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[[Image:Diagram showing the lobes and ducts of a breast CRUK 307.svg|thumb|250px|Diagram of the structure of breast. (CRUK/WC)]] | [[Image:Diagram showing the lobes and ducts of a breast CRUK 307.svg|thumb|250px|Diagram of the structure of breast. (CRUK/WC)]] | ||
The '''breast''' is an important organ | The '''breast''' is an important organ that [[pathologist]]s see quite often because it is often afflicted by [[breast cancer|cancer]]. Before women started [[smoking]] in large numbers, it was a leading cause of cancer death in women. | ||
Fortunately, breast cancer, | Fortunately, breast cancer, in this day, has a relatively good prognosis if it is detected early. | ||
=Clinical= | =Clinical= | ||
===Clinical Presentations of Breast Pathology=== | |||
*'''Abnormal/suspicious screening mammogram''' | |||
**Suspicious microcalcifications and/or suspicious mass. | |||
**Most common history on the specimen requisition | |||
**May be accompanied by a [[BI-RADS]] score. | |||
*Nipple discharge. | *Nipple discharge. | ||
*Pain. | *Pain. | ||
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*New nipple inversion. | *New nipple inversion. | ||
*Skin changes, e.g. ''peau d'orange''. | *Skin changes, e.g. ''peau d'orange''. | ||
===Breast cancer screening=== | ===Breast cancer screening=== | ||
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===Breast radiology=== | ===Breast radiology=== | ||
{{Main|Breast imaging reporting and data system}} | |||
=Specimens= | =Specimens= | ||
Three major specimen types: | |||
#Core needle biopsy (CNB). | #Core needle biopsy (CNB). | ||
#Lumpectomy. | #Lumpectomy. | ||
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Note: | Note: | ||
*Breast [[cytopathology]] is dealt with in the ''[[breast cytopathology]]'' article. | *Breast [[cytopathology]] is dealt with in the ''[[breast cytopathology]]'' article. Breast cytology is almost extinct unless you happen to be in Australia where for reasons unknown, the art is still taken seriously. Breast cytology is not sensitive or specific enough to justify forgoing a CNB. | ||
===Core needle biopsy=== | ===Core needle biopsy=== | ||
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#Mass lesion - usu. obvious what is going on; typically 3 levels. | #Mass lesion - usu. obvious what is going on; typically 3 levels. | ||
#Calcifications - abnormality may be very small; typically 10 levels. | #Calcifications - abnormality may be very small; typically 10 levels. | ||
Note - if you have a high BI-RADS score on the biopsy requisition, and no correlating histologic findings, be sure to correlate with the specimen radiograph, consider leveling the specimen to exhaustion and/or note the lack of a correlating lesion on your report. | |||
===Lumpectomy=== | ===Lumpectomy=== | ||
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*Usually done with sentinel [[lymph node]] biopsy - as one cannot go back later to do this. | *Usually done with sentinel [[lymph node]] biopsy - as one cannot go back later to do this. | ||
=Normal= | =Where to start= | ||
==Resting== | {{Main|Short_power_list#Breast_pathology|Long_power_list#Breast_pathology}} | ||
The following is a starting point for mentally framing routine breast pathology & some of the challenges in breast pathology: | |||
The key to breast pathology is the myoepithelial cell. | |||
**A benign gland has two cell layers - myoepithelial and epithelial. | |||
**The luminal cell is epithelial | |||
**The basal cells is myoepithelial | |||
***The myoepithelial layer is hard to see at times. | |||
***IHC can aid in visualizing the myoepithelial layer. | |||
***The immunostains used in breast pathology for the myoepithelial layer include: [[CK5/6]], SMA, [[p63]] and calponin. | |||
===Questions to Ask=== | |||
*Is it normal or close to normal? | |||
**Are you familiar with normal/altered but benign/physiologic changes in the breast? | |||
**Do the changes observed explain the biopsy (are you sure you are seeing the radiographic lesion)? | |||
**Have you found the microcalcifications? | |||
*Is it a neoplastic but benign? | |||
**Are you familiar with the common benign breast neoplasms? | |||
**Do you know the morphologic criteria for a benign breast gland? | |||
**Do you know how to use IHC to confirm a benign process? | |||
*Is it an in situ carcinoma? | |||
**Are you familiar with DCIS and LCIS and their variants? | |||
**Do you know the morphologic criteria for in situ carcinoma? | |||
**Do you know how to use ICH to confirm an in situ carcinoma? | |||
**Do you know how to report an in situ breast carcinoma? | |||
*Is it invasive carcinoma? | |||
**Do you know the morphologic criteria for an invasive gland? | |||
**Do you know how to use IHC to confirm invasion? | |||
**Do you know the morphologic features of typical invasive breast carcinoma? | |||
**Do you know the subtypes? | |||
**Do you understand the implications of some of the medullary/medullary-like subtype (especially in a young patient)? | |||
**Do you know how to use IHC for prognostication? | |||
**Do you understand the implications of triple negativity? | |||
**Do you know how to report an invasive breast carcinoma? | |||
*Is it something stromal/spindled? | |||
===Important Differential Diagnoses=== | |||
====Papillary Lesions==== | |||
*Nipple adenoma. | |||
*Intraductal papilloma. | |||
*Papillary ductal carcinoma in situ. | |||
*Intracystic papillary carcinoma. | |||
*Intracystic papillary carcinoma with an invasive component. | |||
*Invasive papillary carcinoma. | |||
====Basaloid Lesions==== | |||
*Adenoid cystic carcinoma of the breast. | |||
*Intracystic papillary breast carcinoma, solid variant. | |||
*Invasive papillary breast carcinoma, solid variant. | |||
*Medullary breast carcinoma. | |||
*Medullary-like breast carcinoma. | |||
**Know when to start a discussion about BRCA mutations, triple negativity and the 'basal-like molecular phenotype'. | |||
====Spindle Cell Lesions==== | |||
*Metaplastic breast carcinoma. | |||
*Treated breast carcinoma. | |||
*Mammary myofibroblastoma. | |||
*Phyllodes Tumour - stromal component. | |||
*Desmoid fibromatosis. | |||
*Nodular fasciitis. | |||
=== Additional resources === | |||
*Breast Pathology Info [http://www.breastpathology.info/] | |||
*Digital Atlas of Breast Pathology [http://www.hsc.stonybrook.edu/breast-atlas/] | |||
*Pathology Outlines - Breast Nonmalignant [http://pathologyoutlines.com/breast.html] | |||
*Pathology Outlines - Breast Malignant [http://pathologyoutlines.com/breastmalignant.html] | |||
*WebPathology - Breast [http://www.webpathology.com/atlas_map.asp?section=9] | |||
=Normal breast= | |||
==Resting breast== | |||
*Glands -- normally has two cell layers (like the [[prostate]]). | *Glands -- normally has two cell layers (like the [[prostate]]). | ||
**Myoepithelial cells | **Myoepithelial cells | ||
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May be present: | May be present: | ||
*Calcification: | *[[Breast calcifications|Calcification]]: | ||
**Purple globs (with concentric rings) on H&E = calcium phosphate. | **Purple globs (with concentric rings) on H&E = calcium phosphate. | ||
***Q. How to remember? A. '''P'''urple = '''P'''hosphate. | ***Q. How to remember? A. '''P'''urple = '''P'''hosphate. | ||
**Calcium oxalate visible with (light) polarization - not | **Calcium oxalate visible with (light) [[polarization]] - not associated with [[breast cancer|malignancy]]. | ||
**Often in the lumen of a gland, may be in the stroma. | **Often in the lumen of a gland, may be in the stroma. | ||
**Calcific material typically has a well-demarcated border +/- "sharp corners". | **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.<ref>MUA. 1 October 2010.</ref> | **Radiologists can pick-up calcs (calcifications) that are approximately 100 micrometers; if "calcs" is on the requisition one needs to find calcs this size.<ref>MUA. 1 October 2010.</ref> | ||
***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). | ***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). | ||
Notes: | Notes: | ||
*The architecture is more important than the cytologic features in the diagnosis of malignancy in the breast;<ref>RS. 4 May 2010.</ref> low grade tumours have distorted architecture but normal/near normal cytology. | *The architecture is more important than the cytologic features in the diagnosis of malignancy in the breast;<ref>RS. 4 May 2010.</ref> low grade tumours have distorted architecture but normal/near normal cytology. | ||
===Image=== | |||
*[http://www.breastpathology.info/Images/calcs/FatNec1_700.jpg Breast with calcifications (breastpathology.info)]. | |||
*[http://www.wjso.com/content/7/1/70/figure/F3 Resting breast tissue (wjso.com)]. | |||
==Lactational changes== | ==Lactational changes== | ||
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*Luminal cells enlarged. | *Luminal cells enlarged. | ||
**Vacuolated cytoplasm. | **Vacuolated cytoplasm. | ||
**Hobnail morphology - hang into the lumen. | **[[Hobnail morphology]] - hang into the lumen. | ||
*Myoepithelial cells indistinct - after second trimester. | *Myoepithelial cells indistinct - after second trimester. | ||
*Lactational "adenoma" may undergo infarction - Imagine what an infarcted lactational adenoma could look like in a FNA specimen! | *Lactational "adenoma" may undergo infarction - Imagine what an infarcted lactational adenoma could look like in a FNA specimen! | ||
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*[http://www.webpathology.com/image.asp?case=320&n=7 Lactational changes in an angiosarcoma of the breast (webpathology.com)]. | *[http://www.webpathology.com/image.asp?case=320&n=7 Lactational changes in an angiosarcoma of the breast (webpathology.com)]. | ||
*[http://www.lab.anhb.uwa.edu.au/mb140/CorePages/FemaleRepro/femalerepro.htm#LabMamm Lactating breast (uwa.edu.au)]. | *[http://www.lab.anhb.uwa.edu.au/mb140/CorePages/FemaleRepro/femalerepro.htm#LabMamm Lactating breast (uwa.edu.au)]. | ||
==Major Pathologic Patterns== | ==Major Pathologic Patterns== | ||
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<!-- | <!-- | ||
DDX - PAPILLARY BREAST LESIONS | DDX - PAPILLARY BREAST LESIONS | ||
--> | --> | ||
{{familytree/start}} | {{familytree/start}} | ||
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{{familytree | D | | | | | | E | | | | | | F |D=Unremarkable<br>papillae|E=Atypia ''or'' arch. abnorm.<br>''or'' cellular proliferation|F=Neoplastic cells<br>present}} | {{familytree | D | | | | | | E | | | | | | F |D=Unremarkable<br>papillae|E=Atypia ''or'' arch. abnorm.<br>''or'' cellular proliferation|F=Neoplastic cells<br>present}} | ||
{{familytree | |!| | | |,|-|-|-|+|-|-|-|.| | | |!| |}} | {{familytree | |!| | | |,|-|-|-|+|-|-|-|.| | | |!| |}} | ||
{{familytree | G | | H | | I | | J | | K |G=[[intraductal papilloma|Benign<br>intraductal<br>papilloma]]|H=High grade atypia|I=Low grade atypia<br>''or'' abnorm. arch.|J=''Only'' cellular<br>proliferation|K=[[ | {{familytree | G | | H | | I | | J | | K |G=[[intraductal papilloma of the breast|Benign<br>intraductal<br>papilloma]]|H=High grade atypia|I=Low grade atypia<br>''or'' abnorm. arch.|J=''Only'' cellular<br>proliferation|K=[[Encapsulated papillary carcinoma of the breast|Intracystic<br> (encapsulated)<br>papillary ca.]]}} | ||
{{familytree | | | | | |!| | | |!| | | |!| | | | | |}} | {{familytree | | | | | |!| | | |!| | | |!| | | | | |}} | ||
{{familytree | | | | | L | | |!| | | N | | | | |L=[[DCIS]] in<br>papilloma|N=[[FEHUT]] in<br>papilloma}} | {{familytree | | | | | L | | |!| | | N | | | | |L=[[DCIS]] in<br>papilloma|N=[[FEHUT]] in<br>papilloma}} | ||
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*''FEHUT'' = florid epithelial hyperplasia of the usual type. | *''FEHUT'' = florid epithelial hyperplasia of the usual type. | ||
*''extent'' refers to the size of the abnormal cell population within the papillary lesion. | *''extent'' refers to the size of the abnormal cell population within the papillary lesion. | ||
=Malignant lesions= | =Malignant lesions= | ||
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===General=== | ===General=== | ||
*No increased risk of malignancy. | *No increased risk of malignancy. | ||
**Often ''not'' reported - as it has | **Often ''not'' reported - as it has no clinical signficance. | ||
*Has to be separated from ''[[moderate epithelial hyperplasia]]'' / ''[[florid epithelial hyperplasia]]''. | *Has to be separated from ''[[moderate epithelial hyperplasia]]'' / ''[[florid epithelial hyperplasia]]''. | ||
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==Apocrine metaplasia== | ==Apocrine metaplasia== | ||
{{Main|Apocrine metaplasia of the breast}} | |||
== | ==Duct ectasia== | ||
* | *Dilation of large ducts secondary to luminal obstruction by inspissated secretions | ||
** | *Presentation | ||
**~age 40-50, possibly with cheesy nipple discharge | |||
*Pathology | |||
**Duct lumen dilated and containing foamy macrophages | |||
* | **Necrosis/shedding of epithelium | ||
* | **If duct rupture: chronic and granulomatous inflammation of periductal region | ||
* | **Fibrotic thickening of duct wall | ||
** | |||
* | |||
* | |||
** | |||
<gallery> | <gallery> | ||
Image: | Image:Breast DuctEctasia LP PA.JPG|Breast - Duct Ectasia - low power (SKB) | ||
Image:Breast | Image:Breast DuctEctasia MP2 PA.JPG|Breast - Duct Ectasia - low power (SKB) | ||
Image:Breast DuctEctasia MP PA.JPG|Breast - Duct Ectasia - medium power (SKB) | |||
</gallery> | </gallery> | ||
==Fibrocystic change== | ==Fibrocystic change== | ||
{{Main|Breast fibrocystic changes}} | |||
*[[AKA]] ''fibrocystic changes'' | *[[AKA]] ''fibrocystic changes'' (abbreviated ''FCC''). | ||
==Columnar cell change== | ==Columnar cell change== | ||
{{Main|Columnar cell change of the breast}} | |||
==Gynecomastoid hyperplasia== | ==Gynecomastoid hyperplasia== | ||
*[[AKA]] ''gynecomastia''. | *[[AKA]] ''gynecomastia''. | ||
{{Main|Gynecomastoid hyperplasia}} | {{Main|Gynecomastoid hyperplasia}} | ||
==Breast prostheses== | |||
{{Main|Breast prostheses}} | |||
=Lesions with increased risk of malignancy= | =Lesions with increased risk of malignancy= | ||
==Florid epithelial hyperplasia== | ==Florid epithelial hyperplasia== | ||
*AKA ''florid epithelial hyperplasia of the usual type'', abbreviated ''FEHUT''. | *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]]''. | *AKA ''epithelial hyperplasia'' - term should be avoid as it could lead to confusion with ''[[mild epithelial hyperplasia]]''. | ||
*AKA ''usual ductal hyperplasia'', abbreviated ''UDH''. | |||
{{Main|Florid epithelial hyperplasia}} | |||
* | |||
==Sclerosing adenosis== | ==Sclerosing adenosis== | ||
{{Main|Sclerosing adenosis of the breast}} | |||
==Flat epithelial atypia== | ==Flat epithelial atypia== | ||
*Abbreviated ''FEA''. | |||
{{Main|Flat epithelial atypia}} | |||
* | |||
==Complex sclerosing lesion== | ==Complex sclerosing lesion== | ||
*[[AKA]] ''radial scar''. | *[[AKA]] ''radial scar''. | ||
{{Main|Complex sclerosing lesion}} | |||
=Stromal lesions= | =Stromal lesions= | ||
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==Intraductal papilloma== | ==Intraductal papilloma== | ||
*[[AKA]] ''papilloma''. | *[[AKA]] ''papilloma''. | ||
{{Main|Intraductal papilloma}} | {{Main|Intraductal papilloma of the breast}} | ||
==Lymphocytic mastitis== | ==Lymphocytic mastitis== |
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