Tumors of the breast Course and slide seminar
Zdeněk K I N K O R
Bioptická laboratoř s.r.o.
PLZEŇ
2006
Intraductal papillary lesions of the breast
Intraductal papillary lesions of the breast
actin
3D studies
papilloma
papilom
papillocarcinoma
Intraductal papillary lesions
Intraductal papilloma
Atypical papilloma / DCIS arising in papilloma ?
Intraductal papillary carcinoma
micropapillary DCIS - is not papillary per se micropapillary IDC - is not papillary per se
radiology / macroscopy is not helpfull in discrimination of benign from malignant lesion
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Intraductal papilloma
1. Central (solitary) - large ducts2. Peripheral (multiple papillomatosis) - TDLU____________________________________
benign, complete myoepitelial rim - globoid cells !
necrosis, apocrine / squamous metaplasia, hyperplasia, sclerosis, pseudoinvasion!
peripheral - more often associated with ADH resp. DCIS
(sampling?)
CNB - controversial - excision vs. watch and wait ?
variants - adenomyoepithelioma, mixed tumor, ductal adenoma nipple adenoma
Intraductal papillary carcinoma
1. Central (intracystic, solitary)
2. Diffuse (multiple) - papillary DCIS
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0,5 - 2 % of all breast carcinomas, in situ lesion !
myoepithelial layer absent; papillary, cribriform, solid
pseudoinvasion, „epithelial displacement“ by CNB
CNB - excision ! - adjacent DCIS / IDC ≤ 50 % - margin !
excellent prognosis - axillary/sentinel LN is not necessary
invasive component - usually nonpapillary G1 IDC
Atypical papilloma(ADH / DCIS in papilloma)
controversial - rare, definition, interpretation (CK 5/6)
more often in peripheral papilloma, CNB - excision !
structural a cytologic atypia - kvantitative criteria ? - confined to papilloma - atypical papilloma (AP) - adjacent ducts - analogous to ADH vs. DCIS
AP is not ! - problem papiloma vs. papillary carcinoma - florid ductal hyperplasia in papilloma
recurrences (DCIS, IDC) were found only in cases, where
„atypia“ extended into surrounding ducts outside of original AP
benignmalignant(in situ !)
atypical papiloma
papiloma
carcinoma (DCIS) in papilloma
papillary carcinoma
Take home message central, solitary lesions are more indolent than peripheral and multiple
papilloma in CNB - excision required any time ?! - radiology
AP is rare; papillary carcinoma arises de novo
intraductal (intracystic) papillary carcinoma - in situ lesion does not metastasize !
prognosis (biology?) of papillary lesion is determined mainly by
findings in surrounding ducts
conservative approach (even at invasion) - margin ! (SLN?)
…let´s move to the scope
Breast on Earth
Let´s have a rest
…even cancer cells are
miracle of the nature…
Low-grade adenosquamous carcinoma
actin
Cam 5.2
Low-grade adenosquamous carcinoma
Rosen - 11 cases (AJSP, 1987); 50 cases in total
recurrent, rarely metastasizing lesions - two cases described
bland-looking → mimic benignancy - RSL, nipple syringoma, FT,..
biphasic lesion - both components are tumorous ! 1) epithelial - oval/curved glandular structures display variable luminal
squamous differentiation (distinct imunophenotype) - one/two flat layers of cells lacking overt atypia - absent myoepithelial rim? 2) mesenchymal - mostly hypocellular, collagenous fibrous stroma - heterologous differentiation - extremely rare
LGASC - differential diagnosis
radial scar - CD34+ desmoplastic stroma with central elastosis - complex ductal epithelial proliferation, calcification - intact myoepithelial layer - origin of LGASK in radial scar ? (Gobbi et al.)
phylloid tumor - benign epithelial component, myoepithelial rim - CD34/CD10/CD117+ stromal projection in cystic epithelial spaces, squamous diff. rare - structural heterogeneous; „stromal overgrowth“
nipple syringoma / microcystic adnexal carcinoma - benign and malignant adnexal skin lesions, not related to glandular breast tissue, different nonneoplastic stroma
The natural beauty
of the Silicon valley
( have you ever been there ?! )
Wherever I go
the „breast topic“
attracts me…
Wherever I go
the „breast topic“
attacs me…
female, 81-year-old
Benign spindle cell stromal tumors of the breast
desmin
Benign spindle cell stromal tumors of the breast
heterogeneous group of lesions with functional variability and combination of morpho- and immunophenotype
1) spindle/oval cells, storiform or hemangiopericytoma- like pattern, lipo-, chondro-, osteometaplasia, „floret-like“
cells., nc. palisading, myxoid change, collagen ropes,…
2) CD34, bcl2, CD99, actin, desmin, ER, PR, AR
common precursor - vim+/CD34+ stromal cell
hybrid a NOS features - genetics? (spindle cell lipoma,..)
plasticity of morfofology a immunofenotype(CD34, bcl2, CD99,
actin,desmin, ER, PR, AR)
vim+/CD34+stromal cell
fibroblastic
myofibroblastic
fibrohistiocytic
mixed
Benign spindle cell stromal tumors of the breast
myofibroblastoma
leiomyoma
spindle cell lipoma-like tumor
solitáry fibrous tumor
fibrous histiocytoma
spindle cell tumor NOS
combinations of…
BSST - differential diagnosis
Benign
fibromatosis
nodular fasciitis
schwannoma, neurofibroma
perineurioma
inflammatory pseudotumor
Malignant
metaplastic carcinoma
malignant myoepithelioma ?
MPNST
synovial sarcoma
myofibroblastic sarcoma
leiomyosarcoma
Future or the past ,
the breast will never stop
to interest the mankind
30-year-old female
Angiomatosis of the breast
Actin S
AVL ?
Hemangioma of the breast
Low-grade angiosarcoma of the breast
High-grade angiosarcoma of the breast
perilobular hemangioma - microscopic lesion ( mm sized )
- the only one that invades in TDLU !
hemangioma - capillary, cavernous, complex,..
angiomatosis
subcutaneous nonparenchymal hemangioma
Benign vascular lesions of the breast
Benign vascular lesions of the breast
well circumscribed, < 2cm , ouside the TDLU but ! - angiomatosis - widely dissects throughout the stroma
structural homogeneous, feeding vessel at the periphery, noncommunicating labyrinth of vascular channels - not absolutely valid
papillary endothelial hyperplasia - confusion with AS ! ( reactive, superficial, circumscribed, intravascular - trombus ) CNB - distinction of low-grade AS mostly impossible
Malignant vascular lesions of the breast
unlimited, > 3 cm , intralobular extension
diffuse growth, structuraly heterogeneous - low-grade periphery often mimics benign lesion ( cave CNB ! )
complex anastomosing vasoformative labyrinth permeating the stroma
nuclear atypia, hyperchromasia, endothelial piling, papillary projections - at least in the center
grade does not realiably predict prognosis
Angiosarcoma of the breast
parenchymal - rare, low-grade lesions prevail
postradiation - high-grade, generally cutaneous
- AVL - low-grade precursor ?
- better outcome ??
in axillary dissection lymphedema (Stewart-Treves syndrom)
heterologous component - phylloid tumor
- metaplastic carcinoma
AVL - atypical vascular lesion of the breast ?
controversial, extremely rare lesion (Rosen)
small solitary or multiple red maculopapules arising in radiated skin - shorter half-time, < 3 years
tiny dermal gaping vascular proliferation, hyperchromasia, hobnail cc., inflammatory background; absent: atypia, mitoses, necrosis, endothelial piling,..
association (progression) with AS - no mets so far - part of morphologic spectrum of AS (Brenn et al.) - foci of angiosarcoma undiscernible from AVL ??
The End