Essentials of diagnostic breast pathology: a practical approach

483 Pages·2007·41.17 MB·English

by  Farid Moinfar

Farid Moinfar
Essentials of Diagnostic Breast Pathology
Farid Moinfar
Essentials
of Diagnostic
Breast Pathology
A Practical Approach
With 116 Figures in 1128 Seperate Illustrations and 6 Tables
123
Farid Moinfar,MD
Associate Professor ofPathology
Director,Unit ofBreast & Gynecologic Pathology
Department ofPathology
Medical University Graz
Auenbruggerplatz 25
8036 Graz
Austria
Library ofCongress Control Number:2006932710
ISBN 978-3-540-45117-4 Springer Berlin Heidelberg New York
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Dedication
This work is dedicated with great appreciation and gratitude to
My dear parents,Shamsi and Ali Akbar Moinfar
My wonderful wife,Shokufeh Sodeifi-Moinfar
and
All my teachers and mentors,particularly
Dr.John G.Azzopardi,whose magnificent book
and other papers inspired me,
and Dr.Fattaneh A.Tavassoli,a great mentor and friend.
Preface
Several excellent and comprehensive textbooks have been written on breast pathology [1–5].The magnif-
icent book Problems in Breast Pathology [1] written by John G.Azzopardi, and two more recent great
works by Fattaneh A.Tavassoli [4] and Paul P.Rosen [3] cover almost all aspects of classic and modern
breast pathology.So why should one dare to write a new book on this subject?
Over the past few years,the Department of Pathology,Medical University Graz has organized annual
intensive 5-day courses on diagnostic breast pathology in order to share the experience in this field and
demonstrate and discuss several common diagnostic problems,including tumor-like lesions,intraductal
proliferative lesions,variants of ductal and lobular intraepithelial neoplasias,papillary neoplasms,and a
variety of infiltrating breast carcinomas.During these courses,it has been my constant experience that
most practicing pathologists and pathologists in training appreciate receiving a precise summary of the
diagnostic criteria for each entity combined with a brief and accurate discussion of the main differential
diagnoses.In dealing with a variety ofbreast lesions in daily practice,surgical pathologists want and need
to know the essentials ofdiagnostic breast pathology.
So,the idea to write this book gradually evolved from these diagnostic courses,with a main focus on the
essentials.This book is therefore designed as a diagnostic aid for pathologists when they encounter com-
mon as well as unusual or even challenging and very difficult cases.In trying to achieve this goal,it was
necessary to reduce the text but emphasize case presentations that deal with the described entities.Indeed,
this book contains over 1,100 full-color illustrations demonstrating gross, histologic, cytologic, and
immunohistochemical findings ofcommon as well as challenging benign and malignant breast lesions.
I am most grateful to Dr.Fattaneh A.Tavassoli for her constructive comments,suggestions,and encour-
agement throughout the preparation of this book.I am indebted to the staff pathologists at the Depart-
ment ofPathology,Medical University Graz,who have supported me during the preparation ofthis book.
I am thankful to Drs. Helmut Denk, Manfred Ratschek and Wolfgang Öhlinger for their kind support.
I would like to acknowledge the excellent assistance and expertise of Mrs.Andrea Kaps in preparing the
photomicrographs.I would like to thank the staffofthe publisher,Springer,in particular Mrs.Gabriele M.
Schröder and Mrs.Ellen Blasig for their professional and efficient cooperation and consideration in the
production ofthis book.
Once again,I would like to express my special thanks to my wife,Shokufeh Sodeifi-Moinfar,for her
support and tolerance over the past three years.
Graz,Austria
November 2006 Farid Moinfar
References
1. Azzopardi JG.Problems in breast pathology.WB Saunders,London,1979.
2. Page DL,Anderson TJ.Diagnostic histopathology ofthe breast.Churchill Livingstone,Edinburgh,1987.
3. Rosen PP.Rosen’s breast pathology,2nd edn.Lippincott Williams & Wilkins,Philadelphia,2001.
4. Tavassoli FA.Pathology ofthe breast,2nd edn.Appleton & Lange,Stamford,CT,1999.
5. Tavassoli FA, Devilee P (eds). World Health Organization classification of tumours. Pathology and genetics.
Tumours ofthe breast and female genital organs.IARC Press,Lyon,2003
“One relies on one’s experience. But “experience”can be merely the repetition of the same
error often enough… One must be willing, even anxious, to learn from one’s error. This
requires a degree ofhumility,a readiness to listen to the arguments ofothers,including those
of one’s juniors,and the inclination to re-examine cases in which a mistaken diagnosis has
been made and to analyse the reasons for the original mistake.”
John G.Azzopardi
Problems in Breast Pathology
“Thus I learned early on the great importance of a close correlation between clinical and
pathological studies. Each complements and supplements the other; it is impossible to do
intelligent surgery without a thorough understanding of the pathology of disease and it is
equally impossible to make an intelligent interpretation of pathology without a clear under-
standing of its clinical implications.”
Arthur Purdy Stout
Guiding the Surgeon’s Hand:
The History ofAmerican Surgical Pathology
Juan Rosai (Editor)
Contents
1 The Normal Breast 5 Intraductal Proliferative Lesions
1.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . 2 5.1 Usual Ductal Hyperplasia . . . . . . . . . . . . . . . . . . 68
1.2 Pregnancy and Lactation . . . . . . . . . . . . . . . . . . 2 5.2 Ductal Intraepithelial Neoplasia (DIN) . . . . . . . . . . . 70
1.3 Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5.3 Ductal Intraepithelial Neoplasia (DIN),Flat Type . . . . 72
1.4 Immunoprofile . . . . . . . . . . . . . . . . . . . . . . . . . 3 5.4 Low-Grade Ductal Intraepithelial Neoplasia
(WHO:DIN1b;Atypical Ductal Hyperplasia) . . . . . . . 74
1.5 Further Reading . . . . . . . . . . . . . . . . . . . . . . . . 3
5.5 Ductal Intraepithelial Neoplasia
(WHO:DIN1c–DIN3,DCIS) . . . . . . . . . . . . . . . . . 76
2 Specimen Processing
6 Intraductal Papillary Neoplasms
2.1 Frozen Section . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.2 Core Needle Biopsy . . . . . . . . . . . . . . . . . . . . . . 9
6.1 Central Papilloma . . . . . . . . . . . . . . . . . . . . . . 124
2.3 Excisional Biopsy . . . . . . . . . . . . . . . . . . . . . . . 10
6.2 Peripheral Papilloma . . . . . . . . . . . . . . . . . . . . 124
2.4 Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . 11
6.3 Sclerosing Papilloma . . . . . . . . . . . . . . . . . . . . 125
2.5 Axillary Lymph Nodes . . . . . . . . . . . . . . . . . . . . 11
6.4 Intraductal Papillary Carcinoma
2.6 Sentinel Lymph Nodes . . . . . . . . . . . . . . . . . . . . 12
(Papillary Ductal Intraepithelial Neoplasia) . . . . . . . 125
2.7 Further Reading . . . . . . . . . . . . . . . . . . . . . . . . 12
6.5 Role of Immunohistochemistry
in Diagnosing Intraductal Papillary Neoplasms . . . . 126
3 Fibrocystic Change and Duct Ectasia 6.6 Additional Comments . . . . . . . . . . . . . . . . . . . 126
6.7 Further Reading . . . . . . . . . . . . . . . . . . . . . . . 127
3.1 Fibrocystic Change . . . . . . . . . . . . . . . . . . . . . . 16
3.2 Duct Ectasia (Periductal Mastitis) . . . . . . . . . . . . . . 17
7 Lobular Intraepithelial Neoplasia (LIN)
4 Adenosis 7.1 Synonyms . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
7.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . 156
4.1 Definition,Types,and Macroscopy of Adenosis . . . . . 28 7.3 Microscopic Features . . . . . . . . . . . . . . . . . . . . 156
4.2 Blunt Duct Adenosis . . . . . . . . . . . . . . . . . . . . . 28 7.4 Additional Comments . . . . . . . . . . . . . . . . . . . 156
4.3 Sclerosing Adenosis . . . . . . . . . . . . . . . . . . . . . . 29 7.5 Further Reading . . . . . . . . . . . . . . . . . . . . . . . 157
4.4 Apocrine Adenosis
(Adenosis with Apocrine Metaplasia) . . . . . . . . . . . 30
8 Infiltrating Ductal Carcinoma (NOS Type)
4.5 Tubular Adenosis . . . . . . . . . . . . . . . . . . . . . . . 31
4.6 Adenomyoepithelial Adenosis . . . . . . . . . . . . . . . 31
8.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
4.7 Microglandular Adenosis . . . . . . . . . . . . . . . . . . 32
8.2 Macroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . 180
4.8 Radial Scar/Complex Sclerosing Lesion . . . . . . . . . . 32
8.3 Microscopic Features . . . . . . . . . . . . . . . . . . . . 180
4.9 Collagenous Spherulosis . . . . . . . . . . . . . . . . . . . 34
8.4 Grading . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
8.5 Additional Comments . . . . . . . . . . . . . . . . . . . 181
8.6 Further Reading . . . . . . . . . . . . . . . . . . . . . . . 181
XII Contents
9 Invasive Lobular Carcinoma (ILC) 13 Male Breast Lesions
9.1 Macroscopy . . . . . . . . . . . . . . . . . . . . . . . . . 192 13.1 Gynecomastia . . . . . . . . . . . . . . . . . . . . . . . 366
9.2 Microscopic Features . . . . . . . . . . . . . . . . . . . 192 13.2 Papilloma . . . . . . . . . . . . . . . . . . . . . . . . . . 367
9.3 Additional Comments . . . . . . . . . . . . . . . . . . 192 13.3 Primary Male Breast Carcinoma . . . . . . . . . . . . 367
9.4 Immunohistochemistry of LIN and ILC . . . . . . . . 192 13.4 Further Reading . . . . . . . . . . . . . . . . . . . . . . 367
9.5 Grading . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
9.6 Further Reading . . . . . . . . . . . . . . . . . . . . . . 193 14 Mesenchymal Lesions/Tumors
14.1 Stromal Elastosis . . . . . . . . . . . . . . . . . . . . . . 377
10 Special Types of Breast Carcinomas
14.2 Fat Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . 377
10.1 Tubular Carcinoma . . . . . . . . . . . . . . . . . . . . 223 14.3 Metaplasias . . . . . . . . . . . . . . . . . . . . . . . . . 378
10.2 Mucin-Producing Carcinomas of the Breast . . . . . 224 14.4 Pseudoangiomatous Stromal Hyperplasia . . . . . . 378
10.3 Carcinoma with Neuroendocrine Differentiation . . 226 14.5 Fibromatosis . . . . . . . . . . . . . . . . . . . . . . . . 379
10.4 Invasive Papillary Carcinoma . . . . . . . . . . . . . . 227 14.6 Myofibroblastoma . . . . . . . . . . . . . . . . . . . . 380
10.5 Invasive Micropapillary Carcinoma . . . . . . . . . . 227 14.7 Lipoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
10.6 Apocrine Carcinoma . . . . . . . . . . . . . . . . . . . 228 14.8 Angiolipoma . . . . . . . . . . . . . . . . . . . . . . . . 381
10.7 Secretory Carcinoma . . . . . . . . . . . . . . . . . . . 229 14.9 Granular Cell Tumor . . . . . . . . . . . . . . . . . . . . 382
10.8 Adenoid Cystic Carcinoma . . . . . . . . . . . . . . . 230 14.10 Hamartoma . . . . . . . . . . . . . . . . . . . . . . . . . 383
10.9 Acinic Cell Carcinoma . . . . . . . . . . . . . . . . . . 231 14.11 Perilobular Hemangioma . . . . . . . . . . . . . . . . 383
10.10 Sebaceous Carcinoma . . . . . . . . . . . . . . . . . . 232 14.12 Hemangioma . . . . . . . . . . . . . . . . . . . . . . . . 384
10.11 Infiltrating Cribriform Carcinoma . . . . . . . . . . . 232 14.13 Angiomatosis . . . . . . . . . . . . . . . . . . . . . . . 384
10.12 Medullary Carcinoma . . . . . . . . . . . . . . . . . . . 233 14.14 Angiosarcoma . . . . . . . . . . . . . . . . . . . . . . . 385
10.13 Metaplastic Carcinomas . . . . . . . . . . . . . . . . . 234 14.15 Leiomyosarcoma . . . . . . . . . . . . . . . . . . . . . 386
10.14 Clear Cell (Glycogen-Rich) Carcinoma . . . . . . . . . 237 14.16 Liposarcoma . . . . . . . . . . . . . . . . . . . . . . . . 387
10.15 Lipid-Rich Carcinoma (Lipid-Secreting Carcinoma) 238 14.17 Rhabdomyosarcoma . . . . . . . . . . . . . . . . . . . 387
10.16 Metastatic Carcinoma . . . . . . . . . . . . . . . . . . 238 14.18 Malignant Fibrous Histiocytoma . . . . . . . . . . . . 388
10.17 Inflammatory Carcinoma . . . . . . . . . . . . . . . . 239 14.19 Osteosarcoma . . . . . . . . . . . . . . . . . . . . . . . 389
14.20 Spindle Cell Sarcoma,Not Otherwise Specified
(NOS-Type Mammary Sarcoma) . . . . . . . . . . . . 389
11 Biphasic Tumors
11.1 Fibroadenoma . . . . . . . . . . . . . . . . . . . . . . . 320 15 Myoepithelial Lesions/Neoplasms
11.2 Phylloides Tumor . . . . . . . . . . . . . . . . . . . . . 321
15.1 Background . . . . . . . . . . . . . . . . . . . . . . . . 410
15.2 Immunoprofile . . . . . . . . . . . . . . . . . . . . . . . 410
12 Diseases of the Nipple
15.3 Myoepithelial Cell Hypertrophy . . . . . . . . . . . . 410
12.1 Paget’s Disease . . . . . . . . . . . . . . . . . . . . . . . 352 15.4 Myoepitheliosis (Myoepithelial Hyperplasia) . . . . 411
12.2 Nipple Duct Adenoma . . . . . . . . . . . . . . . . . . 353 15.5 Adenomyoepithelioma . . . . . . . . . . . . . . . . . 411
12.3 (Infiltrating) Syringomatous Adenoma . . . . . . . . 354 15.6 Sarcomatoid Carcinoma with Myoepithelial
Differentiation (Myoepithelial Carcinoma,
Malignant Myoepithelioma) . . . . . . . . . . . . . . 412
Contents XIII
17.10 Intraductal Papillary Carcinoma . . . . . . . . . . . . 442
16 Miscellaneous Lesions
17.11 Infiltrating Ductal Carcinoma . . . . . . . . . . . . . . 442
16.1 Acute Mastitis (Puerperal Mastitis) . . . . . . . . . . . 420 17.12 Infiltrating Lobular Carcinoma . . . . . . . . . . . . . 442
16.2 Subareolar Abscess . . . . . . . . . . . . . . . . . . . . 420 17.13 Tubular Carcinoma . . . . . . . . . . . . . . . . . . . . 443
16.3 Plasma Cell Mastitis . . . . . . . . . . . . . . . . . . . . 420 17.14 Mucinous Carcinoma . . . . . . . . . . . . . . . . . . . 443
16.4 Idiopathic Granulomatous Mastitis . . . . . . . . . . 421 17.15 Medullary Carcinoma . . . . . . . . . . . . . . . . . . . 443
16.5 Lymphocytic Mastitis (Diabetic Mastopathy) . . . . 421 17.16 Apocrine Carcinoma . . . . . . . . . . . . . . . . . . . 443
16.6 Eosinophilic Mastitis . . . . . . . . . . . . . . . . . . . 422 17.17 Adenoid Cystic Carcinoma . . . . . . . . . . . . . . . 443
16.7 Silicone Mastitis and Diseases Associated 17.18 Metaplastic (Sarcomatoid) Carcinoma . . . . . . . . 444
with Cosmetic Augmentation . . . . . . . . . . . . . 422 17.19 Phylloides (Phyllodes) Tumor . . . . . . . . . . . . . . 444
16.8 Further Reading . . . . . . . . . . . . . . . . . . . . . . 422 17.20 Further Reading . . . . . . . . . . . . . . . . . . . . . . 444
16.9 Pathologic Effects
of Adjuvant Radiotherapy . . . . . . . . . . . . . . . . 423
18 Immunohistochemistry (Selected Topics)
16.10 Pathologic Effects
of (Neo)adjuvant Chemotherapy . . . . . . . . . . . 423
18.1 Role of Immunohistochemistry
16.11 Malignant Lymphoma . . . . . . . . . . . . . . . . . . 424
in Diagnostic Breast Pathology . . . . . . . . . . . . . 472
16.12 Diffuse Large B-cell Lymphoma . . . . . . . . . . . . 424
18.2 Immunohistochemistry
16.13 Burkitt’s Lymphoma . . . . . . . . . . . . . . . . . . . 425 in the Differential Diagnosis
16.14 Extranodal Marginal-Zone B-cell Lymphoma of Epithelial Lesions:Myoepithelial Cells . . . . . . . 472
of MALT Type . . . . . . . . . . . . . . . . . . . . . . . . 425 18.3 Carcinomas with Myoepithelial Differentiation
16.15 Follicular Lymphoma . . . . . . . . . . . . . . . . . . . 425 Versus Primary Sarcoma . . . . . . . . . . . . . . . . . 473
18.4 Microinvasive Carcinoma . . . . . . . . . . . . . . . . 473
18.5 Cell Population in Intraductal Proliferative Lesions:
17 Cytopathology of Benign
Homogeneous Versus Heterogeneous
and Malignant Lesions (Selected Topics)
Cell Population (Neoplasia Versus Hyperplasia) . . . 473
18.6 Paget’s Disease . . . . . . . . . . . . . . . . . . . . . . . 474
17.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . 440
18.7 Distinction Between DIN (DCIS) and LIN (LCIS) . . . 474
17.2 Fibrocystic Change . . . . . . . . . . . . . . . . . . . . 440
18.8 Systemic Metastasis of Breast Carcinoma . . . . . . 474
17.3 Proliferative Breast Diseases Without Atypia
(Adenosis,Ductal Hyperplasia) . . . . . . . . . . . . . 440 18.9 Micrometastatic Disease in Axillary Lymph Nodes
(Including Sentinel Nodes) . . . . . . . . . . . . . . . 474
17.4 Proliferative Breast Lesions with Atypia . . . . . . . . 441
18.10 Immunohistochemistry for Prognostic
17.5 Lactating Adenoma and Lactating Changes . . . . . 441
or Predictive Factors in Breast Carcinoma:
17.6 Fibroadenoma . . . . . . . . . . . . . . . . . . . . . . . 441
Hormone Receptors . . . . . . . . . . . . . . . . . . . 475
17.7 Intraductal Papilloma . . . . . . . . . . . . . . . . . . . 441
18.11 HER2/neu Overexpression . . . . . . . . . . . . . . . . 475
17.8 Ductal Intraepithelial Neoplasia
18.12 Further Reading . . . . . . . . . . . . . . . . . . . . . . 475
(Ductal Carcinoma In Situ) . . . . . . . . . . . . . . . . 441
17.9 Lobular Intraepithelial Neoplasia . . . . . . . . . . . 442 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 493