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Repro Path Lab 3


PATHOLOGY OF THE BREAST

Reading Assignment:

Robbins: Pathologic Basis of Disease 8th Ed. Ch. 23, pp. 1065 - 1095 ( 7th Ed., Ch. 23, pp. 1119 - 1154 )


Upon completion of this segment of the course, you should be able to:

  1. Recognize the clinical and microscopic features that fibrocystic breast disease, fibroadenoma, intraductal papilloma, and gynecomastia have in common and the features that are different and allow accurate diagnosis.

  2. Recognize the difference between intraductal carcinoma (DCIS) and invasive carcinoma in terms of microscopic features and the implications of the diagnosis of each on treatment and prognosis.


Fibrocystic Changes in Breast

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This biopsy is from the breast of a 45-year-old woman. A variety of changes are present on this slide, reflecting the heterogeneity of the findings in this condition. Cystically, dilated ducts containing eosinophilic fluid are present, as are foci of intraductal epithelial proliferation (intraductal hyperplasia). Prominent fibrosis, blending intralobular and interlobular connective tissue, is focally present. Another component of this condition is apocrine metaplasia of the ductal epithelium in cystically dilated ducts. Note the microcalcifications in some of the ducts with intraductal hyperplasia as well as in some seemingly normal ducts.

  1. Would this lesion have been evident on mammography? Why?

  2. Which of the microscopic findings in this section, if more extensive, would result in a palpable mass in the breast?



Gynecomastia

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This 49-year-old man had enlargement of both breasts, more pronounced on the left. The characteristic feature of this tissue is the absence of lobule development. Also, note the pale, basophilic, connective tissue immediately surrounding the ducts, which is in contrast to the dense collagen elsewhere in the breast. The epithelium lining some of the ducts is hyperplastic and forms small papillae. This mild intraductal hyperplasia is a common feature of gynecomastia; it is not associated with an increased risk of subsequent carcinoma.

  1. What are the usual causes of gynecomastia?

  2. This patient had asymmetrical bilateral breast enlargement. Is gynecomastia usually unilateral or bilateral?

  3. What would be the appropriate treatment if this breast enlargement occurred in a 12-year-old boy?



Fibroadenoma

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This slide is from a solitary, well-circumscribed, freely mobile mass removed from the left breast of a 23-year-old woman. The most distinctive microscopic feature is the presence of elongated and compressed ducts surrounded by connective tissue of varying cellularity. This growth pattern has been termed “intracanalicular.” The connective tissue surrounding the ducts has a pale, basophilic, appearance. The connective tissue cells (fibroblasts) lack any atypism, cellular crowding, or increased mitotic activity.

  1. What is the most common age of occurrence of these lesions?

  2. Does this lesion imply a clinically significant increased risk of subsequent carcinoma for this patient?

  3. Since lesional tissue extends to the inked margin of excision, should this patient have a re-excisional lumpectomy?

  4. Is mammography useful for detection of these lesions in this age group?



Intraductal Papilloma

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This large papillary lesion was present in a cystically dilated duct in the left upper outer quadrant of the breast of a 41-year-old woman. In this setting it is often termed an intracystic papilloma. Such lesions more commonly present in a subareolar location where they may produce a bloody nipple discharge. The papillary lesion consists of fibrovascular stalks of varying thickness that are covered by a layer of epithelial cells which lack nuclear atypism and are supported by a myoepithelial layer. Foci of apocrine metaplasia are present. The dilated duct, from which the papilloma arises, is lined by attenuated epithelium and myoepithelium. The dense connective tissue at the point of origin of the papilloma in the duct seemingly subdivides the lesion giving the false appearance of more than one lesion.

  1. How would this lesion have been clinically recognized?

  2. Would ultrasonography have been a useful adjunct to diagnosis?

  3. Does this lesion imply an increased risk of breast malignancy?

  4. What is the age range of most patients with intraductal papillomas?



Ductal Carcinoma in situ

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Some of the ducts in this biopsy material from the right breast of a 52-year-old woman manifest abnormal epithelial proliferation, while other areas of the biopsy lack abnormality. Most of the abnormal proliferation has a papillary or cribriform pattern of growth. The neoplastic cells are large, have variably sized irregular nuclei with nucleoli and occasional mitotic figures. This can be considered as a neoplasm of high nuclear grade. There is focal necrosis of these cells in the center of ducts (comedo necrosis) and occasional slides have dystrophic calcifications in this necrotic material. Compare this abnormal proliferation with the normal breast ducts on the slide. In some instances the neoplastic cells in large ducts can be seen to extend into branching lobular ducts. Occasional slides may have a thin rim of blue ink at an edge of the tissue. Painting the gross specimen in this manner allows determination of the proximity of carcinoma to the margin of surgical excision.

  1. What clinical/mammographic finding likely led to this biopsy?

  2. If stromal invasion is present in this biopsy how would you make that diagnosis?



Invasive Ductal Carcinoma

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There is diffuse invasion of breast stroma by carcinoma in this section. The invasive neoplasm lacks a myoepithelial investment. Surrounding the invasive carcinoma are foci of ductal carcinoma in situ with micropapillary and apocrine growth patterns, and with focal central necrosis. Compare the DCIS with the normal ducts present on this slide. Note the pleomorphism of nuclei in both the DCIS and in the invasive carcinoma. The invasive carcinoma is surrounded by a prominent lymphocytic of infiltrate. Is the diameter of the invasive carcinoma in this breast of prognostic importance?

  1. What other factors which can be seen in this breast biopsy material are of prognostic importance??

  2. What are the therapeutic options for the patient?

  3. What is the importance of the DCIS in planning for treatment of this patient?


The answers to the path lab questions will be posted approximately 48-72 hours after the lab sessions. These are abbreviated answers, not a full discussion of the topics. You can find them in the M2 CTools site resources. In the folder for each sequence the will be a folder called 'Path Lab Resources'


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