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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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=Where to start= | =Where to start= | ||
{{Main|Short_power_list#Breast_pathology|Long_power_list#Breast_pathology}} | {{Main|Short_power_list#Breast_pathology|Long_power_list#Breast_pathology}} | ||
The following is a starting point for | 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. | The key to breast pathology is the myoepithelial cell. | ||
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***The myoepithelial layer is hard to see at times. | ***The myoepithelial layer is hard to see at times. | ||
***IHC can aid in visualizing the myoepithelial layer. | ***IHC can aid in visualizing the myoepithelial layer. | ||
***The immunostains used in breast pathology for the myoepithelial layer include: CK5/6, SMA, p63 | ***The immunostains used in breast pathology for the myoepithelial layer include: [[CK5/6]], SMA, [[p63]] and calponin. | ||
===Questions to Ask=== | ===Questions to Ask=== | ||
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**Do you know the morphologic criteria for in situ carcinoma? | **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 use ICH to confirm an in situ carcinoma? | ||
**Do you know how to report an in situ carcinoma? | **Do you know how to report an in situ breast carcinoma? | ||
*Is it invasive 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 morphologic features of typical invasive breast carcinoma? | ||
**Do you know the subtypes? | **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 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 know how to use IHC for prognostication? | ||
**Do you understand the implications of triple negativity? | **Do you understand the implications of triple negativity? | ||
**Do you know how to report | **Do you know how to report an invasive breast carcinoma? | ||
*Is it something stromal/spindled? | |||
===Important Differential Diagnoses=== | ===Important Differential Diagnoses=== | ||
====Papillary Lesions==== | ====Papillary Lesions==== | ||
*Nipple adenoma | *Nipple adenoma. | ||
*Intraductal papilloma | *Intraductal papilloma. | ||
*Papillary ductal carcinoma in situ | *Papillary ductal carcinoma in situ. | ||
*Intracystic papillary carcinoma | *Intracystic papillary carcinoma. | ||
*Intracystic papillary carcinoma with an invasive component | *Intracystic papillary carcinoma with an invasive component. | ||
*Invasive papillary carcinoma | *Invasive papillary carcinoma. | ||
====Basaloid Lesions==== | ====Basaloid Lesions==== | ||
*Adenoid | *Adenoid cystic carcinoma of the breast. | ||
*Intracystic | *Intracystic papillary breast carcinoma, solid variant. | ||
*Invasive | *Invasive papillary breast carcinoma, solid variant. | ||
*Medullary | *Medullary breast carcinoma. | ||
*Medullary-like | *Medullary-like breast carcinoma. | ||
**Know when to start a discussion about BRCA mutations, triple negativity and the 'basal-like molecular phenotype'. | **Know when to start a discussion about BRCA mutations, triple negativity and the 'basal-like molecular phenotype'. | ||
====Spindle Cell Lesions==== | ====Spindle Cell Lesions==== | ||
*Metaplastic | *Metaplastic breast carcinoma. | ||
*Treated | *Treated breast carcinoma. | ||
*Mammary | *Mammary myofibroblastoma. | ||
*Phyllodes | *Phyllodes Tumour - stromal component. | ||
*Desmoid | *Desmoid fibromatosis. | ||
*Nodular | *Nodular fasciitis. | ||
=== Additional resources === | === Additional resources === | ||
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*Pathology Outlines - Breast Malignant [http://pathologyoutlines.com/breastmalignant.html] | *Pathology Outlines - Breast Malignant [http://pathologyoutlines.com/breastmalignant.html] | ||
*WebPathology - Breast [http://www.webpathology.com/atlas_map.asp?section=9] | *WebPathology - Breast [http://www.webpathology.com/atlas_map.asp?section=9] | ||
=Normal breast= | |||
==Resting breast== | |||
*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: | |||
*[[Breast calcifications|Calcification]]: | |||
**Purple globs (with concentric rings) on H&E = calcium phosphate. | |||
***Q. How to remember? A. '''P'''urple = '''P'''hosphate. | |||
**Calcium oxalate visible with (light) [[polarization]] - not associated with [[breast cancer|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.<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). | |||
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. | |||
===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== | |||
*[[AKA]] secretory change, [[AKA]] lactational adenoma, [[AKA]] lactating adenoma <ref>URL: [Breast_pathology#Lactational_changes Breast_pathology#Lactational_changes. Accessed on: 3 October 2011.</ref> | |||
===General=== | |||
*Lactational adenoma generally arises in during or in the few weeks after pregnancy. | |||
*May be present focally in non-pregnant females. | |||
*"Lactational adenoma"- circumscribed mass displacing the normal breast architecture (hyperplasia plus functional/physiologic change) | |||
*"Lactational change"- normal breast tissue architecture preserved (functional/physiologic change). | |||
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.<ref name=pmid2879437>{{Cite journal | last1 = Tavassoli | first1 = FA. | last2 = Yeh | first2 = IT. | title = Lactational and clear cell changes of the breast in nonlactating, nonpregnant women. | journal = Am J Clin Pathol | volume = 87 | issue = 1 | pages = 23-9 | month = Jan | year = 1987 | doi = | PMID = 2879437 }} | |||
</ref> | |||
===Microscopic=== | |||
Features:<ref>URL: [http://flylib.com/books/en/2.953.1.9/1/ http://flylib.com/books/en/2.953.1.9/1/]. Accessed on: 6 August 2011.</ref> | |||
*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. | |||
*Lactational "adenoma" may undergo infarction - Imagine what an infarcted lactational adenoma could look like in a FNA specimen! | |||
DDx: | |||
*[[Secretory carcinoma of the breast]]. | |||
====Images==== | |||
<gallery> | |||
Image:Lactational_change_-_low_mag.jpg | Lactational change - low mag. (WC/Nephron) | |||
Image:Lactational_change_-_high_mag.jpg | Lactational change - high mag. (WC/Nephron) | |||
Image:Breast LactationalChange MP CTR.jpg|Breast - Lactational Change - medium power (SKB) | |||
Image:Breast LactationalChange HP CTR.jpg|Breast - Lactational Change - high power (SKB) | |||
Image:Breast LactationalAdenoma MP CTR.jpg|Breast - Lactational adenoma - medium power (SKB) | |||
Image:Breast LactationalAdenoma HP CTR.jpg|Breast - Lactational adenoma - high power (SKB) | |||
Image:Breast LactationalAdenoma LP SNP.jpg|Breast - Lactational adenoma - low power (SKB) | |||
Image::Breast LactationalAdenoma MP SNP.jpg|Breast - Lactational adenoma - high power (SKB) | |||
Image:Breast LactatingAdenoma (4) PA.JPG|Breast - Lactational adenoma - low power (SKB) | |||
Image:Breast LactationalAdenoma MP SNP.jpg|Lactational adenoma - high power - in this example, the epithelium is flattened with clear bubbly cytoplasm (SKB) | |||
Image:Breast LactatingAdenoma HP PA.JPG|Breast - Lactational adenoma - high power - shows snouting and decapitation secretion. (SKB) | |||
</gallery> | |||
www: | |||
*[http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=2&cat2=9&cat3=0&cat4=3&stype=n Lactational changes (gfmer.ch)]. | |||
*[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)]. | |||
==Major Pathologic Patterns== | ==Major Pathologic Patterns== | ||
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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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===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== | ==Duct ectasia== | ||
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==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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