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

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study of 2658 cases of primary invasive breast carcinoma patients, when histologic grade, lymph node status, and tumor size were considered, histologic grade was the most important independent factor in predicting survival. Yet, when histologic type was also considered in the multivariate analysis, it was found to be independently significant, although comparatively of less importance than histologic grade. Furthermore, histologic grading is important, because disagreements continue to occur between pathologists as to the subclassification of breast carcinoma. This happens because criteria remain controversial (especially in diagnosing medullary carcinoma and making distinctions between infiltrating lobular and duct carcinomas), and clearly mixed and/or intermediate patterns of breast carcinoma occur that can be difficult to classify. Also, some clinicians appear to more easily accept a histologic grade designation than a vaguely understood and sometimes controversial subtype designation. Thus, it is wise to give all invasive breast carcinomas a histologic grade, including the special types like lobular, mucinous, secretory, adenoid cystic, tubular/cribriform carcinomas, etc. Often, as noted above, these types receive well differentiated or mBR grade 1 designation, an expected result given their less aggressive behavior. An exception is medullary carcinoma, for which controversy continues regarding diagnostic criteria and prognosis. Medullary carcinoma is almost always mBR grade 3. In contrast to other studies, Elston et al. (5,6,8) were unable to show an improved outcome for patients with medullary breast carcinoma, even when strict morphologic criteria were imposed. I believe medullary carcinoma can be over diagnosed, and it is a diagnosis difficult to reproduce between competent pathologists (9). The diagnosis of medullary carcinoma has become uncommon in our practice. Histologic grade (especially when using standardized criteria such as the Bloom- Richardson criteria [10-16]) helps place any invasive breast carcinoma into its proper prognostic and therapeutic category, especially when there is controversy or confusion about the proper subtype designation. -5-
INVASIVE BREAST CARCINOMAS THAT ARE CONSIDERED TO HAVE A RELATIVELY GOOD PROGNOSIS 1. Tubular Carcinoma 6. Secretory Carcinoma 2. Cribriform Carcinoma 7. ? Tubulolobular Carcinoma 3. Pure Mucinous (Colloid) Carcinoma 8. ? Classical Lobular Carcinoma 4. Adenoid Cystic Carcinoma 9. ? Medullary Carcinoma 5. Low-Grade Adenosquamous Carcinoma 10. ? Invasive Papillary Carcinoma Note: We believe, as others do (17), that the defining features of special types of breast carcinoma should comprise more than 90% of the tumor, and the closer to 100% the better, especially for the mucinous subtype, which should be "pure". In the table above a “?” designates those carcinomas whose prognoses remain controversial, either because of difficulty in reproducing the diagnosis or because of contradictory reports regarding prognosis. Many papillary carcinomas are preinvasive, a finding that explains their good prognosis in many series. Truly invasive papillary carcinomas likely have a prognosis similar to similar grade and stage InvDC,NST. -6-
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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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Diagnosis: Benign g (Low-grade) Phy
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Page 97 and 98: Illustrative Case 10/8/2011 95
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Page 101 and 102: Dx: Mixed Spindle-cell & Cl Classic
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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
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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 and 140: American Soiety of Clinical Patholo
Page 141: SPECIAL TYPES OF INVASIVE BREAST CA
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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 179 and 180: outcome of patients with intracysti
Page 181 and 182: Case 3: History: A 73 year old fema
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Page 191 and 192: 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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