breast pathology i march 15. 2015
TRANSCRIPT
BREASTBREAST
LYMPHATIC DRAINAGE
AXILLARY (MOSTLY)
INTERNAL MAMMARY
SUPRACLAVICULAR
L
O
B
E
LOBULE
NORMAL lobule
One single
ACINUS(alveolus)
Epithelial cells
MYO-epithelial cells
Histology of the Normal Breast
Terminal duct
Lobular unit
Intralobular stroma
Interlobular stroma
Ductal CarcinomasArise Here
Lobular CarcinomasArise Here
Terminal Duct Lobular Unit
Epithelium
Myoepithelium
Immunostain for Smooth Muscle Actin
Epithelium
Myoepithelium
THREE NORMAL PHASES
• ACTIVE: about 50-50 Gland/Stroma ratio
• LACTATING: Mostly Glands (like
thyroid!!!), >>>50/50
• ATROPHIC: mostly stroma, <<<50/50
Pregnancy/Lactation
Prominent nucleoli
Lactational Change
post menopausal
QUIZ ???
BREAST PATHOLOGY
• DEVELOPMENTAL:• DEGENERATION:• INFLAMMATION:• NEOPLASM:
DEVELOPMENTAL
• MILKLINE REMNANTS• ACCESSORY (axillary) BREAST
TISSUE• NIPPLE INVERSION• MACROMASTIA
accessory nipples.
ACCESSORY
(axillary)
BREAST
TISSUE
Nipple retraction 1) CONGENITAL
2) ACQUIRED: CARCINOMA
3) ACQUIRED: PIERCING
Macromastia.
INFLAMMATION
• Acute Mastitis, staph most common• Duct-Ectaia, Periductal• Fat Necrosis, usually trauma• Lymphcytic, i.e., diabetic• Granulomatous, sarcoid, TB, etc., but
mostly idiopathic
ACUTE MASTITIS
Pap smear of nipple exudate
DUCTESIA
Ductesia CYSTS
Fat necrosis
FAT NECROSIS
FAT NECROSIS
FAT NECROSIS
LYMPHOYCYTIC MASTITISLYMPHOYCYTIC MASTITIS
(DIABETIC MASTOPATHY)(DIABETIC MASTOPATHY)
GRANULOMATOUS MASTITIS
GRANULOMATOUS MASTITIS
Fibrocystic Changes
Non-proliferative epithelium:
(cysts, fibrosis, adenosis). Proliferative (epithelial hyperplasia), without
atypia;• Mild epithelial hyperplasia,
• Moderate epithelial hyperplasia
• Florid epithelial hyperplasia Proliferative with atypia; (= CIS)
• Atypical epithelial hyperplasia.
Sclerosing adenosis.
CLINICAL PRESENTATIONS
•MASS,
palpable or mammographic
• NIPPLE DISCHARGE• PAIN
CYST
Blue dome cyst
FIBROSIS + CYSTS = FIBROCYSTIC DISEASE
FIBROCYSTIC DISEASE
CUBOIDAL
COLUMNARRED COLUMNAR
i.e. “APOCRINE”
ADENOSIS ↑ acini/lobule
CYST, GROSS
CYST, MICROSCOPIC
Duct hyperplasia & Periductal inflammation
Normal acinusNormal Duct
Intraductal Hyperplasia
• Definition: An increase above the normal, 2-cell layer thickness– Mild hyperplasia: 3-4 cell layers thick– Moderate hyperplasia: with epithelial
tufting and bridging– Severe (florid) hyperplasia: filling and
distending ducts
Proliferative Fibrocystic Change WITH Atypia
• Atypical Intraductal Hyperplasia• Atypical Lobular Hyperplasia
Epithelial Hyperplasia
papillary simple hyperplasia
(Ductal papillomatosis)
Moderate hyperplasia
Florid hyperplasia
FEATURES OF “ATYPIA”
• LOSS OF STROMA BETWEEN ACINI
• “SWISS CHEESE” HYPERPLASIA*
• CRIBRIFORMING**
• CELLULAR PLEOMORPHISM
• CELLULAR HYPERCHROMASIA
• INCREASED/ABNORMAL MITOSES*
• “ROMAN” BRIDGES***
• NECROSIS*** (“COMEDO-carcinoma”)
Ductal hyperplasia, Florid atypical
Epithelial Hyperplasia
Ductal hyperplasia
“SCLEROSING” ADENOSIS
Easy mistaken for ca.
SCLEROSING ADENOSIS
(RADIAL SCAR)
“SCLEROSING” ADENOSIS
NEOPLASIA
• Benign epithelial• Fibroadenoma• Intraductal papilloma
• Benign stromal• Benign Phyllodes tumor
• Premalignant• Malignant epithelial (adenocarcinomas )• Ductal, lobular• in-situ, infiltrating
• Malignant stromal• Malignant Phyllodes tumor (
Fibroadenoma
Homogeneous lesion with well circumscribed border
Fibroadenoma (Benign Biphasic Tumor)
Fibroadenomas will “shell out” at surgery
Fibroadenoma
Cleft
Fibroadenoma
FIBROADENOMA
Branching compressed ducts
Homogeneous stroma
Fibroadenoma
FIBROADENOMA
PAPILLOMA
Most papillomas arise in larger mammary ducts
Intraductal papilloma
Intraductal papilloma
Duct lining
Stalk
PAPILLOMA
PAPILLOMA
Relative Risk for Invasive Carcinoma Based on Histologic Evaluation of Breast Tissue Without Invasive Carcinoma
• NON-Proliferative Fibrocystic Changes (1X, No increased risk) – Small simple cysts, apocrine metaplasia, mild epithelial hyperplasia
• Proliferative Fibrocystic Changes (1.5-2X, Slight increased risk) – Moderate to florid hyperplasia– Sclerosing adenosis– Intraductal papilloma– Fibroadenoma
• Proliferative Fibrocystic Changes WITH ATYPIA (3-5X, Moderate increased risk)– Atypical ductal hyperplasia– Atypical lobular hyperplasia
• Carcinoma IN SITU (8-10X, HIGH RISK)– Ductal carcinoma in situ (DCIS)– Lobular carcinoma in situ (LCIS)
Atypical hyperplasia with family history or in a premenopausal woman has a risk of invasive carcinoma similar to DCIS
Relative Risk of Invasive Breast Carcinoma
Phyllodes Tumor
Note the size!
“Leaf-like” architecture
Increased mitotic activity
Malignant Phyllodes Tumor < 15%
6. Breast Cancer Pathology
In Situ CarcinomasInvasive CarcinomasSpecial Subtypes
FEATURES OF “ATYPIA”
• LOSS OF STROMA BETWEEN ACINI
• “SWISS CHEESE” HYPERPLASIA*
• CRIBRIFORMING**
• CELLULAR PLEOMORPHISM
• CELLULAR HYPERCHROMASIA
• INCREASED/ABNORMAL MITOSES*
• “ROMAN” BRIDGES***
• NECROSIS*** (“COMEDO-carcinoma”)
NORMAL DUCT NORMAL ACINUS
ATYPICAL HYPERPLASIA of DUCT ATYPICAL HYPERPLASIA, LOBULE
DCIS
Comedo type
DCIS
Cribriform type
DCIS
DCIS, microcalcifications
DCIS, microcalcifications
DCIS, ROMAN BRIDGES
NORMAL lobule
LCIS
5. Breast Pathology Specimens
Surgical Procedures to Sample Breast Lesions
Fine Needle Aspirate Biopsy of the Breast
• Analogy- predicting the picture of a completed puzzle by examining the unassembled pieces
• May be the initial evaluation of a palpable mass• Advantages over open biopsy:
– Fast– Cost effective– May eliminate an unnecessary procedure
• Disadvantages:– False negatives and false positives
Fine Needle Aspirate Biopsy of the Breast
• Benign Breast Cytology- – Cohesive groups of uniform ductal epithelial
cells without atypia
• Malignant Breast Cytology-– Poorly cohesive cells with atypia
(pleomorphism, enlarged nuclei, large nucleoli, mitotic activity)
– May see necrosis
• The “Triple Test”:– Clinical picture– Mammographic findings– Cytologic findings
Fine Needle Aspiration (FNA)
FNA Cytology Smear Specimen
Fine Needle Aspiration: Benign Ductal Epithelium Versus Breast Cancer
Needle Core Biopsy
Paget disease
Paget disease of the breast
Extramammary Paget disease
Invasive carcinoma
Invasive ductal carcinoma
Invasive lobular carcinoma
Tumor grade
• HISTOLOGY– Glands– Nuclei– Mitosis
• CYTOLOGY– Nuclei
• Size• Membrane• Chromatin• Nucleoli
Nuclear grade 1-3Good correlation with histologic grade