Carolynne Pinder Child Development Nurse Practitioner Pam Schultz adapted Feb 2013.
Session 4. Biopsies. Professor Sarah Pinder
description
Transcript of Session 4. Biopsies. Professor Sarah Pinder
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
Case B - Core 08/261
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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
Case C -(1) Core biopsy - SP08-8208
(2) Excision - SP08-10287
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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)?
C2 = Excision
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Case D - SP08-4462
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ER
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Diagnosis - Metastatic lung carcinoma
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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
Case E - (1) & 2 (2) SP08-9657
5cm mass in breast of 80 year old woman
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Diagnosis?
Received as second opinion.
Diagnosed as grade 1 invasive breast carcinoma.
E2 = Excision
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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
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Diagnosis - “Typical” and atypical
microglandular adenosis.No invasive carcinoma.