Difference between revisions of "Breast pathology"

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Breast pathology (view source)

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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.   


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.


=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}}
 
*0: Incomplete - come back for more imaging.
*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=
=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.


===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.


====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'.


====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.


=== Additional resources ===
=== Additional resources ===
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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)].
===Sign out===
====Reduction mammoplasty====
<pre>
A. Right Breast (630 grams), Reduction Mammoplasty:
- Breast tissue and skin within normal limits.
B. Left Breast (680 grams), Reduction Mammoplasty:
- Breast tissue and skin within normal limits.
</pre>


==Lactational changes==
==Lactational changes==
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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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==Columnar cell change==
==Columnar cell change==
*Abbreviated ''[[CCC]]''.
{{Main|Columnar cell change of the breast}}
*[[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.
*Often purple luminal calcifications
 
DDx:
*Flat epithelial atypia (>2 cell layers).{{Fact}}
**If the columnar cells shows low to intermediate grade atypia the process is termed "flat epithelial atypia"
**If higher grade atyia is present the lesion is termed "flat DCIS" (clinging carcinoma)
 
Image:
*[http://webpathology.com/image.asp?case=652&n=1 Columnar cell change (webpathology.com)].


==Gynecomastoid hyperplasia==
==Gynecomastoid hyperplasia==
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==Sclerosing adenosis==
==Sclerosing adenosis==
===General===
{{Main|Sclerosing adenosis of the breast}}
*Can be scary... can look like [[ductal carcinoma]].
*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.
*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>
===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.
**Can mimic a [[desmoplastic reaction]].
 
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:
*Low-grade ductal carcinoma.
*[[Tubular adenoma of the breast]].
*[[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>


==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>
 
Management:
*Excision.
 
===Microscopic===
Features:
*"Flat" ~ three cells thick.
*Hypercellular gland -- several layers.
*Columnar cell morphology.
*+/-Apical snouts.
 
===Images===
<gallery>
Image:Breast FlatAtypia (3) PA.JPG|Breast - Flat Atypia (SKB)
</gallery>
 
DDx:
*[[Columnar cell change]].
*Columnar cell hyperplasia.
*[[ADH]].
*Flat [[DCIS]] (clinging carcinoma).
*Apocrine cyst - granular cytoplasm.
*[[Tubular carcinoma]] - should be considered due to the association.
 
===Molecular===
*Loss of 16q.
**Not used for [[diagnosis]].


==Complex sclerosing lesion==
==Complex sclerosing lesion==
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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==
Michael
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