CLEAN:

  • Cell spacing is irregular, Lumina are slit-like, Extent is less than 2 mm or 2 ducts, Architecture not DCIS-like, Nuclear atypia not present.

DDx:

Sclerosing adenosis

General

  • Can be scary... can look like ductal carcinoma.
  • Derived from sclerosing[14] (hardening) and adenosis (glandular enlargement).
    • Think scaring + lotsa glands and you're pretty close.
  • Management: follow-up, no further treatment.[15]

Microscopic

Features:

  • Acini are smaller than usual and there are more of them.
    • Acini often slit-like.
  • Fibrosis (scleroses) - pink on H&E surrounds the acini.

Notes:

  • The acini should:
    • Be in lobular arrangements, i.e. in groups (benign appearance at low power) - key feature.
    • Have two cell layers like well-behaved breast glands do.

DDx:

Flat epithelial atypia

General

Epidemiology:

  • Associated with ADH & DCIS; may represent a non-obligate precursor lesion of ADH & DCIS.[17]
  • Low risk of progression to invasive malignancy.[18]

Management:

  • Excision.

Microscopic

Features:

  • "Flat" ~ three cells thick.
  • Hypercellular gland -- several layers.
  • Columnar cell morphology.
  • +/-Apical snouts.

DDx:

Molecular

Complex sclerosing lesion

  • AKA radial scar.

General

  • The term radial scar is a misnomer. It isn't a scar. It isn't associated with prior trauma or surgery.[19]
  • May appear malignant on imaging.[20]
  • Associated with subsequent elevated risk of breast cancer.[21]
  • Management - usu. surgical excision.[22]

Gross

  • Spiculated mass.
  • Usually small - 3-7 mm.

Image

  • Radial scar - gross. (WC)

Microscopic

Features:[22][23]

  • Stellate appearance (low magnification).
  • Center of lesion has "fibroelastosis" - stroma light pink (on H&E) - key feature.
    • Scar like stroma with entrapped normal breast ducts and lobules.
    • Glands appear to enlarge with distance from center of lesion.

Notes:

  • Histomorphologic appearance may mimic a desmoplastic reaction of the stroma - leading to a misdiagnosis of malignancy.
  • "Hyaline - pink stuff on H&E - is the key."[24]

DDx:

Image:

IHC

Features:

  • p63 +ve.
  • Calponin +ve.

Note:

  • HMWK +ve/-ve. (???)

Stromal lesions

This section (below) covers stromal lesions of the breast, which vary from benign to malignant. The most common is (the benign) fibroadenoma.

Non-breast stroma stromal lesions are covered in the soft tissue lesions article. Angiosarcoma (dealt with in the vascular tumours article) is the most common (non-breast stroma) sarcoma of the breast, and classically arises after treatment for a breast carcinoma.

Fibroadenoma

Main article: Fibroadenoma

Phyllodes tumour

  • Previously cystosarcoma phyllodes.
Main article: Phyllodes tumour

Pseudoangiomatous stromal hyperplasia

  • Abbreviated PASH.
  • AKA nodular myofibroblastic stromal hyperplasia of the mammary gland.[25]
Main article: Pseudoangiomatous stromal hyperplasia

Weird stuff

Like in all niches of pathology... there is weird stuff.

Mammary hamartoma

  • AKA breast hamartoma.

General

Gross

  • Well-circumscribed - key feature.

Microscopic

Features:[26]

  • Disordered arrangement of ductal and lobular structures.
  • Normal arrangement of cells with in the ductal structures, i.e. myoepithelium and epithelium present.
  • Variable features:[27]
    1. Adipose tissue - predominant.
    2. Dense fibrosis tissue - predominant.
    3. Cystic glandular dilation.

Notes:

  • If adipose tissue predominates; it may be labeled adenolipoma.[27]

DDx:

Images:

IHC

  • None - it's a H&E diagnosis.

Collagenous spherulosis

General

Microscopic

Features:[29][31]

  • Tubular/cribriform architecture.
  • Intratubular eosinophilic material - key feature.
    • Classical: Arranged like the spokes of a wheel ("radial spikes").
    • Atypical: Granules ~ 1-2 micrometers.
  • No mitotic activity.
  • Two cells populations (epithelial & myoepithelial) - like a well-behaved breast gland.

Notes:

  • Usually small lesions: < 50 spherules per lesion, <100 micrometers.
  • May be multifocal.
  • +/-Calcifications - may prompt biopsy.

DDx:

Images

  • Collagenous spherulosis - intermed. mag. (WC/Nephron)

  • Collagenous spherulosis - very high mag. (WC/Nephron)

www:

Nipple adenoma

  • AKA nipple duct adenoma.
  • AKA nipple adenoma of breast.
  • AKA adenoma of the nipple.
  • AKA florid papillomatosis of the nipple.[32]

General

  • Rare.
  • Reported in men.[32]

Clinical DDx:

Microscopic

Features:

  • Proliferation of epithelial and myoepithelial elements that extends into the breast stroma.[34]

Notes:

  • Not encapsulated.[34]
  • Lacks true fibrovascular cores.[35]
  • Focal necrosis may be present.[36]

DDx:

  • Intraductal papilloma.
    • Found within the duct not the stroma.
    • Often deeper - one should not see skin in the histologic section.

Images

  • Nipple adenoma - low mag. (WC/Nephron)

  • Nipple adenoma - very high mag. (WC/Nephron)

www:

Intraductal papilloma

General

Microscopic

Features:

  • True papillae - nipple-shaped structures with fibrovascular cores.
  • Intraductal proliferation of epithelial and myoepithelial elements.[34]

Notes:

  • Lacks florid hyperplasia.[38]
  • May degeneration and hyalinize to form a sclerosing papilloma.

DDx:

† Size criteria are different in papillomas.

Images

  • Papillary hidradenoma - low mag. (WC/Nephron)

  • Papillary hidradenoma - very high mag. (WC/Nephron)

Lymphocytic mastitis

General

Microscopic

Features:[40]

  • Lymphocytic infiltrates - key feature:
    • Lobules.
    • Perivascular.
  • Enlarged stromal fibroblasts.
  • Stromal collagen with keloid-like changes.

DDx:

  • Diabetic mastopathy - if individual has diabetes.
  • Primary lymphoma of the breast.

Images:

IHC

  • B cell predominant (CD20 > CD3).[39]
    • B cells CD43 -ve.

Molecular

  • Negative clonality studies.

Microglandular adenosis

Not to be confused with microglandular hyperplasia.
  • Abbreviated MGA.

General

  • Controversial thingy.

Management:

  • Excision.

Microscopic

Features:[41]

  • Round glands lined by a single layer of cells.
  • May extend into fat.
  • Lack of desmoplastic stroma.

DDx:

Images:

IHC

Features:[42]

  • S100 +ve.
  • 34BE12 +ve -- focal!

Others:

  • EMA -ve.
    • Tubular carcinoma usu. +ve.
  • GCDFP-15 -ve.[43]
  • Ki-67 <3%.

Adenomyoepithelioma

General

  • Rare lesion consisting of epithelial and myoepithelial elements.
    • May occur in other sites, e.g. tonsil.[44]
  • May be benign or malignant.[45][46]

Note:

Microscopic

Features:[48]

  • Well-circumscribed.
  • Glandular architecture with:
    • Easily identifiable myoepithelial cells - with clear cytoplasm - key feature.
    • Eosinophilic cuboidal epithelial cells.
  • Eosinophilic basement membrane material between glands.

DDx:

Images

  • Adenomyoepithelioma - low mag. (WC/Nephron)

  • Adenomyoepithelioma - high mag. (WC/Nephron)

Webpathology.com:

Mammary myofibroblastoma

General

  • Rare.
  • Excision = cure.
  • Postmenopausal females and older males.[49][50]

Note:

  • In extra-mammary sites the tumour is known as a mammary-type myofibroblastoma may immunohistochemically and histomorphologically overlap with spindle cell lipoma.[51]

Microscopic

Features:[52]

  • Well-circumscribed lesion.
  • Spindle cells without nuclear atypia arranged in fascicles.
  • Interspersed thick bundles of collagen.

Notes:

  • No calcifications.
  • No necrosis.
  • No hemorrhage.

DDx:

Images

  • Mammary myofibroblastoma - low mag. (WC/Nephron)

  • Mammary myofibroblastoma - intermed. mag. (WC/Nephron)

  • Mammary myofibroblastoma - high mag. (WC/Nephron)

www:

IHC

Features:[50]

  • CD34 +ve.[51]
  • Desmin +ve.[51]
  • H-caldesmon +ve.
  • Actin +ve.
  • Vimentin +ve.

Other

  • S100 -ve.
  • Beta-catenin -ve. (???)

Squamous metaplasia of lactiferous ducts

  • Abbreviated SMOLD.
Main article: Squamous metaplasia of lactiferous ducts

Granular cell tumour of the breast

Main article: Granular cell tumour

General

  • Uncommon.

Gross

  • May be a spiculated mass and thus mimic malignancy radiologically.[53]

Microscopic

See granular cell tumour.

See also

References

  1. ↑ URL: http://breastcancer.about.com/od/diagnosis/a/birads.htm. Accessed on: 16 March 2011.
  2. ↑ MUA. 1 October 2010.
  3. ↑ MUA. 1 October 2010.
  4. ↑ RS. 4 May 2010.
  5. ↑ URL: [Breast_pathology#Lactational_changes Breast_pathology#Lactational_changes. Accessed on: 3 October 2011.
  6. ↑ Tavassoli, FA.; Yeh, IT. (Jan 1987). "Lactational and clear cell changes of the breast in nonlactating, nonpregnant women.". Am J Clin Pathol 87 (1): 23-9. PMID 2879437.
  7. ↑ URL: http://flylib.com/books/en/2.953.1.9/1/. Accessed on: 6 August 2011.
  8. ↑ Mulligan AM, O'Malley FP (March 2007). "Papillary lesions of the breast: a review". Adv Anat Pathol 14 (2): 108–19. doi:10.1097/PAP.0b013e318032508d. PMID 17471117.
  9. ↑ O'Malley, Frances P.; Pinder, Sarah E. (2006). Breast Pathology: A Volume in Foundations in Diagnostic Pathology series (1st ed.). Churchill Livingstone. pp. 159-160. ISBN 978-0443066801.
  10. ↑ 10.0 10.1 URL: http://www.hsc.stonybrook.edu/breast-atlas/XIII-03.htm. Accessed on: 16 November 2011.
  11. ↑ URL: http://radiology.uchc.edu/eAtlas/Breast/1693.htm. Accessed on: 16 November 2011.
  12. ↑ Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 542. ISBN 978-1416054542.
  13. ↑ O'Malley, Frances P.; Pinder, Sarah E. (2006). Breast Pathology: A Volume in Foundations in Diagnostic Pathology series (1st ed.). Churchill Livingstone. pp. 159-160. ISBN 978-0443066801.
  14. ↑ URL: http://dictionary.reference.com/browse/sclerosis. Accessed on: 16 March 2011.
  15. ↑ URL: http://www.breastcancercare.org.uk/breast-cancer-information/breast-awareness/benign-breast-conditions/sclerosing-lesions. Accessed on: 30 April 2012.
  16. ↑ 16.0 16.1 Chu et al. (2006). Adenomyoepithelioma of the Breast — A Case Report. Tzu Chi Med J. Vol. 18 No. 1. URL:URL: http://www.tzuchi.com.tw/file/tcmj/95-1/2-8.pdf. Accessed on: 28 April 2012.
  17. ↑ Lerwill, MF. (Apr 2008). "Flat epithelial atypia of the breast.". Arch Pathol Lab Med 132 (4): 615-21. doi:10.1043/1543-2165(2008)132[615:FEAOTB]2.0.CO;2. PMID 18384213.
  18. ↑ Schnitt, SJ. (2003). "The diagnosis and management of pre-invasive breast disease: flat epithelial atypia--classification, pathologic features and clinical significance.". Breast Cancer Res 5 (5): 263-8. doi:10.1186/bcr625. PMID 12927037.
  19. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1072. ISBN 978-1416031215.
  20. ↑ Ung OA, Lee WB, Greenberg ML, Bilous M (January 2001). "Complex sclerosing lesion: the lesion is complex, the management is straightforward". ANZ J Surg 71 (1): 35–40. PMID 11167596.
  21. ↑ URL: http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Radial_Scars.asp. Accessed on: 4 May 2010.
  22. ↑ 22.0 22.1 Kennedy M, Masterson AV, Kerin M, Flanagan F (October 2003). "Pathology and clinical relevance of radial scars: a review". J. Clin. Pathol. 56 (10): 721–4. PMC 1770086. PMID 14514771. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770086/.
  23. ↑ O'Malley, Frances P.; Pinder, Sarah E. (2006). Breast Pathology: A Volume in Foundations in Diagnostic Pathology series (1st ed.). Churchill Livingstone. pp. 91. ISBN 978-0443066801.
  24. ↑ RS. May 2010.
  25. ↑ Leon, ME.; Leon, MA.; Ahuja, J.; Garcia, FU.. "Nodular myofibroblastic stromal hyperplasia of the mammary gland as an accurate name for pseudoangiomatous stromal hyperplasia of the mammary gland.". Breast J 8 (5): 290-3. PMID 12199757.
  26. ↑ O'Malley, Frances P.; Pinder, Sarah E. (2006). Breast Pathology: A Volume in Foundations in Diagnostic Pathology series (1st ed.). Churchill Livingstone. pp. 117. ISBN 978-0443066801.
  27. ↑ 27.0 27.1 URL: http://surgpathcriteria.stanford.edu/breast/mammhamart/. Accessed on: 4 October 2011.
  28. ↑ Tse, GM.; Law, BK.; Ma, TK.; Chan, AB.; Pang, LM.; Chu, WC.; Cheung, HS. (Dec 2002). "Hamartoma of the breast: a clinicopathological review.". J Clin Pathol 55 (12): 951-4. PMC 1769817. PMID 12461066. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1769817/.
  29. ↑ 29.0 29.1 URL: http://surgpathcriteria.stanford.edu/breast/collspher/. Accessed on: 4 September 2011.
  30. ↑ 30.0 30.1 Resetkova, E.; Albarracin, C.; Sneige, N. (Jan 2006). "Collagenous spherulosis of breast: morphologic study of 59 cases and review of the literature.". Am J Surg Pathol 30 (1): 20-7. PMID 16330938.
  31. ↑ URL: http://www.hsc.stonybrook.edu/breast-atlas/V-33.htm. Accessed on: 31 August 2011.
  32. ↑ 32.0 32.1 Boutayeb, S.; Benomar, S.; Sbitti, Y.; Harroudi, T.; Hassam, B.; Errihani, H. (2012). "Nipple adenoma in a man: An unusual case report.". Int J Surg Case Rep 3 (5): 190-2. doi:10.1016/j.ijscr.2011.05.008. PMID 22342578.
  33. ↑ HANDLEY, RS.; THACKRAY, AC. (Jun 1962). "Adenoma of nipple.". Br J Cancer 16: 187-94. PMC 2070922. PMID 13904317. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2070922/?tool=pubmed.
  34. ↑ 34.0 34.1 34.2 "Adenoma of Nipple.". Br Med J 1 (5330): 563. Mar 1963. PMC 2123505. PMID 20789667. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2123505/?page=1.
  35. ↑ URL: http://surgpathcriteria.stanford.edu/breast/nippleadenoma/printable.html. Accessed on: 6 August 2011.
  36. ↑ Lefkowitch, Jay H. (2006). Anatomic Pathology Board Review (1st ed.). Saunders. pp. 307 Q16. ISBN 978-1416025887.
  37. ↑ Zervoudis, S.; Iatrakis, G.; Economides, P.; Polyzos, D.; Navrozoglou, I. (Jan 2010). "Nipple discharge screening.". Womens Health (Lond Engl) 6 (1): 135-51. doi:10.2217/whe.09.81. PMID 20050819.
  38. ↑ URL: http://surgpathcriteria.stanford.edu/breast/nippleadenoma/printable.html. Accessed on: 6 August 2011.
  39. ↑ 39.0 39.1 Valdez, R.; Thorson, J.; Finn, WG.; Schnitzer, B.; Kleer, CG. (Mar 2003). "Lymphocytic mastitis and diabetic mastopathy: a molecular, immunophenotypic, and clinicopathologic evaluation of 11 cases.". Mod Pathol 16 (3): 223-8. doi:10.1097/01.MP.0000056627.21128.74. PMID 12640102.
  40. ↑ URL: http://www.breastpathology.info/Case_of_the_month/2007/COTM_0707%20discussion.html. Accessed on: 28 November 2010.
  41. ↑ 41.0 41.1 URL: http://www.uscap.org/site~/iap2006/slides08-4v.htm. Accessed on: 18 May 2011.
  42. ↑ Joshi, MG.; Lee, AK.; Pedersen, CA.; Schnitt, S.; Camus, MG.; Hughes, KS. (Jan 1996). "The role of immunocytochemical markers in the differential diagnosis of proliferative and neoplastic lesions of the breast.". Mod Pathol 9 (1): 57-62. PMID 8821958.
  43. ↑ Lefkowitch, Jay H. (2006). Anatomic Pathology Board Review (1st ed.). Saunders. pp. 296 Q20. ISBN 978-1416025887.
  44. ↑ Ren, J.; Song, L.; Dang, Q.; Zhang, X.; Jiang, SW.; Zhang, G.; Wang, N.; Liu, Z. et al. (2010). "Primary adenomyoepithelioma of tonsil.". Head Neck Oncol 2: 7. doi:10.1186/1758-3284-2-7. PMID 20356364.
  45. ↑ Howlett, DC.; Mason, CH.; Biswas, S.; Sangle, PD.; Rubin, G.; Allan, SM. (Mar 2003). "Adenomyoepithelioma of the breast: spectrum of disease with associated imaging and pathology.". AJR Am J Roentgenol 180 (3): 799-803. PMID 12591699. http://www.ajronline.org/content/180/3/799.full.
  46. ↑ Zizi-Sermpetzoglou, A.; Vasilakaki, T.; Grammatoglou, X.; Petrakopoulou, N.; Nikolaidou, ME.; Glava, C. (2009). "Malignant adenomyoepithelioma of the breast--case report.". Eur J Gynaecol Oncol 30 (2): 234-6. PMID 19480267.
  47. ↑ Seifert, G. (Sep 1998). "Are adenomyoepithelioma of the breast and epithelial-myoepithelial carcinoma of the salivary glands identical tumours?". Virchows Arch 433 (3): 285-8. PMID 9769134.
  48. ↑ URL: http://www.webpathology.com/image.asp?n=1&Case=322. Accessed on: 16 August 2011.
  49. ↑ Qureshi, A.; Kayani, N.. "Myofibroblastoma of breast.". Indian J Pathol Microbiol 51 (3): 395-6. PMID 18723968.
  50. ↑ 50.0 50.1 Mele, M.; Jensen, V.; Wronecki, A.; Lelkaitis, G. (2011). "Myofibroblastoma of the breast: Case report and literature review.". Int J Surg Case Rep 2 (6): 93-6. doi:10.1016/j.ijscr.2011.02.006. PMC 3199680. PMID 22096693. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3199680/. Cite error: Invalid <ref> tag; name "pmid22096693" defined multiple times with different content
  51. ↑ 51.0 51.1 51.2 McMenamin, ME.; Fletcher, CD. (Aug 2001). "Mammary-type myofibroblastoma of soft tissue: a tumor closely related to spindle cell lipoma.". Am J Surg Pathol 25 (8): 1022-9. PMID 11474286.
  52. ↑ O'Malley, Frances P.; Pinder, Sarah E. (2006). Breast Pathology: A Volume in Foundations in Diagnostic Pathology series (1st ed.). Churchill Livingstone. pp. 131. ISBN 978-0443066801.
  53. ↑ Yang, WT.; Edeiken-Monroe, B.; Sneige, N.; Fornage, BD. (May 2006). "Sonographic and mammographic appearances of granular cell tumors of the breast with pathological correlation.". J Clin Ultrasound 34 (4): 153-60. doi:10.1002/jcu.20227. PMID 16615051.

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