breast pathology 3

Carcinoma of Breast

Dr.CSBR.Prasad, M.D.

Classification of Breast Cancer

• Breast cancers can be classifed histologically based upon the types and patterns of cells that compose them.

• Carcinomas can be invasive (extending into the surrounding stroma) or non-invasive (confined just to the ducts or lobules).

• The "NOS" categories contain carcinomas not easily classified into other histologic types or carcinomas for which minimal tissue was available for diagnosis.

Source: Sabiston – Text book of Surgery, 15th Ed, Vol-1

Medullary carcinoma

Mucinous carcinoma

Adenoid cystic carcinoma

Non-invasive Carcinomas of the Breast

Histologic Type Frequency (%)

5-year Survival (%)

Intraductal Carcinoma (DCIS) 3.6 >99 Lobular Carcinoma in situ (LCIS) 1.6 >99 DCIS & LCIS 0.2 >99 Papillary Carcinoma 0.4 >99 Comedocarcinoma 0.3 >99

Invasive Carcinomas of the Breast

Histologic Type Frequency (%)

5-year Survival

(%) Infiltrating Ductal Carcinoma 63.6 79 Infiltrating Lobular Carcinoma 5.9 84 Infiltrating Ductal & Lobular Carcinoma 1.6 85 Medullary Carcinoma 2.8 82 Mucinous (Colloid) Carcinoma 2.1 95 Comedocarcinoma 1.4 87 Paget's Disease 1.0 79 Papillary Carcinoma 0.8 96 Tubular Carcinoma 0.6 96 Adenocarcinoma, NOS 7.5 65 Carcinoma, NOS 3.5 62

Clinical features

• Mass in the breast• Retraction of the nipple• Pain • Peau d’ orange• Lymphadenopathy• Eczema or ulceration of nipple• Mammographic densities / calcifications• Nipple discharge

Paget’s disease of the nipple.

Peau d’ orange of the breast

Schirrhous carcinoma of the breast.

Note the shrinkning and elevation of the breast with nipple retraction.

Large fungating carcinoma of the right breast with

enlarged axillary lymphnodes.

Carcinoma of the male breast – advanced.

Carcinoma of the male breast.

Lymphangiosarcoma developed after 3years after radical mastectomy.

-Phyllode’s tumor in a women of 18years.

-Weight 18kgs.-Ulceration

(arrow) due to pressure.

Carcinoma in situDCIS – malignant population of cells limited to ducts and lobules by the

basement membrane.

• Vaguely palpable mass• Mammographic calcifications / densities• Incidental finding in biopsy done for some other reason

Sub types (based on the architecture):1-comedo ca2-solid ca3-cribriform ca4-papillary ca5-micropapillary ca

Carcinoma in situ - comedo

• Grossly on the cut surface worm like extrusions (comedons) occur when pressure is applied laterally to the involved area.

• Size of the carcinoma vary, some measuring several centimeters.

The gross appearance of a comedocarcinoma pattern of intraductal carcinoma is seen here, with small, yellow central necrotic areas in the ducts. This pattern is not common, but the overall prognosis for patients with this type of breast carcinoma is generally good. Source: webpath

• Microscopy: solid sheets of pleomorphic cells with

high grade nuclei. central necrosis. intact basement membrane. there may be microcalcifications. periductal concentric fibrosis.

Carcinoma in situ - comedo

Here is a comedocarcinoma pattern of intraductal carcinoma, which is characterized by the presence of rapidly proliferating, high-grade malignant cells. Note the prominent central necrosis in the ducts (arrows). Source: webpath

The cells in the center of the ducts with comedocarcinoma are often necrotic and calcify, as shown here. This central necrosis leads to the gross characteristic of extrusion of cheesy material from the ducts with pressure (comedone-like). Source: webpath

Carcinoma-in-situ of the comedo pattern distending an acinus, not a duct. The lumen contains red cells, necrotic epithelial cells and macrophages

with brown pigment. H&E.http://www.georgetown.edu/dml/educ/path/cpc/gyn_breast/06.html

In-situ and invasive ductal carcinoma with microcalcification. H&E.

http://www.hopkinsbreastcenter.org/pathology/malignant/

Ductal carcinoma in-situ (comedo-type). FNAC. PAP.http://www.hopkinsbreastcenter.org/pathology/malignant/33

Ductal carcinoma in-situ (comedo-type) with central microcalcification. H&E

http://www.hopkinsbreastcenter.org/pathology/malignant/33

Permanent section of the breast lump showing Ductal carcinoma in situ (DCIS - Comedo pattern with central necrosis) along with invasive glands. (H/E, 10x)

http://www.georgetown.edu/dml/educ/path/cpc/gyn_breast/06.html

DCIS ("comedo type), low magnification. (Actual field size 1.5 X 1 mm) This duct has a central plug of necrotic cellular debris (outlined by the arrow heads). The distance from the edge of this necrotic zone to the basal lamina is constant throughout this duct and pathologists assume that the necrosis is due to a lack of a crucial nutrient such as oxygen in cells that have a high metabolic demand. The box shows the area for next Figure. <http://www.georgetown.edu/dml/educ/path/cpc/gyn_breast/06.html>

DCIS ("comedo type"), high magnification. When the cells die, the nuclei undergo pyknosis, or collapse of the nuclear membrane and collapse of the chromatin into dense masses. Over several days, the pyknotic nuclei lose all staining, presumably as the DNA is autolyzed.http://www.georgetown.edu/dml/educ/path/cpc/gyn_breast/06.html

• Monomorphic population of cells • Low to high nuclear grades

• Intraepithelial spaces are evenly distributed and regular in shape – cookie cutter-like

Carcinoma in situ - Cribriform

The classic cribriform pattern of intraductal carcinoma of the breast is shown here. The neoplastic epithelial cells within the duct show minimal hyperchromatism and pleomorphism, but they surround holes with sharp margins, as though punched out by a cookie cutter.

Different cookie cutters

The rigid bars (A) and the round, punched-out open spaces (B) characteristic of this, the most common in situ carcinoma,

are apparent under low magnification. www.wisc.edu/wolberg/comedb_s.html

Both intraductal and infiltrating ductal carcinoma are seen here. Note the intraductal component in the center with cribriform pattern and prominent microcalcifications. Surrounding this are infiltrating carcinoma cells. Source: webpath

Carcinoma in situ – Solid type

• Cells completely fill the involved spaces

Ductal carcinoma in-situ (solid-type). H&E.. http://www.hopkinsbreastcenter.org/pathology/malignant/33

This high power microscopic view demonstrates intraductal carcinoma. Neoplastic cells are still within the ductules and have not broken through into the stroma. Note that the two large lobules in the center contain microcalcifications. Such microcalcifications can appear on mammography. Source: webpath

Carcinoma in situ – Papillary/mcoropapillary types

• Papillary DCIS grows in to spaces and lines the fibrovascular spaces

• No myoepithelial lining

• Micropapillary DCIS shows bulbous protrusions without a fibrovascular core

• May form complex intraductal patterns

Figure 23-18 Noncomedo DCIS. A, Papillary DCIS. Delicate fibrovascular cores extend into a duct and are lined by a monomorphic population of tall columnar cells. Myoepithelial cells are absent. B, Micropapillary DCIS. The papillae are connected to the duct wall by a narrow base and often have bulbous or complex outgrowths. The papillae are solid and do not have fibrovascular cores.

Ductal carcinoma in-situ, micropapillary type. H&E.

Source: jhu week-91case-4

Ductal carcinoma in-situ, micropapillary type. H&E. http://www.hopkinsbreastcenter.org/pathology/malignant/33

Ductal carcinoma in-situ, micropapillary type. FNAC, PAP. http://www.hopkinsbreastcenter.org/pathology/malignant/33

Carcinoma in situ – Paget’s disease

• It’s a rare manifestation of breast ca (1-2%) • Palpable mass is present in 50-60% of cases• Unilateral erythematous eruption with a scale crust• Pruritus is common• May be mistaken for eczema

• Malignant cells extend from DCIS into the nipple without crossing the BM.

• Carcinomas are usually poorly differentiated and over express HER2/Neu

• Prognosis depends on the extent of underlying carcinoma

Figure 23-19 Paget disease of the nipple. DCIS arising within the ductal system of the breast can extend up the lactiferous ducts into nipple skin without crossing the basement membrane. The malignant cells disrupt the normally tight squamous epithelial cell barrier, allowing extracellular fluid to seep out and form an oozing scaly crust over the nipple skin.

Paget's disease of the breast is shown here. Note the overlying hyperkeratosis of the skin, which helps to produce the rough, red, scaling appearance seen grossly, and there is often ulceration. The large cells infiltrating into the epidermis represent intraepithelial extension of an underlying ductal carcinoma in situ or invasive ductal carcinoma. Source: webpath

At high magnification, the large Paget's cells of Paget's disease of breast have abundant clear cytoplasm and appear in the epidermis either singly or in clusters. The nuclei of the Paget's cells are atypical and, though not seen here, often have prominent nucleoli. webpath

A PAS stain demonstrates mucin within the Paget's cells of Paget's disease of the breast. This is evidence for their origin from an underlying ductal carcinoma. By immunoperoxidase staining, they will also be keratin positive and epithelial membrane antigen positive. Source: webpath

Dr.James Paget.Famous man of St. Barts. Described

diseases of breast and bone

DCIS with microinvsion

• Def: foci of tumor cells <0.1cm in diameter invading the stroma.

• Microinvasion is most commonly seen in association with comedocarcinoma.

Lobular Carcinoma in situ - LCIS• Always an incidental finding in biopsies • Not associated with calcifications / densities• Bilateral in 20-40% of women (cf. 10-20% in DCIS)• More common in younger women (80-90% occur before

menopause)

• Small cells that have oval or round nuclei with small nucleoli that do not adhere to one another.

• Signet ring cells containing mucin are present commonly.• LCIS rarely distorts the architecture, and the involved

acini remain recognizable as lobules.• LCIS always express ER/PR and may be negative for

HER2/Neu.

Lobular carcinoma in-situ. H&Ehttp://www.hopkinsbreastcenter.org/pathology/malignant/

Lobular carcinoma in-situ. FNAC, PAP

Infiltrating lobular carcinoma. FNAC, PAP.

Invasive carcinomas

• Almost always present as palpable masses• 50% will have LN mets• Clinical features of malignancy is present• Inflammatory carcinoma is a clinical entity

and is not a specific histological type

Detailed views of the microcalcifications in the CC of

the left breast. [79 year old asymptomatic

woman with screening mammogram.]

http://www.rad.washington.edu/quickcases/cases/Case11/answers.html

Detailed views of the microcalcifications in the CC of the left breast.

This pattern of microcalcifications is classic for ductal carcinoma of the breast. There is not really any differential diagnosis here. This patient needs surgery.

79 year old asymptomatic woman 79 year old asymptomatic woman with screening mammogram.with screening mammogram.

Detailed views of the microcalcifications in the CC of the left breast.

http://www.rad.washington.edu/quickcases/cases/Case11/answers.html

Source: webpath

This mammogram demonstrates a lesion consistent with a neoplasm in the upper portion above and just to the left of the white dot marking the point the patient felt some pain on palpation. On biopsy, this was an infiltrating ductal carcinoma.

Invasive carcinoma - NST• Most common type (70-80%)• Firm to hard and have irregular border• Center of the lesion shows streaks of chaky white

elastotic stroma• Gives a grating sensation while cutting• They are well differentiated with tubules lined by

minimally atypical cells• Typically ER/PR+ when they are WD• And ER/PR- when they are PD

The irregular mass lesion seen here is an infiltrating ductal carcinoma of breast. The center is very firm (scirrhous) and white because of the desmoplasia. There are areas of yellowish necrosis in the portions of neoplasm infiltrating into the surrounding breast. Such tumors appear very firm and non-mobile on physical exam. Source: webpath

This breast biopsy demonstrates a carcinoma. Note the irregular margins and varied cut surface. This small cancer was found by mammography. The margins of the specimen have been inked with green dye following removal to assist in determining whether cancer extends to the margins once histologic sections are made. Source: webpath

Infiltrating ductal carcinoma.Hematoxylin and Eosin stain

This is infiltrating ductal carcinoma of breast. Note the infiltration of ill-defined glands into the surrounding collagenous stroma. There is also a small microcalcification at the lower right of center, a finding that could be seen by mammography. About 65 to 80% of breast cancers are of this type. Source: webpath

This infiltrating ductal carcinoma of breast at low magnification appears to radiate from a central area of desmoplasia. This collagenous component gives the neoplasm a hard "scirrhous" consistency that is palpable. Such an invasive carcinoma may be fixed to underlying chest wall, making it non-mobile. Source: webpath

Note the small nests and infiltrating strands of neoplastic cells with prominent bands of collagen between them in this ductal carcinoma of the breast. It is this marked increase in the dense fibrous tissue stroma that produces the characteristic hard "scirrhous" appearance of the typical infiltrating ductal carcinoma. Note the nerve surrounded by the neoplasm at the lower left. Source: webpath

At high magnification, the pleomorphism of the carcinoma cells within the duct in the center (in a cribriform pattern), as well as the neoplastic cells infiltrating through the stroma and fat, can be seen with this infiltrating ductal carcinoma. webpath

• Clinical presentation is similar to NST• 25% will have diffuse growth pattern without desmoplasia• High incidence of bilaterality

• Most tumors are firm to hard with irregular margins• Minimal desmoplasia• Indian file pattern (typical of LC)• Tumor cells may be seen around the normal duct in

concentric pattern

Invasive Lobular carcinoma

Infiltrating lobular carcinoma. H&E – Indian file pattern

Lobular carcinomas:Lobular carcinomas: They exhibit different pattern of metastasis

They prefer:They prefer:PeritoneumRetroperitoneumMeningesGIT& Ovaries

Mucinous carcinoma

•1-6% of all breast cancers

•Well circumscribed

•Extremely soft

•Majority express hormone receptors

•BRCA1 mutations

•Gray blue gelatinous appearance

•Tumor cell float in a see of mucin

Colloid (mucinous) carcinoma. FNAC, Diff-Quik stain.

Colloid (mucinous) carcinoma. FNAC, PAP.

Colloid (mucinous) carcinoma. H&E.

This variant of breast cancer is known as colloid, or mucinous, carcinoma. Note the abundant bluish mucin. The carcinoma cells appear to be floating in the mucin. This variant tends to occur in older women and is slower growing, and if it is the predominant histologic pattern present, then the prognosis is better than for non-mucinous, invasive carcinomas.

Tubular carcinoma•2% breast cancers

•Multifocal with in one breast 10-55% of cases

•Bilateral in 10-38% of cases

•Well formed tubules

•No myoepithelial layer

•Apocrine snouts in the epithelial cells

Tubular carcinoma. H&E. http://www.hopkinsbreastcenter.org/pathology/malignant/

Ductal carcinoma of the breast showing lymphovascular invasion.

H&E http://www.hopkinsbreastcenter.org/pathology/malignant/33

Tumor embolus from ductal carcinoma in a lymphatic channel. H&E

Medulalry carcinoma• Well circumscribed carcinoma of the breast• May be mistaken for fibroadenoma• Rapidly growing with pushing margins• BRCA1 positive

• Solid syncytium of cells (75% of the tumor)• High nuclear grade• Lymphocytic infiltration• No lymphatic or vascular invasion

Medullary carcinomas account for less than 5% of breast cancers. They can sometimes be large, fleshy masses up to 5 cm in size. At low power, sheets and nests of cells are surrounded by a lymphoid stroma with little desmoplasia. The prognosis with medullary carcinoma is better than for infiltrating ductal or lobular carcinoma. Source: webpath

At high magnification, medullary carcinoma is composed of cells with pleomorphic nuclei that have prominent nucleoli. Though not seen here, foci of necrosis and hemorrhage can be found. Source: webpath

Metaplastic carcinoma

Source: jhu week-113 case-2

St. John's Medical College, Bangalore

This metaplastic breast carcinoma has elements of squamous metaplasia as shown here at high magnification. Such tumors are rare in humans (though common in canines). The metaplastic patterns can include cartilagenous, bony, and myxoid areas as well. Source: webpath

Ductal carcinoma. FNAC. Diff-Quik stain.

Ductal carcinoma, FNAC, Papanicolaou stain

Inflammatory carcinoma• The definition of inflammatory carcinoma is

currently a matter of debate. • Many feel that the diagnosis should be based on

clinical exam with the classic symptoms being increased warmth, erythema, peau d'orange, and skin thickening.

• Others feel that the diagnosis should be made solely on the basis of dermal biopsy.

• The histological appearance is one of diffuse carcinomatous involvement of the dermal lymphatics.

References:Cardenosa, G Breast Imaging Companion. Philadelhia: Lippincott-Raven, 1997 Kopans, D Breast imaging . second edition.Philadelphia: Lippincott Williams & Wilkins 1998

Inflammatory carcinoma

This mastectomy specimen demonstrates the gross findings of "inflammatory" carcinoma of breast. This is not a specific histologic type of breast cancer, but rather it implies dermal lymphatic invasion by some type of underlying breast carcinoma. Such involvement of dermal lymphatics gives the grossly thickened, erythematous, and rough skin surface with the appearance of an orange peel ("peau d'orange"). Source: webpath

The skin overlying the breast has prominent lymphatic spaces filled with small metastases from breast carcinoma. Carcinomas often metastasize to lymphatics. Breast cancers most often metastasize to the axillary lymph nodes, and these nodes are often removed at the time of surgery for breast cancer. Source: webpath

The microscopic appearance of a dermal lymphatic distended by ductal carcinoma of the breast is shown here. This is the hallmark of so-called inflammatory carcinoma of the breast. Source: webpath

Metastatic deposits in breast

Metastatic small cell carcinoma from the lung. FNAC. PAPhttp://www.hopkinsbreastcenter.org/pathology/malignant/

Squamous cell carcinoma. FNAC. PAPhttp://www.hopkinsbreastcenter.org/pathology/malignant/

Metastatic malignant melanoma. FNAC. PAP.http://www.hopkinsbreastcenter.org/pathology/malignant/

Prognostic & predictive factors

• Prognosis is determined by pathological examination of:

1-Primary carcinoma 2-Axillary LNs• This is essential to assess 1-The possible outcome of the disease 2-To choose the appropriate Tx.

• They are divided into: 1-Major PF ((strongest predictor of death from breast cancerstrongest predictor of death from breast cancer))

2-Minor PF

The predictive factors are used to determine the likelihood of response to a particular Tx.

Prognostic & predictive factors

MAJOR PF MINOR PFInvasive Vs in situ Small tumor w or w/o node

positivityDistant mets ER/PR statusLN mets Her-2/NeuTumor size Tumor gradeLocally advanced disease Histological type

Inflammatory carcinoma Proliferation rateDNA contentLVI

Predictive factors - Major

• Invasive Vs in situ - Majority with DCIS when adequate Tx is

given they will be cured of the disease - 50% of invasive Ca show local distant

mets at the time of diagnosis.

• Distant mets: ---with distant mets cure is unlikely ---Long term remission is possible with

hormonally responsive tumors.

Favoured sites for distant mets: Lungs, Bone, Liver, Adrenals and Brain.

• LN mets: --most important factors in the absence of distnat

mets. --LN biopsy is necessary for accurate assessment --Clinical assessment of nodal involvement is very

inaccurate

10yr disease free survival

LN negative 70-80%

One LN positive 35-40%

10 or more LN positive 10-15%

• Sentinel LN biopsy --Radiotracer / colour dye --Identifies the draining LN with high

probability of mets --The question of axillary dissection --Macromets (>0.2cm) – is of proven importance

--Micromets (IHC / RT-PCR) – is of unclear significance

• Tumor size: Risk of axillary LN mets increases with

increasing size of cancer 1-Tumor <1cm LN-negative survival is similar to women witout br.ca 10yr survival is 90% 2-Tumor >2cms 50% will have LN mets Many will die of their disease

• Locally advanced disease:

Tumors with skin or skeletal muscle involvement are frequently associated with concurrent or subsequent distant mets.

• Inflammatory carcinoma: 1-Breast swelling 2-Skin thickening

Very poor prognosis with 3yr survival rate of only 3-10%

Inflammatory carcinoma

The skin overlying the breast has prominent lymphatic spaces filled with small metastases from breast carcinoma. Carcinomas often metastasize to lymphatics. Breast cancers most often metastasize to the axillary lymph nodes, and these nodes are often removed at the time of surgery for breast cancer. Source: webpath

• Women with node + and / or Ca >1cm will benefit from systemic Tx• Women with node – and small carcinoma minor prognostic assessment will tell

who needs additional Tx and who can be left alone.

Among them ER/PR/Her2 are most useful predictors of response to specific Tx.

Predictive factors - Minor

• Histological subtypes:

10yr survival >60% 10yr survival <20% 1-Tubular ca 2-Mucinous ca 3-Medullary ca 4-Lobular ca 5-Papillary ca 6-Adenoid cystic ca

Carcinoma -NST

• Tumor grade: (Scarff-Bloom-Richardson) 1-Nuclear pleomorphism (Small uniform, Moderate

variation, marked variation)

2-Tubule formation (>75%, 10-75%, <10%)

3-Mitotic activity (7, 8-14, >15/10hpf)

10yr survival:Grade-I 80%Grade-II 60%Grade-III 15%

• ER / PR status:

Receptor Response to hormone Tx

Both ER+ & PR+ 80%

Either ER+ or PR+ 40%

ER negativePR negative

Mechanism of estrogen action on cancer cells having estrogen receptor.

The cells of this breast carcinoma are highly positive for estrogen receptor with this immunoperoxidase stain. Source: webpath

This is progesterone receptor (PR) positivity in a breast carcinoma. Carcinomas that are PR positive, but not ER positive, may have a worse prognosis. Source: webpath

This is positive immunoperoxidase staining for C-erb B-2 (HER-2/neu) in a breast carcinoma. Note the membranous staining of the neoplastic cells with the antibody directed against the HER-2 gene product. The drug trastuzumab is a monoclonal antibody directed against HER-2 positive breast cancer cells. Source: webpath

Marker studies• The hormone receptor status of the breast

cancer cells can be useful information for treatment and prognosis.

• The neoplastic cells can express a variety of receptors.

• The presence of these receptors can provide a means for controlling cell growth through chemotherapeutic agents.

Marker studies

• Estrogen receptor (ER)• Progesterone receptor (PR)

Other markers:• Cathepsin D• C-erb B-2 (HER-2/neu)

• In general, cancers in which the cells express estrogen receptor (ER) in their nuclei will have a better prognosis. They can respond to hormonal manipulation.

• The drug tamoxifen is often utilized for this purpose.

• Almost three-fourths of breast cancers expressing ER will respond to this therapy, whereas less than 5% not expressing ER will respond.

Marker studies

• The significance of progesterone receptor (PR) positivity in a breast carcinoma is less well understood.

• In general, cancers that are ER positive will also be PR positive.

• However, carcinomas that are PR positive, but not ER positive, may have a worse prognosis.

Marker studies

• C-erb B-2 (HER-2/neu) is another marker in breast carcinomas, and it is identified around the cytoplasmic membrane of the cells with immunohistochemical methods.

• HER-2 oncogene overexpression is typically the result of gene amplification (more gene copies) and is detected by the fluorescence in situ hybridization (FISH) assay, but in a few cases may be due to transcription activation.

• This gene encodes for an epithelial growth factor receptor on the cell membrane that stimulates cellular proliferation. There is a correlation between HER-2 positivity and high nuclear grade and aneuploidy.

Marker studies

This is positive immunoperoxidase staining for C-erb B-2 (HER-2/neu) in a breast carcinoma. Note the membranous staining of the neoplastic cells with the antibody directed against the HER-2 gene product. The drug trastuzumab is a monoclonal antibody directed against HER-2 positive breast cancer cells. Source: webpath

• LVI (lymphovascular invasion) Tumor cells with in either lymphatic or

vascular spaces is associated with poor prognosis as many have LN mets.

The microscopic appearance of a dermal lymphatic distended by ductal carcinoma of the breast is shown here. This is the hallmark of so-called inflammatory carcinoma of the breast. Source: webpath

Significance of negative surgical margins in Invasive (A) compared with intraductal (B) carcinoma.

• Proliferative rate flow cytometry thymidine labelling mitotic count Ki 67 cyclin E countTumors with high proliferative index are associated

with much worse prognosis.

• Tumror DNA content:

tumor aneuploidy is asociated with worse prognosis.

This mammogram demonstrates a large 10 cm mass lesion consistent with a phyllodes tumor. Source: webpath

Cystosarcoma phyllodes. H&Ehttp://www.hopkinsbreastcenter.org/pathology/malignant/

A phyllodes tumor of the breast is shown here. They arise from interlobular stroma, but unlike fibroadenomas are not common and are much larger. They are low-grade neoplasms that rarely metastasize. They are more cellular than fibroadenomas. Projections of stroma into the ducts create the leaf-like pattern for which these tumors are named

(from the Greek word phyllodes meaning leaf-like).

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