33 Special Types of Invasive Breast Carcinoma: Diagnostic Criteria ...
33 Special Types of Invasive Breast Carcinoma: Diagnostic Criteria ... 33 Special Types of Invasive Breast Carcinoma: Diagnostic Criteria ...
Recently, Jensen et al. (6) compared three different schemes for diagnosing medullary carcinoma and found the Ridolfi et al. (10) criteria to be the best at stratifying a group of patients with a markedly improved prognosis. The Ridolfi criteria included 1) at least 75% of the tumor area composed of a syncytial pattern, 2) completely circumscribed with pushing margins, 3) moderate to marked mononuclear infiltrate in surrounding and supporting stroma, 4) nuclear grade 2 to 3, 5) no intraductal component, and 6) no microglandular differentiation. The presence of fibrosis, necrosis, cystic and/or papillary changes, squamous metaplasia, bizarre cells, and multifocal growth were recorded; but, these features did not exclude the diagnosis. Tumors with a maximum of two of the following features were classified as atypical medullary carcinoma: infiltrative margins, sparse or only peripheral mononuclear infiltrate, grade 1 nuclei, microglands, or an intraductal component. InvDC,NST was diagnosed when the syncytial growth pattern was less than 75% and/or three or more above atypical features were present. These investigators found that the prognosis for atypical medullary carcinoma was essentially the same as for InvDC,NST; and, thus, they found no reason to maintain the category of atypical medullary carcinoma. Of interest, both Tavassoli and Fisher et al. (7) believe that dense fibrosis and/or cord-like structures disqualify the lesion as a typical medullary carcinoma. Ellis et al. (13) defined medullary carcinoma as a breast tumor having all the following features: 1) sheets of large bizarre carcinoma cells forming a syncytial network, 2) moderate to large numbers of lymphoid cells between sheets of tumor cells, 3) a sharply defined pushing margin, 4) usually little fibrous stroma, and 5) usually no carcinoma in situ or lymphatic-vascular invasion. For them, atypical medullary carcinoma was a tumor that deviated from the criteria defined for typical medullary carcinoma but that had medullary features; usually this was either less prominent inflammation, microscopic invasion beyond the sharply defined pushing margin, or dense areas of fibrosis. This group was unable to show an improved outcome for patients with medullary breast carcinoma, even when strict morphologic criteria were imposed. Indeed, in my experience, medullary carcinoma is often overdiagnosed and difficult to reproduce between pathologists. Published studies have documented the problems encountered in the diagnosis of typical medullary carcinoma in a routine clinical context and shown high levels of diagnostic variation between pathologists (26,27,28). Finally, over 90% of medullary carcinomas are estrogen and progesterone receptornegative by any technique (29-31), and these high histologic grade tumors are highly proliferative (32) and typically aneuploid or polyploid (33). 111
Definitive diagnosis of medullary carcinoma on the needle core biopsy cannot be made. It is wise to suggest the possibility of this diagnosis and defer the definitive diagnosis to complete excision of the mass (42). Lumpectomy and radiation is a therapy for patients with true medullary carcinoma, espcially for tumors 3 cm or smaller. Sentinal lymph node biopsy is also recommended for staging. Chemotherapy is usually given to the patients with larger tumor, positive nodes and tumor with lympovascular emboli (42). Differential diagnosis: Obviously, the main differential diagnostic problem is distinguishing between circumscribed and/or “inflamed” examples of InvDC,NST (i.e., “atypical medullary carcinoma”) from “true” medullary carcinoma. This has already been discussed above. Other differential considerations include metastatic tumor to the breast. A metastasis to the breast can be the first sign of a clinically occult tumor, and its proper diagnosis will lead to a search for the primary and the avoidance of unnecessary breast surgery. Besides hematolymphoid malignancies (e.g., anaplastic large-cell lymphoma), and excluding a metastasis from contralateral breast carcinoma, most series show that metastatic melanoma and lung carcinoma account for most cases (greater than 50%) of metastatic disease in the breast (34). Ovarian, gastric, renal, and pancreatic carcinomas comprise most of the remaining tumor types. In men, prostate carcinoma has a predilection for metastasizing to the breast (35). Although it is not likely to be confused with medullary carcinoma, diffuse-type (signet-ring cell) gastric carcinoma can spread to the breast and mimic invasive lobular carcinoma (34); likewise, as mentioned above invasive lobular carcinoma can spread to the stomach and produce linitis plastica (36). Obviously, the distinction would be very difficult, but immunostaining with GCDFP-15 can help since, like S100, GCDFP-15 is positive in about 60% of breast carcinomas. (GCDFP-15 and S100 are also positive in salivary and sweat gland carcinomas, and the melanoma marker HMB-45 has now been reported to be immunoreactive with breast carcinomas [37].) Worth to mentioning is that occult breast carcinoma can be diffusely metastatic to the spleen and present as "idiopathic thrombocytopenic purpura" (38), and that extra-mammary carcinoid can initially present as a breast mass, simulating primary breast carcinoma with neuroendocrine differentiation (39). The absence of an in situ component in the breast should always raise the possibility of a metastatic tumor, but the presence of an in situ component does not always indicate a breast primary. Ovarian carcinomas metastatic to the breast can simulate DCIS by growing within the ducts and lobules and producing microcalcifications mimicking primary carcinoma on mammogram (40,41). Obtaining a complete clinical history and judicious application of immunohistochemistry should aid in the proper identification of metastasis to the breast, thus avoiding unnecessary surgery. Theoretically, rare examples of high-grade 112
- Page 197 and 198: with long-term follow-up [Abstract]
- Page 199 and 200: cystic hypersecretory duct carcinom
- Page 201 and 202: considerable secretion and/or morph
- Page 203 and 204: 4. Tavassoli FA, Norris HJ. Secreto
- Page 205 and 206: Case 6: History: 66 year old female
- Page 207 and 208: Adenoid cystic carcinoma (AdCC) is
- Page 209 and 210: Because more than half of adenoid c
- Page 211 and 212: Another family of salivary gland-ty
- Page 213 and 214: Collagenous spherulosis is a recent
- Page 215 and 216: cases: review of the literature and
- Page 217 and 218: Case 7 the breast associated with l
- Page 219 and 220: size (14). Metaplastic breast carci
- Page 221 and 222: adenoma by others who prefer to avo
- Page 223 and 224: survival rate than is usually repor
- Page 225 and 226: it arises in other soft tissue site
- Page 227 and 228: implies a relative risk for develop
- Page 229 and 230: sclerosing adenosis wherein the str
- Page 231 and 232: overgrowth (136). While acknowledgi
- Page 233 and 234: As noted above, any soft-tissue sar
- 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,
- Page 241 and 242: microscopic, ultrastructural, and i
- Page 243 and 244: 2006 Apr;30(4):450-6 143. Liberman
- Page 245 and 246: Case 8 Case history: A 50 year old
- Page 247: secondary peripheral tumor nodules
- Page 251 and 252: Pathol 1988;19:1340-6. 12. Rosen PP
- Page 253 and 254: 40. Di Bonito; Royen PM, Ziter FMH.
- Page 255: Am J Clin Pathol 1979;72:383-389. 1
Recently, Jensen et al. (6) compared three different schemes for diagnosing medullary<br />
carcinoma and found the Ridolfi et al. (10) criteria to be the best at stratifying a group<br />
<strong>of</strong> patients with a markedly improved prognosis. The Ridolfi criteria included 1) at<br />
least 75% <strong>of</strong> the tumor area composed <strong>of</strong> a syncytial pattern, 2) completely<br />
circumscribed with pushing margins, 3) moderate to marked mononuclear infiltrate in<br />
surrounding and supporting stroma, 4) nuclear grade 2 to 3, 5) no intraductal<br />
component, and 6) no microglandular differentiation. The presence <strong>of</strong> fibrosis,<br />
necrosis, cystic and/or papillary changes, squamous metaplasia, bizarre cells, and<br />
multifocal growth were recorded; but, these features did not exclude the diagnosis.<br />
Tumors with a maximum <strong>of</strong> two <strong>of</strong> the following features were classified as atypical<br />
medullary carcinoma: infiltrative margins, sparse or only peripheral mononuclear<br />
infiltrate, grade 1 nuclei, microglands, or an intraductal component. InvDC,NST was<br />
diagnosed when the syncytial growth pattern was less than 75% and/or three or more<br />
above atypical features were present. These investigators found that the prognosis for<br />
atypical medullary carcinoma was essentially the same as for InvDC,NST; and, thus,<br />
they found no reason to maintain the category <strong>of</strong> atypical medullary carcinoma. Of<br />
interest, both Tavassoli and Fisher et al. (7) believe that dense fibrosis and/or cord-like<br />
structures disqualify the lesion as a typical medullary carcinoma.<br />
Ellis et al. (13) defined medullary carcinoma as a breast tumor having all the<br />
following features: 1) sheets <strong>of</strong> large bizarre carcinoma cells forming a syncytial<br />
network, 2) moderate to large numbers <strong>of</strong> lymphoid cells between sheets <strong>of</strong> tumor<br />
cells, 3) a sharply defined pushing margin, 4) usually little fibrous stroma, and 5)<br />
usually no carcinoma in situ or lymphatic-vascular invasion. For them, atypical<br />
medullary carcinoma was a tumor that deviated from the criteria defined for typical<br />
medullary carcinoma but that had medullary features; usually this was either less<br />
prominent inflammation, microscopic invasion beyond the sharply defined pushing<br />
margin, or dense areas <strong>of</strong> fibrosis. This group was unable to show an improved<br />
outcome for patients with medullary breast carcinoma, even when strict morphologic<br />
criteria were imposed. Indeed, in my experience, medullary carcinoma is <strong>of</strong>ten<br />
overdiagnosed and difficult to reproduce between pathologists. Published studies have<br />
documented the problems encountered in the diagnosis <strong>of</strong> typical medullary<br />
carcinoma in a routine clinical context and shown high levels <strong>of</strong> diagnostic variation<br />
between pathologists (26,27,28).<br />
Finally, over 90% <strong>of</strong> medullary carcinomas are estrogen and progesterone receptornegative<br />
by any technique (29-31), and these high histologic grade tumors are highly<br />
proliferative (32) and typically aneuploid or polyploid (<strong>33</strong>).<br />
111
Change language