6What should we do if we receive a kind of specimen, excised for non palpable lesion with microcalcification?For first step, radiography of the intact specimen is an essential part of the processing of these specimens. This is to ensure that the lesion is contained the calcification.A specimen X-ray should be sent to the pathologist along with the specimen.
8If the mammographic abnormality reveals microcalcification, the pathologist should make every effort to identify them in histologic sections.If X-ray of the sliced tissue specimen is available, all abnormal areas seen should be submitted and labelled on the radiograph.
9If these are not identified in the sections the following steps should be followed: The microcalcification may represent calcium oxalate crystals. These requires polarization lenses to visualize.X-ray of the paraffin blocks and any remaining wet tissue, if any. Multiple level sections can be made of the blocks containing the calcification.Calcification can be leached out by acidic fixatives or shattered out by the microtome blade. The PH of the fixative should be checked regularly.
20Lobulocentric proliferation of acini around a central duct with stromal sclerosis and compression of lumensArises within terminal duct lobular unitMust be at least 2x larger than average lobule2 cell layers may be best appreciated at peripheryMay be difficult to see if center of lesion is sampled in a core needle biopsy
21Most common benign lesion mistaken for invasive carcinoma More difficult to diagnose on core needle biopsy when borders and lobulocentric pattern may not be evaluable1.5-2x increased relative risk for development of invasive carcinoma or 5-7% actual lifetime risk
22Consider surgical consultation about excisional biopsy: No, unless radiographically discordant
24Radial scarTypically, these lesions are identified as 'distortions of architecture'/'stellate lesions' on mammogramsIf calcs are seen, which is not uncommon, they are an added extra rather than the main imaging diagnostic feature
25RADIAL SCARCalcs are normally luminal, fine textured and associated with the various pathological processes seen as part of these lesions e.g. sclerosing adenosis within the lesioncolumnar cell changeusual type epithelial hyperplasia
27Complex sclerosing lesion (CSL) is less specific term Complex sclerosing lesion (CSL) is less specific term. Sometimes defined as a RSL > 1 cm in sizeMost RSLs are microscopic findingsLarger RSLs may present as mammographic density or even palpable massBoth in situ and invasive carcinomas have been reported in association with RSL(>2 cm)
28RADIAL SCAR Central nidus, varying degrees of fibrosis and fibroelastosis in stellate or radial configurationo Associated proliferative epithelial componento Varying degrees of proliferative epithelial changeso Smaller ducts can become entrapped in dense fibrous stroma within central fibrotic region
29RSL is histologic risk factor for subsequent development of breast carcinoma Presence of epithelial atypia, increased size, and multiple lesions are likely associated with increased risk for development of malignancyStudies to identify myoepithelial cells may be helpful in difficult case.However, results of myoepithelial cell studies to rule out malignancy must be interpreted with caution
30Few small-series studies have shown that 40% of patients with radial scar on CNB had carcinoma (DCIS or invasive) at excision; and 22% reported ADH on follow-up excisionShould be excised
32Columnar Cell Change Frequently accompanied by microcalcification Calcs often fine - may be luminal, intra-epithelial or in adjacent stromaOxalate calcs uncommon
33Cells line dilated terminal ductal lobular units (TDLUs) Cystic spaces frequently contain luminal secretions and flocculent materialMolecular studies show genetic changes similar to those found in low-grade DCIS and invasive cancerMorphologic spectrum based on presence and degree of epithelial atypia
34Columnar cell change with periductal calcs Columnar cell change with intra-epithelial calcColumnar cell change with periductal calcs
37FEA What does this mean? Flat epithelial atypia “older term” clinging carcinomaFEA(Flat Epithelial Atypia) represents columnar cell lesion with varying degrees of cytologic atypiaIntraductal alteration of the epithelial cells of 1-5 layers of “low grade” nucleiFrequently coexists with lobular neoplasia and/or tubular carcinomaIf FEA is encountered on excision:Perform multiple levels to look for architectural changes of ADH or low-grade DCISSubmit all tissue for microscopic examination
38FEA found on needle core biopsy: • Surgical excision is recommended• Diagnosis is upgraded to more serious lesion in 20-30% of cases CCC found on needle core biopsy (without atypia)• Most likely incidental finding as result of microcalcifications• Can be followed as long as there are no other worrisome clinical or mammographic findings
40Intraductal papilloma Benign epithelial proliferative lesions characterized bypapillary ingrowths into major ducts (LDP) or smallerducts (SDP)
41Presentation of LDP:Nipple discharge present in 80% of cases: unilateral and spontaneous• Sanguinous or serosanguinous: 70%• Bloody (less common): May be due to papilloma twisting on stalk and infarctionPalpable subareolar massPresentation of SDPFinding on screening mammographyIncidental finding in a biopsy for another lesionUsually does not cause discharge or a palpable mass
42Arborizing fronds of tissue with well-developed central fibrovascular core Lined by epithelial cells, myoepithelial cell layerPresence of myoepithelial cells and their distribution in lesion is helpful diagnostic featureMay require use of myoepithelial markers to aid in the diagnostic evaluation in problematic cases
43Intra ductal papilloma Calcification commonFine luminal calcs and/or coarser calcs seen at periphery associated with sclerosis in and around the papilloma
44Mild increased risk of subsequent carcinoma: 1. 5-2 Mild increased risk of subsequent carcinoma: x relative risk or - 5-7% lifetime riskRisk similar to that for moderate or florid ductal epithelial hyperplasiaSurgical consultation for lesions> 10 mm.
45In core needle biopsies: Management of lesions diagnosed as benign papillomas on core needle biopsy is controversialRisk of carcinoma on excision of benign papillomas is very lowWhen cases are carefully selected and there is good radiologic/pathologic correlation, carcinomas on excision are absent or rare « 5%)However, distinction between benign papillomas and atypical papillomas can be difficult, and some authorities recommend excision of all papillary lesions on core needle biopsyPapillomas with atypia should be excised as 20-60% of cases will reveal carcinoma on excision
47Atypical Lobular Hyperplasia ALH is composed of a monomorphic proliferation ofdiscohesive polygonal or cuboidal cells that are small andround. In lobules, these cells begin to fill acinar spaces,but few are widely distendedrciJ.
48ALH is an incidental finding in breast biopsies performed for other indications Calcifications often present in areas adjacent to ALHThe hallmark feature of ALH, LCIS, and invasive lobular carcinoma is loss of E-cadherin expressionALH is cytologically identical to lobular carcinoma in situ (LClS) but is more limited in extent
50ALH is associated with a 4-5x increased relative risk or a 13-17% lifetime risk of developing invasive carcinomaIn some studies, a strong family history of breast cancer doubles risk of invasive carcinoma to 8xDuctal involvement by ALH (pagetoid extension) is associated with 8x risk or a 26% lifetime risk• LClS has a l0x increased relative risk or a lifetime riskof - 30%• Carcinomas that occur in women after a diagnosis of LN average> 10 years to diagnosis
51ALH may be found as an incidental finding in a core needle biopsy • If there is no other reason for excision, the value of excision based solely on presence of ALH is unclearLikelihood of cancer on excision is higher in the following settings:• Radiologic lesion is a mass or highly suspicious calcifications (linear &/or branching)• ALH shows atypical features, such as higher nuclear grade, or is associated with calcifications
52What is the recommendation? Surgical consultationUp to 20% upgraded at lumpectomy
54Mucocele like lesionsUncommon breast lesion, composed of mucin containingcysts that may rupture
55MLL is usually asymptomatic Screening mammograms may show mass or calcificationsRange from benign to ADH or DCIS to mucinous carcinoma30% of mucocele-like lesions were identified as mucinous carcinoma on surgical excision
56Data are limited, and excision is recommended whenever an atypical mucocele-like lesion or acellular stromal mucin identified on CNB