Nбdorovй intraduktбlnн papilбrnн proliferace

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Tumors of the breast Course and slide seminar
Zdenek K I N K O R Bioptická
laborator s.r.o. PLZEN
2006
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Intraductal papillary lesions of the breast
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Intraductal papillary lesions of the breast
actin
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3D studies
papilloma
papilom
papillocarcinoma
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Intraductal papillary lesions

• Intraductal papilloma
• Atypical papilloma / DCIS arising in papilloma ?
• Intraductal papillary carcinoma
• micropapillary DCIS - is not papillary
  per se
• micropapillary IDC - is not
  papillary per se
• radiology / macroscopy is not helpfull in
  discrimination of
• benign from malignant lesion

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Intraductal papilloma

• 1. Central (solitary) - large ducts
• 2. Peripheral (multiple papillomatosis) -
  TDLU
• ____________________________________
• benign, complete myoepitelial rim - globoid
  cells !
• necrosis, apocrine / squamous metaplasia,
  hyperplasia,
• sclerosis, pseudoinvasion!
• peripheral - more often associated with ADH resp.
  DCIS (sampling?)
• CNB - controversial - excision vs. watch and wait
  ?
• variants - adenomyoepithelioma, mixed tumor,
  ductal adenoma
• nipple adenoma

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Intraductal papillary carcinoma

• 1. Central (intracystic, solitary)
• 2. Diffuse (multiple) - papillary DCIS
• __________________________________________
• 0,5 - 2 of all breast carcinomas, in situ
  lesion !
• myoepithelial layer absent papillary,
  cribriform, solid
• pseudoinvasion, epithelial displacement by CNB
• CNB - excision ! - adjacent DCIS / IDC 50 -
  margin !
• excellent prognosis - axillary/sentinel LN is not
  necessary
• invasive component - usually nonpapillary G1 IDC

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Atypical papilloma(ADH / DCIS in papilloma)

• controversial - rare, definition,
  interpretation (CK 5/6)
• more often in peripheral papilloma, CNB -
  excision !
• structural a cytologic atypia - kvantitative
  criteria ?
• - confined to papilloma -
  atypical papilloma (AP)
• - adjacent ducts -
  analogous to ADH vs. DCIS
• AP is not ! - problem papiloma vs.
  papillary carcinoma
• - florid ductal
  hyperplasia in papilloma
• recurrences (DCIS, IDC) were found only in cases,
  where atypia extended into surrounding ducts
  outside of original AP

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papillary carcinoma
papiloma
malignant (in situ !)
benign
atypical papiloma
carcinoma (DCIS) in papilloma
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Take home message

• central, solitary lesions are more indolent than
  peripheral and
• multiple
• papilloma in CNB - excision required any time ?!
  - radiology
• AP is rare papillary carcinoma arises de novo
• intraductal (intracystic) papillary carcinoma -
  in situ lesion
• does not metastasize !
• prognosis (biology?) of papillary lesion is
  determined mainly by
• findings in surrounding ducts
• conservative approach (even at invasion) - margin
  ! (SLN?)

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lets move to the scope
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Breast on Earth
Lets have a rest
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even cancer cells are miracle of the nature
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Low-grade adenosquamous carcinoma
actin
Cam 5.2
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Low-grade adenosquamous carcinoma

• Rosen - 11 cases (AJSP, 1987) 50 cases in
  total
• recurrent, rarely metastasizing lesions - two
  cases described
• bland-looking ? mimic benignancy - RSL,
  nipple syringoma, FT,..
• biphasic lesion - both components are tumorous !
  
• 1) epithelial - oval/curved glandular
  structures display variable luminal
  
• squamous
  differentiation (distinct imunophenotype)
• - one/two flat layers
  of cells lacking overt atypia
• - absent
  myoepithelial rim?
• 2) mesenchymal - mostly hypocellular,
  collagenous fibrous stroma
• - heterologous
  differentiation - extremely rare

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LGASC - differential diagnosis

• radial scar - CD34 desmoplastic
  stroma with central elastosis
• - complex
  ductal epithelial proliferation, calcification
• - intact
  myoepithelial layer
• - origin of
  LGASK in radial scar ? (Gobbi et al.)
• phylloid tumor - benign epithelial component,
  myoepithelial rim
• -
  CD34/CD10/CD117 stromal projection in cystic
• epithelial
  spaces, squamous diff. rare
• - structural
  heterogeneous stromal overgrowth
• nipple syringoma / microcystic adnexal carcinoma
  - benign and
• malignant adnexal skin lesions, not related
  to glandular breast tissue,
• different nonneoplastic stroma

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The natural beauty of the Silicon valley ( have
you ever been there ?! )
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Wherever I go the breast topic attracts me
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Wherever I go the breast topic attacs me
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female, 81-year-old
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Benign spindle cell stromal tumors of the breast
desmin
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Benign spindle cell stromal tumors of the breast

• heterogeneous group of lesions with functional
  variability and combination of morpho- and
  immunophenotype
• 1) spindle/oval cells, storiform or
  hemangiopericytoma-
• like pattern, lipo-, chondro-,
  osteometaplasia, floret-like
• cells., nc. palisading, myxoid change,
  collagen ropes,
• 2) CD34, bcl2, CD99, actin, desmin, ER,
  PR, AR
• common precursor - vim/CD34 stromal cell
• hybrid a NOS features - genetics? (spindle cell
  lipoma,..)

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Benign spindle cell stromal tumors of the breast
vim/CD34 stromal cell
myofibroblastoma
leiomyoma
myofibroblastic

• plasticity of morfofology
• a immunofenotype
• (CD34, bcl2, CD99,
• actin,desmin,
• ER, PR, AR)

spindle cell lipoma-like tumor
fibroblastic
solitáry fibrous tumor
fibrohistiocytic
spindle cell tumor NOS
fibrous histiocytoma
mixed
combinations of
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BSST - differential diagnosis

• Benign
• fibromatosis
• nodular fasciitis
• schwannoma, neurofibroma perineurioma
• inflammatory pseudotumor

• Malignant
• metaplastic carcinoma
• malignant myoepithelioma ?
• MPNST
• synovial sarcoma
• myofibroblastic sarcoma
• leiomyosarcoma

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Future or the past , the breast will never
stop to interest the mankind
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30-year-old female
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Angiomatosis of the breast
Actin S
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Hemangioma of the breast
AVL ?
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Low-grade angiosarcoma of the breast
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High-grade angiosarcoma of the breast
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Benign vascular lesions of the breast

• perilobular hemangioma - microscopic lesion ( mm
  sized )
• -
  the only one that invades in TDLU !
• hemangioma - capillary, cavernous, complex,..
• angiomatosis
• subcutaneous nonparenchymal hemangioma

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Benign vascular lesions of the breast

• well circumscribed, lt 2cm , ouside the TDLU
  
• but ! - angiomatosis - widely dissects
  throughout the stroma
• structural homogeneous, feeding vessel at the
  periphery,
• noncommunicating labyrinth of vascular
  channels - not
• absolutely valid
• papillary endothelial hyperplasia - confusion
  with AS !
• ( reactive, superficial, circumscribed,
  intravascular - trombus )
• CNB - distinction of low-grade AS mostly
  impossible

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Malignant vascular lesions of the breast

• unlimited, gt 3 cm , intralobular extension
• diffuse growth, structuraly heterogeneous -
  low-grade
• periphery often mimics benign lesion ( cave
  CNB ! )
• complex anastomosing vasoformative labyrinth
• permeating the stroma
• nuclear atypia, hyperchromasia, endothelial
  piling,
• papillary projections - at least in the
  center
• grade does not realiably predict prognosis

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Angiosarcoma of the breast

• parenchymal - rare, low-grade lesions prevail
• postradiation - high-grade, generally
  cutaneous
• - AVL -
  low-grade precursor ?
• - better outcome
  ??
• in axillary dissection lymphedema
  (Stewart-Treves syndrom)
• heterologous component - phylloid tumor
• 
  - metaplastic carcinoma

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AVL - atypical vascular lesion of the breast ?

• controversial, extremely rare lesion (Rosen)
• small solitary or multiple red maculopapules
  arising
• in radiated skin - shorter half-time, lt 3
  years
• tiny dermal gaping vascular proliferation,
  hyperchromasia,
• hobnail cc., inflammatory background
• absent atypia, mitoses, necrosis,
  endothelial piling,..
• association (progression) with AS - no mets so
  far
• - part of morphologic spectrum of AS
  (Brenn et al.)
• - foci of angiosarcoma undiscernible
  from AVL ??

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The End