Session 4. Biopsies. Professor Sarah Pinder. Case A - SP08-9685.
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Transcript of Session 4. Biopsies. Professor Sarah Pinder. Case A - SP08-9685.
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Diagnosis - Angiosarcoma.
5 years after radiotherapy for breast carcinoma in wide local
excision
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Angiosarcoma
• Majority of angiosarcomas negative for CKs but epithelioid areas may stain positively in up to 35% of cases
• Conversely, less than 2% stain of breast carcinomas positive for CD31 and CD34
Macias-Martinez V. Am J Surg Pathol 1997;21:599-604
Meis-Kindblom JM. Am J Surg Pathol 1998;22:683-697
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• Infiltrative margins
• Nests, cords & strands of epithelioid tumour cells within a myxohyaline stroma
• Epithelioid cells show prominent intracytoplasmic vacuolisation, occasionally containing erythrocytes
• IHC profile may suggest carcinoma - CK 7 +ve and CK 18 +ve, but express vascular antigens (CD31, CD34 & Factor VIII)
• Also negative for high molecular weight cytokeratins, e.g. CK 14, characteristic feature of metaplastic breast carcinoma
Epithelioid haemangioendothelioma
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Diagnosis - Seeding of epithelial cells after
previous core biopsy of papillary lesion
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Seeding of Malignant CellsAfter core biopsy
Harter. Radiology. 1992;185;713-4
May be relatively common
2 out of 47 consecutive cases
Grabau. Eur J Surg Oncol. 1993;19;192-4
Uncertain significance
Benign and malignant epithelial displacement also noted after FNA and other needling procedures
Youngson. Am J Clin Pathol 1995;103;598-602 Youngson. Am J Surg Pathol 1994;18;896-903
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Epithelial displacement in breast lesions
• 53 cases of epithelial cell displacement• US core (24 cases), mammotome core (16), FNAC (8),
anaesthetic injection (3), suture placement (5) & wire localization (1) • Displacement of epithelial cells occurred in biopsy tract
(42 cases), lymphatic channels (5), both (4), breast stroma (2)• Diagnoses included intraductal papilloma (6 cases),
DCIS (45; 15 with invasive carcinoma), 2 pure invasive carcinoma • Except in 3 cases, associated with underlying papillary
lesion
Nagi C. Arch Pathol Lab Med. 2005;129:1465-9
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Malignant Cell Displacement
• 352 cancer excisions
• Tumour cell displacement in 32% patients after large-gauge needle core biopsy
• 76 cases displacement of 1 or 2 clusters, 38 cases displacement of multiple fragments
• Incidence & amount inversely related to interval between core & excision• 42% of patients with interval of <15 days • 31% of patients with interval of 15-28 days• 15% of tumours excised >28 days after core
Diaz LK. AJR Am J Roentgenol. 1999;173:1303-13
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Diagnosis - Phyllodes tumour with
liposarcoma
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Features of phyllodes tumours and fibroadenomas in core biopsy
• 12 features in previous core biopsy specimens of 36 excised phyllodes tumours & 38 excised fibroadenomas
• 4 features significantly more common in cores from phyllodes tumours & had a kappa statistic of > 0.6:
– stromal cellularity increased in at least 50% compared with typical fibroadenoma– stromal overgrowth (x10 field with no epithelium)– fragmentation – adipose tissue within stroma
Lee AHS et al. Histopathol. 2007;51:336-44
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Needle Core Biopsy Reporting
• Combination of architectural & stromal features
• Mild increase in stromal cellularity alone insufficient for definitive diagnosis of PT
• Report as “fibroepithelial lesion” if cannot be certain whether represents cellular FA or benign PT on core
Fibroadenoma (FA) or Phyllodes Tumour (PT)?
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ER
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Metastases to Breast
• Usually manifestation of disseminated disease
• Average interval from primary to breast secondary, about 2 years
• Breast lesion is initial sign of tumour in about 25%
• Generally poor prognosis
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Metastases to breast - common sites of origin
• Malignant melanoma 87
• Lung 78
• Ovary 50
• Prostate 39
• Kidney 24
• Stomach 15
• Ileum 13
Alva & Shetty-Alva 1999
Lymphoma
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Metastatic Carcinoma to the Breast
18 cases in 10 yrs at Nottingham City Hospital*
– Lung: 5 – Ovary: 5 – Melanoma: 4– Thyroid: 1– Kidney: 1– Oesophagus: 1– (Prostate: 1)
*Lee AHS. J Clin Pathol 2007; 60: 1333-1341
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How to reach a correct diagnosis
• H & E - Unusual histological pattern (does not look like NST, lobular, tubular, mucinous, etc)
• No DCIS or LCIS
• ER negative (mostly)
• Clinical history & mammogram
• Immunohistochemistry• Ck 7 and 20• TTF-1• WT1• HMB45• CD20• GCDFP-15• Chromogranin, CD10, CD56
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•Consider metastasis if morphology is not typical for primary carcinoma
•Compare with primary
• Immunohistochemistry
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CK7
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TTF1
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Diagnosis?
Received as second opinion.
Diagnosed as grade 1 invasive breast carcinoma.
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Diagnosis?
IHC?
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ER
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Diagnosis ?
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?Microglandular adenosis
?Atypical microglandular adenosis
?Invasive carcinoma in microglandular adenosis
?Combination of the above
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Atypical Microglandular Adenosis
• 108 cases at M.D. Anderson between 1983 and 2007 that had diagnosis of MGA
• 65 had available material for review
• Inclusion criteria were glands of MGA expressing S-100 protein and lacking myoepithelial layer
• 11 out of 65 qualified to have an MGA component; myoepithelial layer detected in remaining 54 cases which were classified as adenosis
• 3 of 11 had uncomplicated MGA, 2 had AMGA, 6 had MGACA
Khalifeh IM et al. Am J Surg Pathol. 2008;32:544-52
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Carcinoma in AMGA• Multiple invasive components in the MGACA cases
• All had a duct-forming component; basal-like component in 2 cases, acinic-like in 2, matrix producing in 4, sarcomatoid in 1, adenoid cystic in 1
• All strong and diffuse CK8/18 & EGFR expression but no ER, PR or HER2, or CK5/6
• Ki-67 and p53 labelling indices was < 3% in all MGAs, 5% to 10% in the AMGAs and > 30% in MGACAs
• 2 out of 6 MGACA cases developed metastasis and died of disease
• Khalifeh IM et al. Am J Surg Pathol. 2008;32:544-52
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Carcinoma in MGA• Memorial Sloan-Kettering Cancer Center
• Breast carcinoma arose in or in conjunction with microglandular adenosis (MGA) in 14 of 60 (23%)
• Carcinoma in the MGA in 13 patients
• In situ carcinoma in expanded MGA glands composed of cells with vesicular poorly differentiated nuclei
• When it arose in MGA, basement membranes present in benign MGA and in situ carcinoma but tended to be disrupted in invasive foci
• Strong immunoreactivity for cytokeratin, S-100 & cathepsin D in carcinomas
• 2 PR positive, 1 ER positive, 1 HER2 positive, 4 p53 protein positive
James BA, Cranor ML, Rosen PP. Am J Clin Pathol. 1993;100:507-13
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Collagen IV