world health organization 4thed classification of tumours
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World Health Organization 4thed
Classification of Tumours of the BreastSG Jordan, SB O’Connor, TJ Lawton
Departments of Radiology and Pathology and Laboratory Medicine
Introduction Invasive Breast Carcinoma (IBC) Molecular Subtypes
Clinical Patterns
References
Acknowledgements
Fibroepithelial Tumours
The World Health Organization (WHO) establishes the standard
for histopathologic diagnoses, defining diagnoses on a per organ
system basis.
The most recent classification of breast tumors is the 4th edition
published in 2012. The publication reflects the views of a
Working Group that convened for a Consensus and Editorial
Meeting at the International Agency for Research on Cancer
(IARC), Lyon France September 1-3, 2011. 90 authors from 24
countries contributed. The end result is an authoritative
reference book that serves as the international standard for
oncologists and pathologists.
This exhibit is designed to increase radiologists’ and
technologists’ understanding of breast pathology, ie to enhance
CME and CEU at this conference.
Breast Cancer 2018
Estimated new cases and deaths from breast cancer in the US
New cases: 266,120 (female); 2,500 (male)
Deaths: 40,920 (female); 500 (male)
IBC No Special Type and Invasive Lobular Carcinoma together account for 70-90% of
invasive carcinoma tumour types. We must be knowledgeable about these and the
remaining 10-30% of invasive carcinoma tumour types. Given the sheer annual number
of newly diagnosed breast cancers, the uncommon breast tumour types ie special
tumour types will be seen in your practice.
Epithelial Tumours
Invasive breast carcinomaInvasive carcinoma of no special type
Invasive lobular carcinoma
Tubular carcinoma
Cribriform carcinoma
Mucinous carcinoma
Carcinoma with medullary features
Carcinoma with apocrine differentiation
Carcinoma with signet-ring-cell differentiation
Invasive micropapillary carcinoma
Metaplastic carcinomas
Carcinoma with neuroendocrine features
Secretory carcinoma
Invasive papillary carcinoma
Acinic cell carcinoma
Mucoepidermoid carcinoma
Polymorphous carcinoma
Oncocytic carcinoma
Lipid-rich carcinoma
Glycogen-rich clear cell carcinoma
Sebaceous carcinoma
Salivary gland/skin adnexal type tumours
Epithelial-myoepithelial tumours
Precursor lesions
Ductal carcinoma in situ
Lobular neoplasia
Intraductal proliferative lesions
Papillary lesions
Benign epithelial proliferations
Invasive NST Invasive Lobular
Tubular
DCIS
Medullary Metaplastic
Mucinous
Fibroadenoma
Phyllodes: Benign, Borderline, Malignant
Hamartoma
Lakhanii SR, Ellis IO, et al. WHO Classification of Tumours of the Breast,
4th edition. Lyon, France: International Agency for Research on Cancer
(IARC) Press 2012
Mesenchymal Tumours
WHO 4thed Broad Categories
Epithelial Tumours
Mesenchymal Tumours
Fibroepithelial Tumours
Tumours of the Nipple
Malignant Lymphoma
Metastatic Tumours
Tumours of the Male Breast
Clinical Patterns
Nodular fasciitis Myofibroblastoma
Desmoid-like fibromatosis Inflammatory myofibroblastic tumour
Lipoma Liposarcoma
Angiosarcoma Rhabdomyosarcoma
Osteosarcoma Pseudoangiomatous stromal hyperplasia
Leiomyoma Leiomyosarcoma
Benign vascular lesions - haemangioma, angiomatosis, atypical vascular
Granular cell tumour and benign peripheral nerve-sheath tumours -
neurofibroma and schwannoma
PASHMucinous Carcinoma
MyofibroblastomaLipoma
Fibroadenoma
Differences in the molecular definition of breast
carcinomas account for the heterogeneity of breast
cancer presentation and clinical course. Knowledge
of the differing tendencies of each type of breast
carcinoma assists in understanding disease prognosis
and directing care recommendations.
Molecular Subtypes 2017
Luminal A
Luminal B
Her2 enriched
Basal type
These are defined by their gene expression pattern:
Luminal are hormone receptor+ with associated
genes, distinguished as low (luminal A) or high
(luminal B) Ki67; Her2 enriched are HER2+; Basal
type are TNBC, and have catalogued clinical
patterns and treatment responses/outcomes per
subtype.
Tumours of the Nipple
Paget Disease
Nipple adenoma
Syringomatous tumor of the nipple (SyT)
Joanna Schneider UNC SOM Class of 2019
North Carolina Radiological Society
Paget Nipple adenoma
Metastatic Tumours
Tumours of the Male Breast
Defined: Tumour-like or tumour conditions
occurring exclusively in a male
Gynecomastia
Male breast cancer
Defined: Metastasis to the breast from a malignancy arising outside the breast
Wide range of extramammary malignancies can metastasize:
Haematological malignancies, Melanoma, Carcinomas of lung, ovary, prostate,
kidney and stomach, Carcinoid
In children: Rhabdomyosarcoma and Lymphoma
Mammography most commonly shows round, circumscribed mass(es) that are
rarely spiculated or calcified. These require CNB for diagnosis
Gynecomastia Male breast CA
Phyllodes Invasive Lobular DCIS
2017
NEW! in this WHO edition are 2 Clinical Patterns
BILATERAL BREAST CANCER (BBC)
Defined: primary carcinoma developing in both
breasts. One must first exclude metastasis from
contralateral cancer (CBC), pts with local, regional,
distant mets more likely to have CBC. BBC certain
if one breast is DCIS or the histologies are
different. 2-6% of breast cancers are BBC.
INFLAMMATORY BREAST CANCER
Defined: Rare but aggressive form of invasive
cancer with distinct clinical and/or pathologic
characteristics. The clinical inflammatory sx are due
to the presence of numerous dermal lymphatic
emboli, with rapid breast enlargement and skin
redness, edema, orange-peel. A skin bx is
NOT required but is helpful as it confirms dermal
lymphatic involvement. Invasive cancer NST grade
3 is the most common histologic type.
• https://seer.cancer.gov/statfacts/html/breast.html
• Dillon DA, Guidi AJ, Schnitt SJ. Chapter 28: Pathology
of Invasive Breast Cancer, in Harris JR, Lippman ME,
Morrow M, Osborne CK. Diseases of the Breast, 4th
edition, Lippincott Williams & Wilkins, 2010
• Lakhani SR, Reis-Filho JS, van de Vijer MJ.
Molecular pathology overview in Lakhani, SR, Ellis,
IO et al. WHO Classification of Tumours of the
Breast, 4th edition. Lyon, France: International Agency
for Research on Cancer (IARC) Press 2012
• Yerushalmi R, Hayes M, Gelmon K. Breast carcinoma
- rare types: review of the literature. Annals of
Oncology 20: 1763–1770, 2009
Medullary Carcinoma Invasive Micropapillary Papilloma with DCIS Invasive Carcinoma NST
GCT
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