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