33 Special Types of Invasive Breast Carcinoma: Diagnostic Criteria ...

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mitotic grade 1). Case 5: Farnaz Hasteh, MD History: 29 year old female with a breast lump who was felt by patient. Mammogram found a 2 cm suspicious mass under the nipple Submitted diagnosis: Invasive secretory carcinoma (well-differentiated invasive breast carcinoma, overall mBR grade 1; nuclear grade 2, tubule grade 2, mitotic grade 1). Case 6: Noel Weidner, MD History: 66 year old female with 2.5 cm cystic-solid left breast mass with soft, tan cut surfaces. Submitted diagnosis: Adenoid Cystic Carcinoma Case 7: Noel Weidner, MD History: A 57 year old female with 3.4 cm well definied breast mass with firm, solid white cut surfaces. Submitted diagnosis: Metaplastic carcinoma, spindle-cell carcinoma variant (poorly differentiated invasive breast carcinoma, overall mBR grade 2; nuclear grade 3, tubule/papillary grade 3, mitotic grade 2). Case 8: Noel Weidner, MD History: A 50 year old female with round firm beast mass. Submitted diagnosis: Medullary Carcinoma (poorly differentiated invasive breast carcinoma, overall mBR grade 3; nuclear grade 3, tubular grade 3, mitotic grade 3). Unknown cases Farnaz Hasteh, MD -3-
SPECIAL TYPES OF INVASIVE BREAST CARCINOMA INTRODUCTION Depending on the series cited, up to 35% of invasive breast carcinomas can be considered of “special” type (1,2). Invasive breast carcinomas not meeting the criteria of “special” type are usually designated by the generic term “invasive duct carcinoma, not otherwise specified” (InvDC,NOS) or of no special type (InvDC,NST). This term can be useful for distinguishing these tumors from other specific forms of invasive breast carcinoma (e.g., tubular, lobular, medullary, metaplastic, colloid, adenoid cystic carcinoma, etc.). Many of the invasive breast carcinomas of special type (InvC,ST) have a relatively favorable prognosis, but this only applies to those tumors composed entirely or in very large part (i.e., 90% or more) of the special pattern (1). Also, InvDC,NOS may be used to designate tumors that express in small part, rather than purely, one or more characteristics of the specific types of breast carcinoma. More specifically, InvCa,NOS can have limited microscopic foci (i.e., less than 10%) of special types of differentiation. Examples of InvCa,NOS, containing 10 to 90% of a special type of carcinoma, can be diagnosed as “mixed ductal and special-type carcinomas” (see table below). Mixed patterns are quite common, and in one review of 1000 breast carcinomas, ~33% of invasive breast carcinoma expressed combinations of features (3). The discussion that follows focuses primarily on invasive carcinomas, although selected in situ carcinomas are also included. Although certain types of breast cancer have a better prognosis than others, Elston et al. (4,5) and Periera et al. (6) continue to grade all histologic types of invasive carcinoma; a practice which is still encouraged. Indeed, their data on grading include grades of the various special types (6), regardless of the fact that special types of invasive breast carcinoma that have a favorable prognosis usually (but not always) fall into the SBR grade 1 category. This association suggests that, in most cases, the correlation of tumor grade with outcome can be explained by the fact that most of these special tumor types are SBR grade 1 tumors. Indeed, ~20% of breast carcinomas are grade 1 by the modified Bloom-Richardson (mBR) criteria (5,6), and some suggest that "special-type" carcinomas comprise about the same number of all invasive breast carcinomas. However, Clayton and Hopkins. (7) were able to show prognostic significance of histologic grading within the category of infiltrating ductal (no special type) carcinoma, and Pereira et al. (6) have found that histologic grade and tumor type, when used together, more accurately predict prognosis (see table below). In this latter -4-
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33 Special Types of Invasive Breast
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Special Types of Invasive Breast Ca
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INVASIVE BREAST CARCINOMAS CONSIDER
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ER Neg. PR Neg. HER2 Neg. CK 5/6 Po
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Triple-negative Breast Carcinomas
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E-cadherin E-cadherin EGFR ++ ER ne
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ER/PR Positive HER2 Negative INVASI
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Tubulolobular Signet-ring Histiocyt
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Illustrative Example: 61 y/o female
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E-Cadherin ER PR 10/8/2011 17
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LCIS vs DCIS • Patients with lobu
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Examples of E-cadherin staining in
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Classic Low-grade DCIS - E-cadherin
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E-cadherin IHC CASE D 10/8/2011 25
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E-cadherin IHC CASE E 10/8/2011 27
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Literature Summary: Correlation of
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10/8/2011 31
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CD10 SMA MIB-1 10/8/2011 33
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Carter et al. Cancer 1977 & 1983
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Differential Diagnosis: 1. Invasive
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10/8/2011 39
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SYNAPTOPHYSIN SMA 10/8/2011 41
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Nassar et al. (AJSP 2006;30:501-7.)
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Special Types of Invasive Breast Ca
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Tubular carcinoma • It has been d
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Tubular carcinoma Histopathology
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Flat Epithelial Atypia When should
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Microglandular adenosis + reticulin
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mitosis ductal ductal, NST tubular
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Treatment • Breast conservation t
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Cribriform carcinoma Histopathology
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Cribriform carcinoma Prognosis •
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Cribriform Carcinoma Pearls of Path
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Clinicopathological features Mucino
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Case 4 Mucinous carcinoma Mixed muc
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Treatment • Breast conservation a
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Incipient mucocele-like lesion Cyst
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10/8/2011 73
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10/8/2011 75
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SMA Dx: Spindle-cell Breast Carcino
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Dx: Pure Squamous Carcinoma 10/8/20
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Osseous Differentiation (Osteosarco
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Spindle-cell Carcinoma of the Breas
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Phyllodes y Tumors Phyllodes Tumor
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Page 91 and 92: Diagnosis: Malignant (High-grade) P
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Page 97 and 98: Illustrative Case 10/8/2011 95
Page 99 and 100: SMA Calponin 10/8/2011 97
Page 101 and 102: Dx: Mixed Spindle-cell & Cl Classic
Page 103 and 104: Dx: Adenomyoepithelioma, Epithelioi
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Page 109 and 110: Case 1 • 40 year old female • B
Page 111 and 112: What is your diagnosis? 1. Invasive
Page 113 and 114: Case 4 • Irregular large breast m
Page 115 and 116: Case 6 • Needle core biopsy of a
Page 117 and 118: 343 What is your best diagnosis? 1.
Page 119 and 120: 349 Case 9 What is your diagnosis?
Page 121 and 122: Case 11 Case 11 Case 12 • A 68 ye
Page 123 and 124: Case 13 • Needle core biopsy of a
Page 125 and 126: What is your diagnosis? 1. Intracys
Page 127 and 128: What is your best interpretation? 1
Page 129 and 130: Case 18 What is your best interpret
Page 131 and 132: Case 20 • 35 year old female with
Page 133 and 134: Negative ER stain NEG ER Case 22
Page 135 and 136: What is your best interpretation? 1
Page 137 and 138: What is your diagnosis? 1. Secretor
Page 139: American Soiety of Clinical Patholo
Page 143 and 144: INVASIVE BREAST CARCINOMAS THAT ARE
Page 145 and 146: of lymphoid cells between sheets of
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Page 149 and 150: molecular subtypes. Indeed, the pea
Page 151 and 152: In summary, basal-like breast cance
Page 153 and 154: Page et al. (15) described a pleomo
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Page 163 and 164: References (lobular carcinoma): 1.
Page 165 and 166: 25. Richter GO, Dockerty MB, Claget
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Page 171 and 172: whether these lesions are in situ o
Page 173 and 174: irregular margin suggests the prese
Page 175 and 176: ich in elastic fibers. The connecti
Page 177 and 178: (i.e., much better than an antibody
Page 179 and 180: outcome of patients with intracysti
Page 181 and 182: Case 3: History: A 73 year old fema
Page 183 and 184: cases. In this small tubular carcin
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Page 187 and 188: Sclerosing papillary proliferations
Page 189 and 190: 9. Bondeson L, Lindholm K. Aspirati
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43. Green I, McCormick B, Cranor M,
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mucinous carcinoma (7,11,12,14). In
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mucinous carcinoma. A fine-needle a
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with long-term follow-up [Abstract]
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cystic hypersecretory duct carcinom
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considerable secretion and/or morph
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4. Tavassoli FA, Norris HJ. Secreto
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Case 6: History: 66 year old female
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Adenoid cystic carcinoma (AdCC) is
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Because more than half of adenoid c
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Another family of salivary gland-ty
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Collagenous spherulosis is a recent
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cases: review of the literature and
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Case 7 the breast associated with l
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size (14). Metaplastic breast carci
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adenoma by others who prefer to avo
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survival rate than is usually repor
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it arises in other soft tissue site
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implies a relative risk for develop
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sclerosing adenosis wherein the str
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overgrowth (136). While acknowledgi
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As noted above, any soft-tissue sar
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J Med 73:1078-1082, 1973. 11. Barne
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40. Thorner PS, Kahn HJ, Baumal R,
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75. Fekete P, Petrek J, Majmudar B,
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microscopic, ultrastructural, and i
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2006 Apr;30(4):450-6 143. Liberman
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Case 8 Case history: A 50 year old
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secondary peripheral tumor nodules
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Definitive diagnosis of medullary c
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Pathol 1988;19:1340-6. 12. Rosen PP
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40. Di Bonito; Royen PM, Ziter FMH.
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Am J Clin Pathol 1979;72:383-389. 1
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