Transcript Breast tumors

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
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Intraductal papilloma
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Atypical papilloma / DCIS arising in papilloma ?
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Intraductal papillary carcinoma
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micropapillary DCIS - is not papillary per se
micropapillary IDC - is not papillary per se
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radiology / macroscopy is not helpfull in discrimination of
benign from malignant lesion
Intraductal papilloma
1. Central (solitary) - large ducts
2. Peripheral (multiple papillomatosis) - TDLU
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benign, complete myoepitelial rim - globoid cells !
necrosis, apocrine / squamous metaplasia, hyperplasia,
sclerosis, pseudoinvasion!
peripheral - more often associated with ADH resp. DCIS
(sampling?)
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CNB - controversial - excision vs. watch and wait ?
variants - adenomyoepithelioma, mixed tumor, ductal adenoma
nipple adenoma
Intraductal papillary carcinoma
Central (intracystic, solitary)
2. Diffuse (multiple) - papillary DCIS
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1.
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0,5 - 2 % of all breast carcinomas, in situ lesion !
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myoepithelial layer absent; papillary, cribriform, solid
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pseudoinvasion, „epithelial displacement“ by CNB
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CNB - excision ! - adjacent DCIS / IDC ≤ 50 % - margin !
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excellent prognosis - axillary/sentinel LN is not necessary
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invasive component - usually nonpapillary G1 IDC
Atypical papilloma
(ADH / DCIS in papilloma)
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controversial - rare, definition, interpretation (CK 5/6)
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more often in peripheral papilloma, CNB - excision !
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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
papillary carcinoma
papiloma
benign
atypical papiloma
malignant
(in situ !)
carcinoma (DCIS) in papilloma
Take home message
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central, solitary lesions are more indolent than peripheral and
multiple
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papilloma in CNB - excision required any time ?! - radiology
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AP is rare; papillary carcinoma arises de novo
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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
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Rosen - 11 cases (AJSP, 1987); 50 cases in total
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recurrent, rarely metastasizing lesions - two cases described
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bland-looking → mimic benignancy - RSL, nipple syringoma, FT,..
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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
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radial scar
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CD34+ desmoplastic stroma with central elastosis
complex ductal epithelial proliferation, calcification
intact myoepithelial layer
origin of LGASK in radial scar ? (Gobbi et al.)
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phylloid tumor - benign epithelial component, myoepithelial rim
- CD34/CD10/CD117+ stromal projection in cystic
epithelial spaces, squamous diff. rare
- structural heterogeneous; „stromal overgrowth“
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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
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heterogeneous group of lesions with functional variability
and combination of morpho- and immunophenotype
1)
spindle/oval cells, storiform or hemangiopericytomalike pattern, lipo-, chondro-, osteometaplasia, „floret-like“
cells., nc. palisading, myxoid change, collagen ropes,…
2)
CD34, bcl2, CD99, actin, desmin, ER, PR, AR
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common precursor - vim+/CD34+ stromal cell
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hybrid a NOS features - genetics? (spindle cell lipoma,..)
Benign spindle cell stromal tumors of the breast
vim+/CD34+
stromal cell
myofibroblastoma
leiomyoma
myofibroblastic
spindle cell lipoma-like
tumor
solitáry fibrous tumor
spindle cell tumor NOS
fibrous histiocytoma
combinations of…
plasticity of morfofology
a immunofenotype
(CD34, bcl2, CD99,
actin,desmin,
ER, PR, AR)
fibroblastic
fibrohistiocytic
mixed
BSST - differential diagnosis
Benign
Malignant
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fibromatosis
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metaplastic carcinoma
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nodular fasciitis
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malignant myoepithelioma ?
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MPNST
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synovial sarcoma
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myofibroblastic sarcoma
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leiomyosarcoma
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schwannoma, neurofibroma
perineurioma
inflammatory pseudotumor
Future or the past ,
the breast will never stop
to interest the mankind
30-year-old
female
Angiomatosis of the breast
Actin S
Hemangioma of the breast
AVL ?
Low-grade angiosarcoma of the breast
High-grade angiosarcoma of the breast
Benign vascular lesions of the breast
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perilobular hemangioma - microscopic lesion ( mm sized )
- the only one that invades in TDLU !
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hemangioma - capillary, cavernous, complex,..
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angiomatosis
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subcutaneous nonparenchymal hemangioma
Benign vascular lesions of the breast
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well circumscribed, < 2cm , ouside the TDLU
but ! - angiomatosis - widely dissects throughout the stroma
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structural homogeneous, feeding vessel at the periphery,
noncommunicating labyrinth of vascular channels - not
absolutely valid
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papillary endothelial hyperplasia - confusion with AS !
( reactive, superficial, circumscribed, intravascular - trombus )
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CNB - distinction of low-grade AS mostly impossible
Malignant vascular lesions of the breast
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unlimited, > 3 cm , intralobular extension
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diffuse growth, structuraly heterogeneous - low-grade
periphery often mimics benign lesion ( cave CNB ! )
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complex anastomosing vasoformative labyrinth
permeating the stroma
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nuclear atypia, hyperchromasia, endothelial piling,
papillary projections - at least in the center
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grade does not realiably predict prognosis
Angiosarcoma of the breast
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parenchymal - rare, low-grade lesions prevail
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postradiation - high-grade, generally cutaneous
- AVL - low-grade precursor ?
- better outcome ??
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in axillary dissection lymphedema (Stewart-Treves syndrom)
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heterologous component - phylloid tumor
- metaplastic carcinoma
AVL - atypical vascular lesion of the breast ?
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controversial, extremely rare lesion (Rosen)
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small solitary or multiple red maculopapules arising
in radiated skin - shorter half-time, < 3 years
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tiny dermal gaping vascular proliferation, hyperchromasia,
hobnail cc., inflammatory background;
absent: atypia, mitoses, necrosis, endothelial piling,..
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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