Cystically Dominant Lesions Fundamental skill of diagnostic - - PowerPoint PPT Presentation

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Cystically Dominant Lesions

• f the Breast

UCSF 32nd Annual Current Issues in Anatomic Pathology and Cytology

SANDRA J. SHIN, MD PROFESSOR OF PATHOLOGY AND LABORATORY MEDICINE CHIEF OF BREAST PATHOLOGY WEILL CORNELL MEDICINE

Pattern-based diagnosis in breast pathology

Fundamental skill of diagnostic pathologists Surprisingly, not necessarily the first step when evaluating a

new lesion or proliferation. Instead, slide is scanned for key morphologic features diagnostic for specific entities - arriving at the diagnosis faster

Pattern-based evaluation as an initial step Helps to generate a complete differential diagnosis that

includes even uncommon or rare lesions

Most useful in core biopsies since key diagnostic features

may not be present or compromised

Top 6 patterns seen in breast pathology

Small glandular proliferation Spindle cell proliferation Cystically dominant lesions Vascular lesions Fibroepithelial lesions Papillary lesions

Top 6 patterns seen in breast pathology

Small glandular proliferation Spindle cell proliferation Cystically dominant lesions- focus on core biopsies Vascular lesions Fibroepithelial lesions Papillary lesions

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MAMMO CALCS NEEDLE CORE BIOPSY

DIAGNOSIS

Cystically Dominant Lesions with calcs +/- secretions

Larger caliber ducts Cysts in the fibrocystic disease Duct stasis/ duct ectasia Cystic hypersecretory lesions Juvenile Papillomatosis Lobulocentric / TDLU Columnar cell lesions and flat epithelial atypia Pregnancy-like (pseudolactational) change or

hyperplasia

Mucocele-like lesions

Secretions and Calcifications

Secretions May or may not be present within glandular/cystic

lumens

Vary in amount, color, consistency None are pathognomic for an entity Calcifications Associated with full spectrum of breast disease Vary in amount, size, appearance, location None are pathognomic for an entity

www.pathology.washington.edu

Cysts of fibrocystic disease

Blue-domed Cyst

5/27/2016 3 Cysts of fibrocystic disease

Calcium Oxalate Crystals Thin, translucent lightly eosinophilic

• r basophilic secretions

Cysts of fibrocystic disease Cysts of fibrocystic disease on core biopsy

No excisional biopsy if there is pathologic-radiologic concordance

Duct ectasia

Courtesy of Dr. Timothy D’Alfonso

5/27/2016 4 Duct ectasia

No calcifications Fluffy translucent lightly eosinophilic secretions Macrophages

Duct stasis

Translucent pale blue/gray secretions

Duct ectasia on core biopsy

No excisional biopsy if there is pathologic-radiologic concordance

Cystic Hypersecretory Lesions

5/27/2016 5 Cystic hypersecretory lesions

CAN BE MISTAKEN FOR CYSTS OF FIBROCYSTIC DISEASE AT SCANNING MAGNIFICATION

Cystic hypersecretory hyperplasia

Parallel Cracks “Venetian Blinds” Retracted Dense Colloid-Like Histiocytes Lymphocytic inflammation

5/27/2016 6 Atypical cystic hypersecretory hyperplasia

Am J Surg Pathol 2014; 38:45-53

10 patients; female; average age 63 years Clinical presentation: mass but also calcifications and bloody nipple discharge Microscopic extent: 9 mm (2 mm to 2.7 cm) Histology: micropapillary growth pattern; intermediate or high nuclear grade arising in a background of CHH and/or atypical CHH Biomarker profile: ER+ HER2- (80%) ER/PR- HER2- (20%) including one case with microinvasive carcinoma and micrometastasis to one SLN 1/10 (10%) lacked investing myoepithelium by p63, SMM, CK5 Treatment of 4 patients: EXBX + RT (2 patients); EXBX + RT + Chemo (1 patient); MX + Tamoxifen (1 patient) Clinical follow-up: All NED mean 5.5 years Cystic hypersecretory (in-situ) carcinoma

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Cystic hypersecretory (in-situ) carcinoma DIMINISHED SECRETIONS AND HIGH NUCLEAR GRADE

ER

Invasive cystic hypersecretory carcinoma

Cystic hypersecretory hyperplasia on core biopsy

Recommend excisional biopsy regardless of pathologic-radiologic concordance or lack of atypia

Columnar cell lesions Flat epithelial atypia

5/27/2016 8 Columnar cell change Flat epithelial atypia (columnar cell change with atypia)

Courtesy of Dr. Stuart Schnitt

FLAT EPITHELIAL ATYPIA (COLUMNAR CELL CHANGE WITH ATYPIA)

Courtesy of Dr. Stuart Schnitt

FLAT EPITHELIAL ATYPIA (COLUMNAR CELL HYPERPLASIA WITH ATYPIA)

5/27/2016 9 Hallmark Features

Columnar Cell Change

Elongated nuclei Epithelial polarization No cytologic atypia Round or irregular shaped

lumens

Monolayer or broad

papillary tufting growth pattern

No mitoses Calcifications

Flat Epithelial Atypia

Rounded nuclei Loss of epithelial

polarization “jumbled”

Low grade cytologic

atypia-monomorphic

Round shaped lumens Monolayer or

pseudostratified growth pattern

No mitoses Calcifications

Flat Epithelial Atypia Columnar Cell Change Columnar Cell Hyperplasia

Courtesy

• f
• Dr. Stuart

Schnitt

Yamashita Y, et al. Virchows Arch March 2016 Morphometric Analysis 7917 nuclei of 22 FEA cases 5010 nuclei of 13 CCC/CCH cases Results/Conclusions Nuclear roundness was more characteristic of FEA than CCC/CCH (statistically significant; p<0.001) Nuclear roundness was more characteristic of FEA with malignancy than FEA without malignancy (statistically significant; p<0.001)

Flat Epithelial Atypia Columnar Cell Change Columnar Cell Hyperplasia

Courtesy

• f
• Dr. Stuart

Schnitt

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FEA Tubular ca CCL/FEA Inv tubular ca LCIS Courtesy of

• Dr. Stuart

Schnitt

Abdel-Fatah T, et al AJSP 2007;31:417-426

+1q

• 16q

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p63

Recommend excisional biopsy only if flat epithelial atypia is identified

Juvenile Papillomatosis

Juvenile Papillomatosis

Rosen PP, et al. Cancer 1985;55:1345-1352 30 yrs or younger (range 12-48; mean 23) Painless and mobile mass – clinically mistaken for fibroadenoma Usually solitary, sometimes bilateral 25/180 (14%) recurrent JP Family history of breast cancer: Majority of secondary relatives (23/39; 59%) were from maternal side

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Courtesy of Dr. Timothy D’Alfonso

Spectrum of benign changes arranged in a localized fashion: Cysts – simple or apocrine; with luminal histiocytes Hyperplasia- ductal and apocrine with histologic merging Papillary epithelial proliferation (papillomas

• r papillomatosis)

Sclerosis/ radial sclerosing changes

Juvenile Papillomatosis

Merging of Ductal and Apocrine Hyperplasia

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Lobular carcinoma in-situ (LCIS) Arising in Juvenile Papillomatosis

Pts with carcinoma:

slightly older at time

• f JP dx (27 yrs versus

23 yrs) and higher frequency of positive family history (56%)

Management: EXBX

with clear margins of JP; clinical follow up

• f pt and pt’s female

relatives

Juvenile Papillomatosis and Carcinoma

Juvenile Papillomatosis on Core Biopsy

Recommend excisional biopsy with clear margins

Pregnancy-like (pseudolactational) change/hyperplasia

5/27/2016 14 Pregnancy-like (pseudolactational) change

Am J Surg Pathol 2000; 24(12):1670-1674

12 cases of PLH as primary dx (4- NCB; 8- EXBX) 5/12 performed for mammo calcs 4/12 mass; 1/12 “abnl mammo”; 1/12 galactorrhea 5/12 co-existing CHH 3/5 merging and with atypia 1/5 separate and PLH with atypia 1/5 separate and no atypia 4/5 with co-existing CHH also showed atypia Take home messages: Do not mistake PLH for ADH Recognize PLH and CHH can co-exist and even merge

Pregnancy-like Change

Pregnancy-like Hyperplasia Atypical Pregnancy-like Hyperplasia

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Histologically Combined PLH and CHH Lesions

Am J Surg Pathol 2004; 28:789-793

9 cases of DCIS (plus inv ca in 1) arising from PLH and CHH All women; age 35-49 years old (average 42) 6/9 performed for mammo calcs 2/9 mass; 1/9 nipple discharge 5/9 merging PLH and CHH (one or both with atypia) DCIS: 2/9 micropapillary type, both from PLH 7/9 CHC type; 4 arising from atypical CHH; 1 also had invasive ca – well diff IFDC- 4mm with ITC in 1 SLN Take home messages: If PLH or CHH with atypia or combined PLH-CHH without atypia are identified in NCB; recommend EXBX Atypical Pregnancy-like Hyperplasia Micropapillary DCIS

Calcifications Associated With Pregnancy-like (pseudolactational) Proliferations

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Secretions in Pregnancy-like (pseudolactational) Proliferations

Pregnancy-like change on core biopsy

Recommend excisional biopsy

• nly if atypia or combined PLH-CHH is identified

Mucocele-like lesions

Mucocele-like lesion

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Calcifications Associated With Mucocele-like Lesions Secretions in Mucocele- like Lesions

Pathologic upgrade rate in EXBX of benign MLL diagnosed in core biopsy

Authors Year N total excised N upgrade Upgrade diagnosis % upgrade Ha et al 2015 23

• Diorio et al

2015 35 2 DCIS 5.7 Rakha, et al 2013 54 2 DCIS 4 Sutton et al 2012 22

• Jaffer et al

2011 45 1 DCIS 2.2 Carkaci et al 2011 9

• Take home messages:

Most MLLs today are biopsied due to their association with calcs Even in studies with an inherent selection bias, the pathologic upgrade rate is low Recent studies suggest that not all benign MLLs need to be excised

5/27/2016 18 Mucocele-like lesion in core biopsy

Recommend excisional biopsy

• nly if atypical ductal hyperplasia
• r carcinoma is identified

Not all benign MLLs may need to be excised and such cases should be managed in a multidisciplinary setting MLLs and columnar cell lesions

• ccurring as a

morphologic continuum

Fadare O, Mariappan MR J Med Case Reports 2008; 2:138

Thank You