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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 for the continuance of the species and one that [[pathologist]]s see quite often because it is often afflicted by [[breast cancer|cancer]]. Before women started [[smoking]] in large numbers, it was the number one cause of cancer death in women (in Canada). | | 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. |
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| 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. | | Fortunately, breast cancer, in this day, has a relatively good prognosis if it is detected early. |
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| =Clinical= | | =Clinical= |
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| **Suspicious microcalcifications and/or suspicious mass. | | **Suspicious microcalcifications and/or suspicious mass. |
| **Most common history on the specimen requisition | | **Most common history on the specimen requisition |
| **May be accompanied by a BI-RADS score (see below) | | **May be accompanied by a [[BI-RADS]] score. |
| *Nipple discharge. | | *Nipple discharge. |
| *Pain. | | *Pain. |
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| ===Breast radiology=== | | ===Breast radiology=== |
| BI-RADS = Breast Imaging Reporting And Data System:<ref>URL: [http://breastcancer.about.com/od/diagnosis/a/birads.htm http://breastcancer.about.com/od/diagnosis/a/birads.htm]. Accessed on: 16 March 2011.</ref>
| | {{Main|Breast imaging reporting and data system}} |
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| *0: Incomplete - come back for more imaging.
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| *1: Negative.
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| *2: Benign finding(s).
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| *3: Probably benign -- often short follow-up.
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| *4: Suspicious abnormality -- needs biopsy.
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| *5: Highly suggestive of malignancy.
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| *6: [[Pathologist]] says there is a malignancy.
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| =Specimens= | | =Specimens= |
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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 and calponin | | ***The immunostains used in breast pathology for the myoepithelial layer include: [[CK5/6]], SMA, [[p63]] and calponin. |
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| ===Questions to Ask=== | | ===Questions to Ask=== |
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| ====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. |
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| ====Basaloid Lesions==== | | ====Basaloid Lesions==== |
| *Adenoid Cystic Carcinoma of the Breast | | *Adenoid cystic carcinoma of the breast. |
| *Intracystic Papillary Breast Carcinoma, Solid Variant | | *Intracystic papillary breast carcinoma, solid variant. |
| *Invasive Papillary Breast Carcinoma, Solid Variant | | *Invasive papillary breast carcinoma, solid variant. |
| *Medullary Breast Carcinoma | | *Medullary breast carcinoma. |
| *Medullary-like Breast Carcinoma | | *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'. |
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| ====Spindle Cell Lesions==== | | ====Spindle Cell Lesions==== |
| *Metaplastic Breast Carcinoma | | *Metaplastic breast carcinoma. |
| *Treated Breast Carcinoma | | *Treated breast carcinoma. |
| *Mammary Myofibroblastoma | | *Mammary myofibroblastoma. |
| *Phyllodes Tumor - stromal component | | *Phyllodes Tumour - stromal component. |
| *Desmoid Fibromatosis | | *Desmoid fibromatosis. |
| *Nodular Fasciitis | | *Nodular fasciitis. |
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| === Additional resources === | | === Additional resources === |
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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 assoc. with malignancy. | | **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". |
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| *[http://www.breastpathology.info/Images/calcs/FatNec1_700.jpg Breast with calcifications (breastpathology.info)]. | | *[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)]. | | *[http://www.wjso.com/content/7/1/70/figure/F3 Resting breast tissue (wjso.com)]. |
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| ===Sign out===
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| ====Reduction mammoplasty====
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| <pre>
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| A. Right Breast (630 grams), Reduction Mammoplasty:
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| - Breast tissue and skin within normal limits.
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| B. Left Breast (680 grams), Reduction Mammoplasty:
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| - Breast tissue and skin within normal limits.
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| </pre>
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| ==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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| {{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=[[Encapsulated papillary carcinoma of the breast|Intracystic<br> (encapsulated)<br>papillary ca.]]}} | | {{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 not clinical signficance. | | **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== |
| ===General===
| | {{Main|Apocrine metaplasia of the breast}} |
| *Benign/not significant. Can be considered to be pretty wallpaper in the house of breast pathology.
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| ====Etiology====
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| *Increased number of mitochondria.
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| **In other body sites this has different names, e.g. ''[[Hurthle cell change]]'' (thyroid), ''[[oncocytoma|oncocytic]] change'' (kidney - [[oncocytoma]], thyroid).
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| ===Microscopic===
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| Features:
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| *Eosinophilic cytoplasm - '''key feature'''.
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| *Voluminous pink cytoplasm.
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| *Apocrine snouts may be present.
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| **Small protrusiona at the apical aspect of the cell (composed of cytoplasm and plasma membrane).
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| *Central round nucleus
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| **Prominent nuclear membrane.
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| **Prominent, often single nucleolus.
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| Note:
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| *Apocrine changes, i.e. cytoplasmic eosinophilia, can appear in malignant tumours; eosinophilia doesn't make something benign.
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| ====Images====
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| <gallery>
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| Image:Fibrocystic_change_-_very_high_mag.jpg | FCC with apocrine metaplasia (right bottom of image) - high mag. (WC/Nephron).
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| Image:Breast ApocrineChange HP CTR.jpg|Breast - Apocrine Change - high power (SKB)
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| </gallery>
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| ==Duct ectasia== | | ==Duct ectasia== |
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| ==Fibrocystic change== | | ==Fibrocystic change== |
| *Abbreviated ''FCC''.
| | {{Main|Breast fibrocystic changes}} |
| *[[AKA]] ''fibrocystic changes''. | | *[[AKA]] ''fibrocystic changes'' (abbreviated ''FCC''). |
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| ===General===
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| *Really common.
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| *Benign.
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| ===Microscopic===
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| Features:
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| *Dilated glands - '''key change'''.
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| **Glands normal: two cell layers present.
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| *Often seen together with ''apocrine metaplasia''.
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| ====Images====
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| <gallery>
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| Image:Fibrocystic_change_-_intermed_mag.jpg | FCC - intermed. mag. (WC/Nephron)
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| Image:Fibrocystic_change_-_very_high_mag.jpg | FCC - high mag. (WC/Nephron)
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| Image:Phyllodes_tumour_-_very_low_mag.jpg | FCC - left of image - and a phyllodes tumour - very low mag. (WC/Nephron)
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| </gallery>
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| ==Columnar cell change== | | ==Columnar cell change== |
| *Abbreviated ''[[CCC]]''.
| | {{Main|Columnar cell change of the breast}} |
| *[[AKA]] ''blunt duct adenosis''.
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| ===General===
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| *Columnar cell change is associated with (benign) calcification - '''key point'''.
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| ===Microscopic===
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| Features:
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| *Secretory cells (line gland lumen) have columnar morphology.
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| *May have "apical snouts".
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| **Blebs or round balls eosinophilic material appear to be adjacent to the cell at their luminal surface.
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| **The snouts are attached to the cell-- appear as round ball only in the plane of section.
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| *Cytoplasm +/-eosinophilia.
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| *Often purple luminal calcifications
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| DDx:
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| *Flat epithelial atypia (>2 cell layers).{{Fact}}
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| **If the columnar cells shows low to intermediate grade atypia the process is termed "flat epithelial atypia"
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| **If higher grade atyia is present the lesion is termed "flat DCIS" (clinging carcinoma)
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| Image:
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| *[http://webpathology.com/image.asp?case=652&n=1 Columnar cell change (webpathology.com)].
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| ==Gynecomastoid hyperplasia== | | ==Gynecomastoid hyperplasia== |
| *[[AKA]] ''gynecomastia''. | | *[[AKA]] ''gynecomastia''. |
| {{Main|Gynecomastoid hyperplasia}} | | {{Main|Gynecomastoid hyperplasia}} |
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| | ==Breast prostheses== |
| | {{Main|Breast prostheses}} |
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| =Lesions with increased risk of malignancy= | | =Lesions with increased risk of malignancy= |
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| ==Florid epithelial hyperplasia== | | ==Florid epithelial hyperplasia== |
| *[[AKA]] ''florid epithelial hyperplasia'', abbreviated ''FEH''.
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| *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''. |
| ===General===
| | {{Main|Florid epithelial hyperplasia}} |
| *Mild increased risk of malignancy ~ 1.5-2x.<ref>{{Ref PCPBoD8|542}}</ref> | |
| *Has to be separated from ''[[mild epithelial hyperplasia]]''.
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| Note:
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| *''Moderate epithelial hyperplasia'' redirects to this section.
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| **It is generally not separated from FEH, as the prognosis is thought to be the same.
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| ===Microscopic===
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| Features:<ref>{{Ref BP|159-160}}</ref>
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| *Breast glands with ''more than'' four cell layers above the basement membrane - '''key feature'''.
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| *Irregular cell spacing; streaming.
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| *Slit-like lumina, esp. at the periphery of the duct.
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| *No [[DCIS]]-like architecture (not cribriform, not papillary, not micropapillary, not solid).
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| *No nuclear atypia - usually no [[nucleoli]].
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| Memory device ''CLEAN'':
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| *'''C'''ell spacing is irregular, '''L'''umina are slit-like, '''E'''xtent is less than 2 mm or 2 ducts, '''A'''rchitecture ''not'' DCIS-like, '''N'''uclear atypia ''not'' present.
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| DDx:
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| *[[Mild epithelial hyperplasia]].
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| *[[Atypical ductal hyperplasia]].
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| *Cribriform [[ductal carcinoma in situ]]
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| ===Sign out===
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| <pre>
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| A. Right Breast (570 grams), Reduction Mammoplasty:
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| - Benign breast tissue with proliferative fibrocystic changes.
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| - Benign skin.
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| B. Left Breast (580 grams), Reduction Mammoplasty:
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| - Breast tissue and skin within normal limits.
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| </pre>
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| Note:
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| *"Proliferative fibrocystic changes" = UDH + fibrocystic changes.
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| ==Sclerosing adenosis== | | ==Sclerosing adenosis== |
| ===General===
| | {{Main|Sclerosing adenosis of the breast}} |
| *Can be scary... can look like [[ductal carcinoma]].
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| *Derived from ''sclerosing''<ref>URL: [http://dictionary.reference.com/browse/sclerosis http://dictionary.reference.com/browse/sclerosis]. Accessed on: 16 March 2011.</ref> (hardening) and ''adenosis'' (glandular enlargement).
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| **Think ''scaring'' + ''lotsa glands'' and you're pretty close.
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| *Management: follow-up, no further treatment.<ref>URL: [http://www.breastcancercare.org.uk/breast-cancer-information/breast-awareness/benign-breast-conditions/sclerosing-lesions http://www.breastcancercare.org.uk/breast-cancer-information/breast-awareness/benign-breast-conditions/sclerosing-lesions]. Accessed on: 30 April 2012.</ref>
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| ===Microscopic===
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| Features:
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| *Acini are smaller than usual and there are more of them.
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| **Acini often slit-like.
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| *Fibrosis (scleroses) - pink on H&E surrounds the acini.
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| **Can mimic a [[desmoplastic reaction]].
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| Notes:
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| *The acini should:
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| **Be in lobular arrangements, i.e. in groups (benign appearance at low power) - '''key feature'''.
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| **Have two cell layers like well-behaved breast glands do.
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| DDx:
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| *Low-grade ductal carcinoma.
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| *[[Tubular adenoma of the breast]].
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| *[[Adenomyoepithelioma]].<ref name=chu>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 http://www.tzuchi.com.tw/file/tcmj/95-1/2-8.pdf]. Accessed on: 28 April 2012.</ref>
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| ==Flat epithelial atypia== | | ==Flat epithelial atypia== |
| ===General===
| | *Abbreviated ''FEA''. |
| Epidemiology:
| | {{Main|Flat epithelial atypia}} |
| *Associated with ADH & DCIS; may represent a non-obligate precursor lesion of ADH & DCIS.<ref name=pmid18384213>{{Cite journal | last1 = Lerwill | first1 = MF. | title = Flat epithelial atypia of the breast. | journal = Arch Pathol Lab Med | volume = 132 | issue = 4 | pages = 615-21 | month = Apr | year = 2008 | doi = 10.1043/1543-2165(2008)132[615:FEAOTB]2.0.CO;2 | PMID = 18384213 }}</ref> | |
| *Low risk of progression to invasive malignancy.<ref name=pmid12927037>{{Cite journal | last1 = Schnitt | first1 = SJ. | title = The diagnosis and management of pre-invasive breast disease: flat epithelial atypia--classification, pathologic features and clinical significance. | journal = Breast Cancer Res | volume = 5 | issue = 5 | pages = 263-8 | month = | year = 2003 | doi = 10.1186/bcr625 | PMID = 12927037 }}</ref>
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| Management:
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| *Excision.
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| ===Microscopic===
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| Features:
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| *"Flat" ~ three cells thick.
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| *Hypercellular gland -- several layers.
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| *Columnar cell morphology.
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| *+/-Apical snouts.
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| ===Images===
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| <gallery>
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| Image:Breast FlatAtypia (3) PA.JPG|Breast - Flat Atypia (SKB)
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| </gallery>
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| DDx:
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| *[[Columnar cell change]].
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| *Columnar cell hyperplasia.
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| *[[ADH]].
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| *Flat [[DCIS]] (clinging carcinoma).
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| *Apocrine cyst - granular cytoplasm.
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| *[[Tubular carcinoma]] - should be considered due to the association.
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| ===Molecular===
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| *Loss of 16q.
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| **Not used for [[diagnosis]].
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| ==Complex sclerosing lesion== | | ==Complex sclerosing lesion== |
| *[[AKA]] ''radial scar''. | | *[[AKA]] ''radial scar''. |
| ===General===
| | {{Main|Complex sclerosing lesion}} |
| *The term ''radial scar'' is a misnomer. It isn't a ''scar''. It isn't associated with prior trauma or surgery.<ref name=Ref_PBoD8_1072>{{Ref PBoD8|1072}}</ref>
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| *May appear malignant on imaging.<ref name=pmid11167596>{{cite journal |author=Ung OA, Lee WB, Greenberg ML, Bilous M |title=Complex sclerosing lesion: the lesion is complex, the management is straightforward |journal=ANZ J Surg |volume=71 |issue=1 |pages=35–40 |year=2001 |month=January |pmid=11167596 |doi= |url=}}</ref>
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| *Associated with subsequent elevated risk of breast cancer.<ref>URL: [http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Radial_Scars.asp http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Radial_Scars.asp]. Accessed on: 4 May 2010.</ref>
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| *Management - usu. surgical excision.<ref name=pmid14514771>{{cite journal |author=Kennedy M, Masterson AV, Kerin M, Flanagan F |title=Pathology and clinical relevance of radial scars: a review |journal=J. Clin. Pathol. |volume=56 |issue=10 |pages=721–4 |year=2003 |month=October |pmid=14514771 |pmc=1770086 |doi= |url=}}</ref>
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| ===Gross===
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| *Spiculated mass.
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| *Usually small - 3-7 mm.
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| ====Image====
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| <gallery>
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| Image:Radial_scar.jpg | Radial scar - gross. (WC)
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| </gallery>
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| ===Microscopic===
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| Features:<ref name=pmid14514771>{{cite journal |author=Kennedy M, Masterson AV, Kerin M, Flanagan F |title=Pathology and clinical relevance of radial scars: a review |journal=J. Clin. Pathol. |volume=56 |issue=10 |pages=721–4 |year=2003 |month=October |pmid=14514771 |pmc=1770086 |doi= |url=}}</ref><ref name=Ref_BP91>{{Ref BP|91}}</ref>
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| *Stellate appearance (low magnification).
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| *Center of lesion has "fibroelastosis" - stroma light pink (on H&E) - '''key feature'''.
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| **Scar like stroma with entrapped normal breast ducts and lobules.
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| **Glands appear to enlarge with distance from center of lesion.
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| Notes:
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| *Histomorphologic appearance may mimic a [[desmoplastic reaction]] of the stroma - leading to a misdiagnosis of malignancy.
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| *"[[Hyaline]] - pink stuff on H&E - is the key."
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| DDx:
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| *[[Invasive ductal carcinoma]] - should be considered if the lesion is asymmetrical ''or'' glands are dilated centrally.
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| ====Images====
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| *[http://www.breastpathology.info/Images/Benign/Radial_scar/rs3a_700.jpg Radial scar (breastpathology.info)].
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| ===IHC===
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| Features:
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| *p63 +ve.
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| *Calponin +ve.
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| Note:
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| *HMWK +ve/-ve. (???)
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| =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}} |
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| ==Lymphocytic mastitis== | | ==Lymphocytic mastitis== |