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Difference between revisions of "Breast pathology"
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The world of pathology can neatly be divided into two... those that like the breast and those that don't. | The world of pathology can neatly be divided into two... those that like the breast and those that don't. | ||
=Clinical= | |||
Classic presentation: | Classic presentation: | ||
*Nipple discharge. | *Nipple discharge. | ||
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# The incidence of breast cancer is lower. | # The incidence of breast cancer is lower. | ||
=Specimens= | |||
Breast comes in three main flavours: | Breast comes in three main flavours: | ||
#Core needle biopsy (CNB). | #Core needle biopsy (CNB). | ||
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#Calcifications - abnormality may be very small; typically 10 levels. | #Calcifications - abnormality may be very small; typically 10 levels. | ||
=Normal histology= | |||
*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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*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. | ||
=Where to start= | |||
The following entities are a starting point for understanding | The following entities are a starting point for understanding routine breast pathology & some of challenges in breast pathology: | ||
#Apocrine change. | #Apocrine change. | ||
#*Pink benign cells. | #*Pink benign cells. | ||
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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. | 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. | *Normal. | ||
*Benign. | *Benign. | ||
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*''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= | |||
==Non-invasive breast cancer== | ==Non-invasive breast cancer== | ||
{{main|Non-invasive breast cancer}} | {{main|Non-invasive breast cancer}} | ||
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This is includes descriptions of the usual types... and the not so common ones. | 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 ''epithelial hyperplasia of the usual type (EHUT)'' - instead of - ''benign breast tissue''. | 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 ''epithelial hyperplasia of the usual type (EHUT)'' - instead of - ''benign breast tissue''. | ||
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**In other body sites this has different names, e.g. ''[[Hurthle cell change]]'' (thyroid), ''[[oncocytoma|oncocytic]] change'' (kidney - [[oncocytoma]], thyroid). | **In other body sites this has different names, e.g. ''[[Hurthle cell change]]'' (thyroid), ''[[oncocytoma|oncocytic]] change'' (kidney - [[oncocytoma]], thyroid). | ||
=== | ===Microscopic=== | ||
Features: | Features: | ||
*Eosinophilic cytoplasm. | *Eosinophilic cytoplasm. | ||
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==Fibrocystic change== | ==Fibrocystic change== | ||
*Abbreviated ''FCC''. | |||
===General=== | ===General=== | ||
*Really common. | *Really common. | ||
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==Flat epithelial atypia== | ==Flat epithelial atypia== | ||
===Epidemology=== | ===Epidemology=== | ||
*Associated with LCIS.<ref>MUA 5 | *Associated with LCIS.<ref>MUA. 5 March 2009.</ref> | ||
===Microscopic=== | ===Microscopic=== | ||
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===General=== | ===General=== | ||
*Can be scary... can look like [[ductal carcinoma]]. | *Can be scary... can look like [[ductal carcinoma]]. | ||
*Derived from ''sclerosing''<ref>[http://dictionary.reference.com/browse/sclerosis http://dictionary.reference.com/browse/sclerosis]</ref> (hardening) and ''adenosis'' (glandular enlargement) | *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) | ||
**Think ''scaring'' + ''lotsa glands'' and you're pretty close. | **Think ''scaring'' + ''lotsa glands'' and you're pretty close. | ||
=== | ===Microscopic=== | ||
Features: | |||
*Acini are smaller than usual and there are more of them. | *Acini are smaller than usual and there are more of them. | ||
*Fibrosis (scleroses) - pink on H&E surrounds the acini. | *Fibrosis (scleroses) - pink on H&E surrounds the acini. | ||
**Can mimic a [[dysmoplastic reaction]]. | **Can mimic a [[dysmoplastic reaction]]. | ||
== | Notes: | ||
*The acini should be: | |||
**In lobular arrangements, i.e. in groups. | |||
**Round. | |||
**Have two cell layers - like good breast glands do. | |||
==Complex sclerosing lesion== | |||
===General=== | ===General=== | ||
*AKA ''''' | *[[AKA]] ''radial scar''. | ||
**The term is a misnomer. It isn't a ''scar''. It isn't associated with prior trauma or surgery.<ref name=Ref_PBoD8_1072>{{PBoD8|1072}}</ref> | |||
*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> | *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> | ||
*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> | *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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===General=== | ===General=== | ||
*Very common benign finding. | *Very common benign finding. | ||
*The pathology is in the stroma; so, the lesion is really a misnomer by the naming rules. | |||
**It ought to be called ''adenofibroma'', as the glandular component is benign and the stromal component lesional. | |||
Management: | |||
*Local excision. | *Local excision (without a large margin). | ||
=== | ===Microscopic=== | ||
Features (not otherwise specified): | |||
*Myxoid stroma -- most '''important feature'''. | *Myxoid stroma -- most '''important feature'''. | ||
**Stroma is white/pale on H&E -- normal stroma is pink on H&E. | **Stroma is white/pale on H&E -- normal stroma is pink on H&E. | ||
*Compression of glandular elements -- commonly seen. | *Compression of glandular elements -- commonly seen. | ||
* | Features (juvenile variant): | ||
** | *"Looks more malignant": | ||
** | **More mitoses. | ||
**More atypical nuclei. | |||
**More cellular. | |||
Notes: | |||
*There is stuff about ''intracanalicular'' vs. ''pericanalicular''.<ref>URL: [http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970216-9 http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970216-9]. Accessed on: 16 March 2011.</ref> It is irrelevant; there is no prognostic difference between the two. | |||
*The ''juvenile variant'', as the name suggests, is typically found in younger patients. | |||
===DDx=== | ===DDx=== | ||
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*Factor VIII -ve. | *Factor VIII -ve. | ||
=Weird stuff= | |||
Like in all niches of pathology... there is weird stuff. | |||
==Diabetic mastopathy== | ==Diabetic mastopathy== | ||
===General=== | |||
*Diabetes mellitus. | |||
===Microscopic=== | |||
Features:<ref>URL: [http://www.breastpathology.info/Case_of_the_month/2007/COTM_0707%20discussion.html http://www.breastpathology.info/Case_of_the_month/2007/COTM_0707%20discussion.html]. Accessed on: 28 November 2010.</ref> | Features:<ref>URL: [http://www.breastpathology.info/Case_of_the_month/2007/COTM_0707%20discussion.html http://www.breastpathology.info/Case_of_the_month/2007/COTM_0707%20discussion.html]. Accessed on: 28 November 2010.</ref> | ||
* Stromal collagen with keloid-like changes. | * Stromal collagen with keloid-like changes. | ||
* Lymphocytic infiltrates: | * Lymphocytic infiltrates: | ||
** Lobules. | ** Lobules. | ||
** | ** Perivascular. | ||
* Enlarged stromal fibroblasts. | * Enlarged stromal fibroblasts. | ||
=Breast radiology= | |||
BI-RADS = Breast Imaging Reporting And Data System<ref>[http://breastcancer.about.com/od/diagnosis/a/birads.htm http://breastcancer.about.com/od/diagnosis/a/birads.htm]</ref> | BI-RADS = Breast Imaging Reporting And Data System<ref>[http://breastcancer.about.com/od/diagnosis/a/birads.htm http://breastcancer.about.com/od/diagnosis/a/birads.htm]</ref> | ||
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*6: Pathologist says there is a malignancy. | *6: Pathologist says there is a malignancy. | ||
=See also= | |||
*[[Breast cytopathology]]. | *[[Breast cytopathology]]. | ||
*[[Salivary gland]]. | *[[Salivary gland]]. | ||
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*[[Non-invasive breast cancer]]. | *[[Non-invasive breast cancer]]. | ||
=References= | |||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Breast pathology]] | [[Category:Breast pathology]] | ||
=External links= | |||
*[http://www.breastpathology.info/Case_of_the_month/cotm_root.html A collection of breast pathology cases (breastpathology.info)]. | *[http://www.breastpathology.info/Case_of_the_month/cotm_root.html A collection of breast pathology cases (breastpathology.info)]. | ||