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 ________________________________
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
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
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
benign malignant (in situ !) atypical papiloma papiloma carcinoma (DCIS) in papilloma papillary carcinoma
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?)
Benign spindle cell stromal tumors of the breast desmin
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,..)
plasticity of morfofology a immunofenotype (CD34, bcl2, CD99, actin,desmin, ER, PR, AR) vim+/CD34+ stromal cell fibroblastic myofibroblastic fibrohistiocytic mixed Benign spindle cell stromal tumors of the breast myofibroblastoma leiomyoma spindle cell lipoma-like tumor solitáry fibrous tumor fibrous histiocytoma spindle cell tumor NOS combinations of…
perilobular hemangioma - microscopic lesion ( mm sized ) - the only one that invades in TDLU ! hemangioma - capillary, cavernous, complex,.. angiomatosis subcutaneous nonparenchymal hemangioma Benign vascular lesions of the breast
well circumscribed, < 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
Malignant vascular lesions of the breast unlimited, > 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
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
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, < 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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