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

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1986. 160. Rosso R, Gianelli U, Carnevali L: Acquired progressive lymphangioma of the skin following radiotherapy for breast carcinoma. J Cutan Pathol 22:164–167, 1995. 161. Majeski J, Austin RM, Fitzgerald RH: Cutaneous angiosarcoma in an irradiated breast after breast conservation therapy for cancer: association with chronic breast lymphedema. J Surg Oncol 74(3):208–212, 2000. 162. Parham DM, Fisher C: Angiosarcomas of the breast developing post radiotherapy. Histopathology 31:189–195, 1997. 163. Tan PH, Lui GG, Chiang G, Yap WM, Poh WT, Bay BH. Ductal carcinoma in situ with spindle cells: a potential diagnostic pitfall in the evaluation of breast lesions. Histopathology. 2004;45:343-51 107
Case 8 Case 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). MEDULLARY CARCINOMA Background: Medullary carcinoma is defined in the WHO classification of breast tumors (1) as a “well circumscribed carcinoma composed of poorly differentiated cells with scant stroma, no glangular component and prominent lymphoid infiltration." The diagnosis of “true” medullary carcinomas requires strict application of diagnostic criteria; and, when done properly, some report that it constitutes ~5% of breast carcinomas (2-5). Like others, I believe those tumors with atypical features are best considered within the group of InvDC,NST (until additional studies indicate otherwise)(6,7) or invasvie ductal carcinoma with medullary features (42). Successful treatment by lumpectomy and primary radiotherapy has been reported (8), and many (but not all) studies indicate an improved prognosis over InvDC,NST, when compared stage for stage with InvDC,NST (2-4,9-12). For example, Moore and Foote (9) reported that 11.5% of their patients with medullary carcinoma died of tumor within five years, despite the fact that 42% of patients had axillary node metastases. Richardson (4) reported that the 5-year disease-free survival of their 99 patients was 78%, with death due to disease in only 10%. There was 95% 20-year disease free survival for stage I patients in this series and 61% for stage II patients (2). Patients with medullary carcinoma tend to have a lower frequency of axillary node metastases than patients with atypical medullary or InvDC,NST (3,11,10); and, when present, nodal metastases are usually found in three or fewer nodes (3,10). Stage II medullary carcinoma patients have a more favorable prognosis than comparable patients with non-medullary carcinoma. But, patients with tumors larger than 3 cm or with four or more positive nodes have high recurrence rates that are not appreciably different from the recurrence rates of patients with infiltrating duct carcinoma. Ellis et al. (13) and Periera et al. (14) do not report a significantly different survival for all patients with medullary carcinoma, compared to patients with InvDC,NST (i.e., 51% vs. 46%, respectively, at 10 years follow up). They emphasize that this holds even when strict criteria are applied for the diagnosis. However, review of their data show that the 10-year survival for mBR grade 3 InvDC,NST is 39%, whereas it is 51% for medullary carcinoma. All medullary carcinomas were mBR grade 3 in their series. Possibly, this group will accept some improved survival for patients with 108
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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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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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Diagnosis: Malignant (High-grade) P
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10/8/2011 91
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Illustrative Case 10/8/2011 95
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SMA Calponin 10/8/2011 97
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Dx: Mixed Spindle-cell & Cl Classic
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Dx: Adenomyoepithelioma, Epithelioi
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Case 1 • 40 year old female • B
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What is your diagnosis? 1. Invasive
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Case 4 • Irregular large breast m
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Case 6 • Needle core biopsy of a
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343 What is your best diagnosis? 1.
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349 Case 9 What is your diagnosis?
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Case 11 Case 11 Case 12 • A 68 ye
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Case 13 • Needle core biopsy of a
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What is your diagnosis? 1. Intracys
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What is your best interpretation? 1
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Case 18 What is your best interpret
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Case 20 • 35 year old female with
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Negative ER stain NEG ER Case 22
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What is your best interpretation? 1
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What is your diagnosis? 1. Secretor
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American Soiety of Clinical Patholo
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SPECIAL TYPES OF INVASIVE BREAST CA
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INVASIVE BREAST CARCINOMAS THAT ARE
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of lymphoid cells between sheets of
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studied, this taxonomy identifies s
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molecular subtypes. Indeed, the pea
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In summary, basal-like breast cance
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Page et al. (15) described a pleomo
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The classical pattern of infiltrati
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pathologic findings indistinguishab
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east carcinomas with overlapping fe
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standard" LCIS (their figure 2), wh
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References (lobular carcinoma): 1.
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25. Richter GO, Dockerty MB, Claget
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Breast Cancer Cooperative Group). L
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invasive micropapillary carcinoma m
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whether these lesions are in situ o
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irregular margin suggests the prese
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ich in elastic fibers. The connecti
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(i.e., much better than an antibody
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outcome of patients with intracysti
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Case 3: History: A 73 year old fema
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cases. In this small tubular carcin
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carcinoma in almost all tubular car
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Sclerosing papillary proliferations
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9. Bondeson L, Lindholm K. Aspirati
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43. Green I, McCormick B, Cranor M,
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Page 235 and 236: J Med 73:1078-1082, 1973. 11. Barne
Page 237 and 238: 40. Thorner PS, Kahn HJ, Baumal R,
Page 239 and 240: 75. Fekete P, Petrek J, Majmudar B,
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Page 243: 2006 Apr;30(4):450-6 143. Liberman
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Page 251 and 252: Pathol 1988;19:1340-6. 12. Rosen PP
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Page 255: Am J Clin Pathol 1979;72:383-389. 1
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