session 5

Session 5

Diagnosis - Sclerosing adenosis with

lobular neoplasia.

No invasion in images provided.

Update - Risk with LISN

Meta-analysis 9 studies of 228 patients

15% ipsilateral, 9% contralateral carcinoma

Ipsilateral 3x more likely than contralateral

• A “model of premalignancy for ALH intermediate between a local precursor and a generalised risk for both breasts”

Page DL. Lancet. 2003;361:125-9

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.



Is there a sub-group of pre-invasive LCIS? LCIS with Microinvasion

6 LCIS with microinvasion described

Nemoto T et al. J Surg Oncol 1998; 67; 41-46

Case 19

Diagnosis - Fibrocystic change with

papillomas and florid usual epithelial hyperplasia

Case 32

Diagnosis - Fibrocystic change with

atypical lobular hyperplasia and flat high grade DCIS

Case 54

Diagnosis - Radial scar with florid usual

epithelial hyperplasia

• Central fibro-elastosis with entrapped tubular structures

• Usual epithelial hyperplasia

• Helpful features – retraction around tubular structures – often seen in radial scars

• Lack of fibroblastic stromal reaction (commonly, but not invariably seen (!) in tubular carcinoma)

• Confirm presence of myoepithelial cells and exclude diagnosis of tubular carcinoma (e.g. with smooth muscle myosin or smooth muscle actin or p63)

• In the epithelial proliferation look for (a) mixed population, (b) streaming and (c) slit-like peripheral spaces

Radial Scar

Case 44

Diagnosis - High grade DCIS with comedo-

type necrosis and cancerisation of lobules.

No invasion or microinvasion.

MicroinvasionMicroinvasion• DCIS with a focus of invasion less than 1mm in

max. dimension• More than one focus, if each less than 1mm

Individual deposits may vary in size from a few islands to 1 mm diameter

• In the non-specialised, interlobular or inter-ductal connective tissue - neoplastic islands definitely within interlobular fibrous or adipose tissue

Excludes:Ultrastructural or immunocytochemical evidence of

breached or discontinuous basement membrane"Cancerisation of lobules"

Microinvasion

Observations

• Associated with high-grade comedo DCIS more than other types

• Increasing risk of axillary node involvement with increasing duct space involvement (>50 ducts)

Microinvasion

Problems of interpretation

• Duct boundary poorly defined

• Periductal fibrosis

• Indistinct basement membrane zone

• Tangential cutting of involved duct/lobule

Microinvasion

Tips

• Outside organoid structures

• Involves non-specialised stroma

• Host lymphocytic response

• No myoepithelial component

Microinvasion

Key points

• Restrictive definition

• Rare

• Axillary node involvement low

• Prognosis very good

Case 11a

Diagnosis -Medullary-like carcinoma





CASE ?

• 36 year old patient

• Mastectomy and ALND post chemotherapy

• 5 months previously had core from 41mm mobile hypoechoic mobile mass in RUOQ





Core Biopsy• B5, invasive carcinoma of provisional (core)

grade 3 (333) and no special type

• ER = 6/8

• PGR = 0/8

• HER2 = negative (score 0)





Diagnosis

Residual carcinoma cells mimicking histiocytes





• Central fibrotic scarring usually seen

• Patchy chronic inflammation within and around fibrosis

• Oedema or mucinous or myxoid changes to stroma or even areas of necrosis

• Cancer cells may mimic histiocytes, and vice versa, but collections of macrophages may also be present

• Cytokeratin IHC invaluable

Post-Chemotherapy Changes





Grade 1 Some alteration to individual cells but no overall reduction in numbers compared to pre-treatment core

Grade 2 Mild loss of invasive cells, still high cellularityGrade 3 Considerable reduction, up to 90% lossGrade 4 Marked reduction - only small clusters of

widely dispersed cells detectedGrade 5 No invasive carcinoma, in situ carcinoma or

tumour stroma may still be noted

Bonadonna G et al. J Natl Cancer Inst. 1990 3;82:1539-45Smith IC et al. J Clin Oncol 2002;20:1456-66

Response to Chemotherapy





Response to Chemotherapy

1. Disappearance of all tumour

2. Presence of in situ carcinoma but no residual invasive tumour & no metastatic carcinoma found in the lymph nodes

3. Invasive carcinoma present with stromal changes, such as sclerosis or fibrosis

4. Few modifications of appearance of tumour

Chevallier B et al. Am J Clin Oncol 1993;16:223–228

session 5

Documents

diagnosis of tubular

diagnosis fibrocystic

diagnosis high grade

diagnosis radial scar

epithelial proliferation

invasive lcis

focus of invasion

update risk