Mammary Pathology

Catherine Genestie Hpital de la Piti-Salptri`re, Paris o e e e June 20, 2011

Histology Reminder

There are two structures: Excretory ducts and connective tissue. Excretory ducts open individually through pores at the nipple level. There are 9 to 10 proximal lactiferous ducts. They divide by dichotomy (into two parts) and they end in the lobules by the acini (an acinus refers to any cluster of cells that resembles a many-lobed berry, such as a raspberry; acinus is Latin for berry) (see gure 10).

Breast prole: A: Ducts B: Lobules C: Dilated section of duct to hold milk D: Nipple E: Fat F: Pectoralis major muscle G: Chest wall/rib cage

Enlargement: A: Normal duct cells B: Basement membrane C: Lumen (center of duct)

Figure 1: Breast anatomy (sources: Wikipedia and http://www.breastcancer.org/).

Histology
a) Ducts have two cell layers, internal layer and external layer, delimited by a basement membrane. External layer contains myoepithelial cells (contractile). Internal layer is made up of mucosecretory cells. b) Connective tissue contains lymph blood vessels and collagen. The structure of the breast modies according to the hormonal cycle: Pregnancy: Increase of the number and of the size of the acini (lactescent lobule). Menopause: Reduction of the ducts and of the connective tissue.

Extractions for Pathology Anatomy

What are the extractions that a pathologist may have to analyse?

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2.1

Cytology

Only cells are analysed. In case of a mammary leaking, the material is spread on a glass slide: It is xed then stained by Papanicolaou technique. In case of detection of a nodule, a needle aspiration under echographic control can be performed if the nodule is of small size. Cells are extracted through a manual draining.

2.2

Histology or microscopic study

Study of a tissue. 2.2.1 Biopsy

After the detection of a nodule inside the breast, a biopsy may be performed either during a consultation with a simple ne needle aspiration which provides small size fragments (5 mm core samples), or at the operating block where a surgical operation will provide bigger size samples. Advantages: Diagnostic. If it is an inltrative carcinoma, the histoprognosis grade and hormonal receptor tests are performed. If the tumour is inammatory (PEV, pousse volutive or acute exarcerbation, designates rapidly progressing breast e e cancer / PEV-0 = patients without inammatory signs and no history of rapid tumour growth / PEV-1 = patients who describe rapid tumour growth but who show no inammatory signs / PEV-2 = patients with inammatory signs involving less than half of the breast / PEV-3 = patients with inammatory signs involving more than half of the breast) or of a big size, the malignancy diagnostic being known, a rst chemotherapy can be launched. 2.2.2 Tumourectomy

A tumourectomy is the removal of the tumour. It is a surgical operation performed at the operating block. Indication: Microcalcications An echographic tracking is performed at the operating block, allowing to put a hook next to microcalcications. The hook guides the surgeon during the operation. A tumourectomy for microcalcications must be sent to the laboratory. Its position must be recorded and a radiography of it must be provided, showing the microcalcications. Palpable nodule In case of a palpable nodule, an extemporaneous analysis is often requested. The extemporaneous analysis aims at modifying the progress of a surgical operation. If the nodule is a benign tumour, the operation is stopped. If the nodule is a carcinoma, an axillary curage is performed (the axilla is the area directly under the joint where the arm connects to the shoulder). A secondary surgical revision of the tumourectomy is performed if the surgical limits are incomplete. A mammectomy can be performed if the cancer is of big size or bifocal (two sites). Conducting the extemporaneous analysis. The nodule is taken during the operation. Its position must always be recorded and clinical and radiological data must be provided together with the biopsy. Two analyses are performed: A macroscopic analysis (study of the fresh nodule): It gives information about the colour, the size, the consistency of the nodule, and the nodule position gives information about the surgery limitations. A histology analysis: Within the nodule, a small size fragment (5 mm.) is collected, quickly frozen and cut at the cryostat (a device used to maintain cold cryogenic temperatures), then stained with toluidine blue. Extemporaneous analysis is rejected if: There is no nodule;

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Nodule size is smaller than 10 mm. The lesion is a papillary tumour (a benign epithelial tumour forming a rounding mass) or a carcinoma in situ, the extemporaneous analysis must be stopped in order to give priority to the nal histology analysis. In case of carcinoma in situ lesions discovered during an extemporaneous analysis, there is some restrictions about the possibility to nd invasive seeds after inclusion of the whole nodule. In case of phyllode tumour (large, fast growing masses that form from the periductal (around a duct) stromal cells (connective tissue) of the breast) or in case of radial scars, result of the analysis will be delayed and the surgery team must understand and accept this decision. If the tumour has already been treated by radiotherapy or chemotherapy, or if it is a recurring tumour, the extemporaneous analysis can be dicult. 2.2.3 Mastectomy

A mastectomy is the surgical removal of one or both breasts, partially or completely. A mastectomy is performed either if the tumour is of big size (more than 4 cm.), or after a tumourectomy. 2.2.4 Axillary curage

The axilla is the area directly under the joint where the arm connects to the shoulder (see Figureg:axillary-lymphnodes). A minimum of 8 axillary nodes must be found to go for axillary curage.

Lymph node areas adjacent to breast area. A: Pectoralis major muscle B: Axillary lymph nodes: levels I C: Axillary lymph nodes: levels II D: Axillary lymph nodes: levels III E: Supraclavicular lymph nodes F: Internal mammary lymph nodes Figure 2: Axillary lymph nodes (source: http://www.breastcancer.org/).

Macroscopic Care

See macroscopic protocol.

Breast Cancer
Cancer in situ. Histology shows a malignant epithelial proliferation located in the ducts and lobules light, without inltration of the neighbouring parenchyma (the parenchyma are the functional parts of an organ in the body. This is in contrast with the stroma which refers to the structural tissue of organs). The basal membrane remains. THERE IS NO INFILTRATION. We distinguish two types of proliferation: Either a ductal type cell proliferation (cells look like cells of lactiferous ducts), or a lobular type cell proliferation (cells look like lobule cells) (see Figure 4). Inltrating cancer is a cancer invading the mammary tissue, evolving locally then making metastasis (rst relay: The axillary nodes).

There are two types of breast cancers (see Figure 3):

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Figure 3: Schematic outline of breast tumour progression. Tumourigenesis goes through dened histologic and clinical stages and is driven by progressively accumulating genetic, epigenetic, and microenvironmental alterations. Thin and thick black circles indicate the breast and the basement membrane surrounding the ducts, respectively. Myoepithelial/basal cells (green cells) synthesize and are in direct contact with the basement membrane, whereas luminal epithelial cells (red cells) lay on top of the myoepithelium. A major distinguishing feature of the in situ to invasive carcinoma transition is the disappearance of the basement membrane and the myoepithelial cell layer. (Source: American Association for Cancer Research (AACR), Clinical Cancer Research, vol. 14 no. 2 339341, January 2008.)

Normal breast with lobular carcinoma in situ in an enlarged crosssection of the lobule. Breast prole: A: Ducts B: Lobules C: Dilated section of duct to hold milk D: Nipple E: Fat F: Pectoralis major muscle G: Chest wall/ rib cage Enlargement: A: Normal lobular cells B: Lobular cancer cells C: Basement membrane Figure 4: Lobular carcinoma in situ (source: http://www.breastcancer.org/).

4.1
4.1.1

Carcinoma In Situ
Ductal Carcinoma In Situ (DCIS)

Discovery Most often, a ductal carcinoma in situ (see Figure 5) is revealed by the existence of microcalcications during a mammography. Their prevalence is in sharp increase thanks to screening. At the present time they represent 20% to 30% of the cancers. Other possibility to discover them include mammary leaking, showing a Paget disease or, more rarely, a palpable nodule. Criteria necessary in a report Size Size of ductal carcinoma in situ is an important criterion for proposing a treatment. Clinical and macroscopic examinations of the nodule by the pathologist do not allow to assess its size because of the modication of the mammary parenchyma. Mammography under-estimate the nodule size. Only the microscopic analysis can assess the size, so it is important to take properly a nodule by tumourectomy for microcalcications, nodule which must always be provided to the pathologists together with its orientation and a radiography. The metallic hook put before the operation does not give the orientation. When the nodule has a size lower than 3 cm., it is completely included after

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Normal breast with noninvasive ductal carcinoma in situ (DCIS) in an enlarged crosssection of the duct. Breast prole: A: Ducts B: Lobules C: Dilated section of duct to hold milk D: Nipple E: Fat F: Pectoralis major muscle G: Chest wall/rib cage Enlargement: A: Normal duct cells B: Ductal cancer cells C: Basement membrane D: Lumen (centre of duct) Figure 5: Ductal carcinoma in situ (source: http://www.breastcancer.org/). staining (by identifying the surgery excision borders) and by identifying slices in a consecutive order. For nodules bigger than 3 cm., their surface is stained with indian ink. Parallel sagittal cuts are made every 0.3 cm. (sagittal plane is a vertical plane which passes from front to rear dividing the body into right and left sections), individually identied and labelled (excision limits are marked using indian ink of dierent colours). During histologic analysis, ductal carcinoma in situ lesions are quantied by counting the number of slices (blocks) containing ductal carcinoma in situ lesions. Example: Among 20 blocks, there are 10 blocks containing ductal carcinoma in situ. A block has a thickness of 3 mm., so the size of the ductal carcinoma in situ lesion is 10 3 = 30 mm. Another method, nodule peeling, is also performed. Quality of Margins This is a prognostic criterion about recurrence. Indeed, according to recent studies, the distribution of ductal carcinoma in situ looks segmental and multifocal, developing inside a segment; multifocality being dened as a site of ductal carcinoma in situ located in the same quadrant as the main lesion. Multicentricity, dened as a site of ductal carcinoma in situ separated by 4 cm. from the main site of ductal carcinoma in situ lesions is currently not much considered, however multicentricity exists when the ductal carcinoma in situ is large. In 50% of the cases, the ductal carcinoma in situ has a continuous extension in the lactiferous ducts, and a discontinuous extension in the other 50% of cases. For the discontinuous extension type, the seeds are separated by a 10 mm. distance, the gap. These two notions are important to accept the importance of the quality of exeresis (surgical removal of any part or organ, roughly synonymous to excision) when taking care of patients. Two methods exist for exeresis: Either the study of the orientated cuts by the surgeon, or the study of inked borders by the pathologist. If the second method is made, the pathologist must specify the distance in mm. between the ductal carcinoma in situ lesions and the border of the exeresis, the minimum distance necessary is currently unknown, it can be from 4 mm. to 20 mm. according to dierent authors; if the minimum distance is reached, specify if the exeresis border is sharp or not. The Holland Nuclear Grade This is the classication advised by the european group of pathologists. It has been proposed by Holland in 1994. It is a prognostic criterion. The grade depends on the aspect of cancer cell nuclei. If nuclei are of a small size, regular among each other, having a thin chromatin, the grade is I. If nuclei are of variable size (pleomorphic), with lumpy chromatin, the grade is III (see Table 1). [Holland et al., 1994] Holland R., Peterse J.L., Millis R.R., et al, Ductal carcinoma in situ: A proposal for a new classication, Seminars in Diagnostic Pathology, 1994(11): 167-180. Necrosis Necrosis located inside the inltrating area is also a prognosis factor, especially if necrosis is large, and if it reaches the basal membrane. This increases the risk of microinvasion.

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Well dierentiated (score I)

Monomorphic cells, few mitoses, pronounced architectural dierentiation (polarization), necrosis uncommon, psammomatous calcications. Intermediate between the poorly and welldierentiated categories. Pleomorphic cells, frequent mitoses, minimal or no architectural dierentiation, necrosis usually present, amorphous calcications.

Intermediately dierentiated (score II) Poorly dierentiated (score III)

Table 1: The Holland nuclear grading for ductal carcinoma in situ. Histologic Report The histologic report must contain the following information in case of ductal carcinoma in situ: Histologic size; Holland nuclear grade; Is there necrosis or not; Surgery exeresis limits. Morphologic Classication Denition of Holland nuclear grade: This is the classication advised by the european group of pathologists. It has been proposed by Holland in 1994. It is a prognostic criterion. The grade depends on the aspect of cancer cell nuclei. If nuclei are of a small size, regular among each other, having a thin chromatin, the grade is I. If nuclei are of variable size (pleomorphic), with lumpy chromatin, the grade is III (see Table 1). When duct carcinoma in situ lesions have dierent grades, the highest grade will be the global grade for the biopsy. In 1995, Silverstein has proposed a simpler classication based on nuclear grade and necrosis (see Table 2). Grade I Grade II Grade III Low or intermediary nuclear grade without necrosis Low or intermediary nuclear grade with necrosis High nuclear grade with necrosis

Table 2: The Silverstein grading for ductal carcinoma in situ. Special ductal carcinoma in situ have been described recently: Papillary intra-cystic carcinoma: It is characterized by a proliferation of papillary architecture. Papilla have a thin axis, covered by a proliferation of cells, all the cells being of a same single type. Myoepithelial cells have disappeared. Smooth muscular actin is negative, so it discards the diagnostic of intra-duct papilloma. Other criteria such as absence of apocrine metaplasia and inammatory reorganisation allows also to discard this diagnostic. Apocrine carcinoma in situ is characterized by a proliferation of large size cells, having a vast clear or eosinophilic cytoplasm and a pleomorphic nucleus having a lumpy chromatin and a protruding nucleolus. The dierentiating diagnostic is atypical apocrine metaplasia. Neuroendocrine carcinoma in situ is of adenoid architecture, having cells positive to chromogranine and synaptophysine antibodies. Prognosis of these dierent types is not dierent from usual ductal carcinoma in situ lesions.

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A: Cancer cells B: Basement membrane C: Lumen (centre of duct) Figure 6: Ductal carcinoma in situ, cribriform cell growth sub-type (source: http://www.breastcancer.org/).

A: Cancer cells B: Basement membrane C: Lumen (centre of duct) Figure 7: Ductal carcinoma in situ, papillary cell growth sub-type (source: http://www.breastcancer.org/). Atypical Ductal Hyperplasia and Intraduct Carcinoma Diagnosis of atypical ductal hyperplasia (see Fidure 9) is a diagnosis excluding ductal carcinoma in situ. Diagnosis of atypical ductal hyperplasia is made when we wonder if there is an ductal carcinoma in situ and if the lesions are spreading. Characteristics: Proliferation of monomorphic cells, with s slight increase of the nucleus-cytoplasm ratio, with circular and hyperchromatic nuclei. There are two types: Occurrence of a seed of atypical ductal hyperplasia within a ductal epithelial hyperplasia; Occurrence of real lesions, both from architectural and cytolgy points of view, but which size is no more than 2 mm. (Tavassoli). However, if ducts contain a high grade ductal carcinoma in situ, whatever its size, the diagnosis of ductal carcinoma in situ must be made. Relative risk associated with atypical ductal hyperplasia is 9.8 (Tavassoli) with a latency duration of 8.3 years, whereas the relative risk associated with simple ductal hyperplasia is 2.6 with a latency duration of 14.3 years. Mico-Inltrating Carcinoma It is not observed frequently, and it is not registerred in the classication of the World Health Organisation. It belongs to the group of inltrating carcinomas with a prevailing ductal element in situ.

A: Living cancer cells B: Dying cancer cells C: Cell debris (necrosis) D: Basement membrane Figure 8: Ductal carcinoma in situ, comedo cell growth sub-type (source: http://www.breastcancer.org/).

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Figure 9: Range of ductal carcinoma in situ (source: http://www.breastcancer.org/). Histologic characteristics are bulks of cancer cells, size of the bulks being less than 2 mm. Diagnosis is dicult, requiring to make several biopsies frequently and to cut at dierent levels. The ductal carcinoma in situ diagnosis does not seem to be modied by the existence of micro-inltrating seeds. Intra-Lobular Carcinoma Most often, intra-lobular carcinoma is identied by chance. From the histology point of view, acini of lobules or of ducts contain an epithelial proliferation made up of monomorphic cells, enlarging the light, and it has the appearance of a bag of marbles. However, the diagnostic of atypical lobular hyperplasia and of intra-lobular carcinoma is often very dicult to assess. and inter-observer reproducibility is very low. Two classications have been proposed by Tavassoli and Page, but none of these two classications has proved to be of real value for prognosis or to help improve reproducibility. For many authors, it may exist a continuum between these lesions and the fact that it could be the same disease. For now, atypical lobular hyperplasia and intra-lobular carcinoma are more considered as risk factors than as real neoplasia, while ductal carcinoma in situ is truly considered as real neoplasia. This is why Haagensen has proposed the expression of lobular neoplasia in situ. The extension of this expression to breast has to be evaluated.

4.2

Inltrating Carcinoma

Samples brought to pathologists are either a tumourectomy-axillary curage or a mastectomy-axillary curage.

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Figure 10: Dierence between hyperplasia and hypertrophy (source: Wikipedia). Which histologic criteria have to be mentioned in a report when doing a conservative care? Histologic type. Histoprognosis grade. Intraductal carcinoma. Hormone receptors. Size. Quality of the surgery exeresis borders. Carcinomatous embolus. Number of glands examined and number of glands inltrated with or without breaking of the basement membrane. Axillary Glands The inltration of glands is the most important prognosis criterion to predict the risk of metastasis and the chances of survival. A minimum number of 10 glands must be sampled. Prognosis depends according to the number of inltrated glands: The rate of metastasis is 65% for 1 to 3 inltrated glands, and it is of 86% if there is more than three inltrated glands. However, the value for prognosis of the breaking of the basement membrane and micrometastasis is not clearly demonstrated. Number of glands examined. Number of glands inltrated:

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Figure 11: Mammary epithelial cells escape the basement membrane of a breast duct, becoming invasive breast cancer. Arrow number 1: Cancerous mammary epithelial cells contained within a breast ducts basement membrane, a condition known as as ductal carcinoma in situ. Arrow number 2: Cancerous mammary epithelial cells that have escaped the basement membrane, becoming invasive. (Source: Britt-Marie Ljung, MD, University of California San Francisco, professor of clinical pathology.)

quantity: partial / bulk membrane broken Size Size of the tumour is correlated to the risk of glands inltration and to the survival of the patient. All the lesions are measured at macroscopic level and/or at microscopic level. At macroscopic level, the tumour is measured in its three dimensions. At histology level, the inltrating area is measured. In case of a dierence between these two measures, the biggest one will be retained. Histoprognosis Grade Both the Scar, Bloom and Richardson histoprognosis grade and the Elston and Ellis [1] one give a prognosis value to the risk of metastasis and to the survival of the patient. The grade is assessed on all histological types of inltrating cancer, except the medullary carcinoma type. Both Scar, Bloom and Richardson grade and Elston and Ellis grade have three grades I, II and III obtained from the addition of three criteria: Architecture, cytonuclei atypicality and number of mitoses. Each of the three criteria are rated 1, 2 or 3 (see Table 3). The assessment of the criteria of the Elston and Ellis grade is semi-quantitative. The addition of the three criteria gives the grade: Grade I: 3, 4, 5 Grade II: 6, 7 Grade III: 8, 9 Both Elston and Ellis and Scar, Bloom and Richardson grades are used. In its report, the pathologist must mention which grading system he has used. However, the Elston and Ellis grading system is recommended because it is more reproducible. The number of mitosis, alone or within the grade, is currently the best labelling of cell proliferation, and furthermore it is a crucial and independant prognosis factor. Many pathlogists specify the number of mitosis enumerated over 10 high power elds. However, some rules must be respected: Reduce the delay between the tumour exeresis and its xation (the technique of preserving a specimen for microscopic study), a perfect technic,

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Criterion Architecture Cytonuclei atypicality

Score 1 3 1 3

Scar, Bloom and Richardson Tumour contains only ducts Tumour contains no duct

Elston and Ellis More than 75% of the tumour is made up of ducts Less than 10% of the tumour is made up of ducts

Regular and monomorphic nuclei Pleomorphic nuclei with distinct atypicality Number of mitosis is assessed from 20 high power elds at the peripheral of the tumour. The highest number of mitosis per high power eld is retained. Number of mitosis = 0 or 1 Number of mitosis = 2 Number of mitosis = 3 or more The number of mitosis is assessed on 10 consecutive high power elds. The total number of mitosis on these 10 high power elds depends on the diameter of the high power eld (see Figure 12). Less than 11 mitosis Between 11 and 20 mitosis 21 mitosis or more

Number of mitosis

1 2 3

Table 3: Scar, Bloom and Richardson and Elston and Ellis grading systems.

Figure 12: Number of mitotic count per 10 high power elds by eld diameter (reproduced from [2]).

choose the most active mitotic area at 25X and count at 40X over 10 high power elds, and identify truly mitotic cells according to Van Diest and Baak criteria (no nucleus membrane, basophilic cytoplasm, hairy extensions clearly recognisable, either as a ball, or on a plane, or as two balls, see Figure 13). The histologic type of inltrating carcinoma has a prognosis value assessed. Classication of invasive carcinomas: Inltrating ductal adenocarcinoma (see Figure 14) Inltrating lobular adenocarcinoma (see Figure 15) Tubulous adenocarcinoma Mucinous or colloid mucous carcinoma Cystic adenoidal carcinoma Apocrine carcinoma Papillary carcinoma Metaplastic carcinoma

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(a) Prophase is a stage of mitosis in which the chromatin condenses (it becomes shorter and fatter) into a highly ordered structure called a chromosome in which the chromatin becomes visible. Mitosis in prophase stage are not counted for mitosis count.

(b) Metaphase is a stage of mitosis in the eukaryotic cell cycle in which condensed & highly coiled chromosomes, carrying genetic information, align in the middle of the cell before being separated into each of the two daughter cells.

(c) Anaphase is the stage of mitosis when chromosomes separate in an eukaryotic cell. Each chromatid moves to opposite poles of the cell, the opposite ends of the mitotic spindle, near the microtubule organizing centers.

(d) Telophase is a stage of mitosis in a eukaryotic cell in which the eects of prophase and prometaphase events are reversed. Two daughter nuclei form in the cell. The nuclear envelopes of the daughter cells are formed from the fragments of the nuclear envelope of the parent cell. As the nuclear envelope forms around each pair of chromatids, the nucleoli reappear.

Figure 13: The dierent mitosis stages.

Medullary carcinoma Carcinomas of good prognosis are the tubulous adenocarcinoma, the mucinous adenocarcinoma, the cystic adenoidal carcinoma and the inltrating cribriform carcinoma. The most frequent is the inltrating ductal adenocarcinoma (75%). 70% of inltrating carcinomas contain intra-duct component. The assessment of this intra-duct component is essential. If the intra-duct component is of big size and is located at the peripheral, the risk of recurrence is higher. World Health Organization denes the inltrating ductal carcinoma with prevailing intra-duct component as when the intra-duct component is four times as big as the inltrating component, suggesting a lineage between both. Depending on series, lobular carcinoma represents 4% to 11% of all inltrating carcinomas. Lobular carcinoma is characterised mainly by its absence at clinical, radiological and macroscopic levels. For the same grade, prognosis of intra-lobular carcinoma is almost comparable to prognosis of ductal carcinoma. Medullary carcinoma is a rare malignant tumour for which the prognosis was considered to be good so far. However, according to many authors, the prognosis of medullary carcinoma could be only slightly better than the prognosis of a grade III intra-ductal carcinoma. Five histological criteria should be visible in order to assess the diagnosis:

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Normal breast with invasive ductal carcinoma (IDC) in an enlarged crosssection of the duct. Breast prole: A: Ducts B: Lobules C: Dilated section of duct to hold milk D: Nipple E: Fat F: Pectoralis major muscle G: Chest wall/ rib cage Enlargement: A: Normal duct cells B: Ductal cancer cells breaking through the basement membrane C: Basement membrane Figure 14: Invasive ductal carcinoma (source: http://www.breastcancer.org/).

Normal breast with invasive lobular carcinoma (ILC) in an enlarged crosssection of the lobule. Breast prole: A: Ducts B: Lobules C: Dilated section of duct to hold milk D: Nipple E: Fat F: Pectoralis major muscle G: Chest wall/ rib cage Enlargement: A: Normal cells B: Lobular cancer cells breaking through the basement membrane C: Basement membrane Figure 15: Invasive lobular carcinoma (source: http://www.breastcancer.org/). 1. Tumour is of a limited size. 2. Stroma is rich in lymphocytes. 3. The architecture is of syncytium type (more than 75%) (a syncytium is a large cell-like structure, lled with cytoplasm and containing many nuclei). 4. There is no gland. 5. There is no in situ carcinoma. Other types of carcinomas: Metaplasia Carcinoma A metaplasia carcinoma is characterised by a metaplasia inside an intra-ductal carcinoma (same stem cell). The most used classication is the classication of Foschini: Carcinoma with partial or full epidermoid metaplasia (epidermoid carcinoma of ductal origin) Sarcomatoid carcinomas (a malignant tumour arising from connective tissues):

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1. Biphase (carcinosarcoma1 or carcinoma with fusiform cells2 , metaplasia carcinoma: They associate a batch carcinoma and/or epidermoid and a batch of undierentiated sarcoma with fusiform cells or with heterologous tissues. 2. Monophase (carcinoma with fusiform cells malignant myoepithelial tumour): Single batch sarcoma which epithelial origin is conrmed by positive epithelial markers. The metaplasia carcinoma grows rapidly, it has irregular borders on the radiography, very few metastasis, but it is of bad prognosis. Apocrine Carcinoma The inltrating apocrine carcinoma is characterised by cells (see apocrine carcinoma in situ, section 4.1.1, page 6). Reports about apocrine carcinoma disagree about its prognosis. Carcinomatous Embolus If there is a carcinomatous embolus, its quantity must be mentionned. The carcinomatous embolus is a prognosis factor for N patients about metastasis risk and survival, while for N+ patients it is a local recurrence risk. Method to search for carcinomatous embolus: The carcinomatous embolus must be searched for at the peripheral of the tumour. not at the center of the tumour. One has to look for clusters of carcinomatous cells in lymphatic cavities or vascular cavities bordered by endothelial cells.3 Ductal Carcinoma In Situ The following criteria must be mentioned in the report:

Localisation of the intra-ductal carcinoma: At the peripheral or at the center of the inltrating area; Evaluate the ratio of intra-ductal carcinoma relatively to the whole inltrating carcinoma; Nuclear grade; Is there any necrosis inside the intra-ductal carcinoma. If there is a large portion of ductal carcinoma in situ at the peripheral of the inltrating area, there is a higher risk of recurrence. Quality of the surgical exeresis borders If carcinoma reaches the borders of the exeresis, the risk of local recurrence is higher. The degree by which carcinoma reaches the border (minimal/focal/massive), the topography and the type (carcinoma inltrating and/or in situ) must be reported as well as the distance in mm. between the cancer and the nearest surgery border. The minimum distance required is currently under investigation. Hormonal Receptors Most often, there is a search for hormonal receptors through immunochemistry study by using monoclonal antibody. Only the nuclear staining of the inltrating area is taken into account. If more than 10% of the cells are marked, the receptor is considered as positive. The eciency of tamoxifen can be predicted from the positive result of hormonal receptors (predictive factors about the response to hormonotherapy). The progesterone receptor may also have a prognosis value on recurrence. Technical rules: A good xation is important. External calibration reference for each xation technique. The calibration reference can be a block of paran containing three samples at dierent intensity levels (low, medium, high). It can help make the xation technique more homogeneous. Internal calibration reference to help the validation of the xation technique when the inltrating area is negative to hormonal receptors.
1 Carcinosarcoma: A malignant tumour that is a mixture of carcinoma (cancer of epithelial tissue, which is tissue that lines or covers the internal organs) and sarcoma (cancer of connective tissue, such as bone, cartilage, and fat). 2 Fusiform: Formed like a spindle, wider in the middle and tapering toward the ends; cigar-shaped. 3 Endothelial cells line the entire circulatory system, from the heart to the smallest capillary. These cells reduce turbulence of the ow of blood, allowing the uid to be pumped farther. The endothelium is the thin layer of cells that lines the interior surface of blood vessels, forming an interface between circulating blood in the lumen and the rest of the vessel wall.

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Content of the report. The search for hormonal receptors through immunohistochemistry shows: Oestrogen receptor: Percentage and intensity of cells Progesterone receptor: Percentage and intensity of cells Conclusion: Oestrogen receptor (+ or ), Progesterone receptor (+ or ). Other factors: S-phase4 : Studied by cytometry5 ow. It is a prognosis factor about the creation of metastasis and about survival. However, this technique has to be standardised and made applicable to all patients. p536 : Apoptosis and cell cycle. p53 is detectable in carcinomatous cell nucleus, but its prognosis value is lower than classical criteria. HER2/neu (also know as ErbB-2)7 : Growth receptor. Predictive value for herceptin. Risk factors of recurrence after curation: Age Grade III histoprognosis Hormonal receptors negative Bank of the exeresis is reach and there is a large intra-ductal area Vascular embolus Risk factors for metastasis: Size N+ Number of N+ Age Grade III Vascular embolus

Conclusion

A report must be clear, without ambiguity, and report all the histoprognosis information in order to assess a therapeutic strategy.

References
[1] C.W. Elston and I.O. Ellis. Pathological pronostic factors in breast cancer. I. The value of histological grade in breast cancer: Experience from a large study with long-term follow-up. Histopathology, 19:403410, 1991. [2] Fattaneh A. Tavassoli. Pathology of the Breast. McGraw-Hill Professional, second edition, April 1999.
(synthesis phase) is the part of the cell cycle in which DNA is replicated. is a group of biological methods used to measure various parameters of cells. 6 p53 (also known as protein 53 or tumour protein 53), is a tumour suppressor protein that in humans is encoded by the TP53 gene. It regulates the cell cycle and, thus, functions as a tumour suppressor that is involved in preventing cancer. As such, p53 has been described as the guardian of the genome, the guardian angel gene, and the master watchman, referring to its role in conserving stability by preventing genome mutation. 7 HER2/neu (also known as ErbB-2) stands for Human Epidermal growth factor Receptor 2 and is a protein giving higher aggressiveness in breast cancers. It is a member of the ErbB protein family, more commonly known as the epidermal growth factor receptor family. Approximately 30% of breast cancers have an amplication of the HER2/neu gene or overexpression of its protein product. Overexpression of this receptor in breast cancer is associated with increased disease recurrence and worse prognosis. Because of its prognostic role as well as its ability to predict response to trastuzumab (Herceptin US brand name) (see below), breast tumours are routinely checked for overexpression of HER2/neu. Overexpression of the HER2 gene can be suppressed by the amplication of other genes and the use of the drug Herceptin.
5 Cytometry 4 S-phase

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Glossary
acinus An acinus refers to any cluster of cells that resembles a many-lobed berry, such as a raspberry; acinus is Latin for berry. 1, 8 actin Actin is a globular protein found in all eukaryotic cells. Actin is the monomeric subunit of two types of laments in cells: microlaments, one of the three major components of the cytoskeleton, and thin laments, part of the contractile apparatus in muscle cells. Thus, actin participates in many important cellular processes including muscle contraction, cell mobility, cell division and cytokinesis, vesicle and organelle movement, cell signalling, and the establishment and maintenance of cell junctions and cell shape. 6 adenoid Adenoids (or pharyngeal tonsil, or nasopharyngeal tonsil) are a mass of lymphoid tissue situated posterior to the nasal cavity, in the roof of the nasopharynx, where the nose blends into the throat. (Lymphoid tissue associated with the lymphatic system is concerned with immune functions in defending the body against the infections and spread of tumors. It consists of connective tissue with various types of white blood cells enmeshed in it, most numerous being the lymphocytes). 6 apocrine Apocrine is a term used to classify exocrine glands (glands that secrete their products (including hormones and other chemical messengers) into ducts (duct glands) which lead directly into the external environment) in the study of histology. Cells which are classied as apocrine bud their secretions o through the plasma membrane producing membrane bound vesicles in the lumen. 6, 14 apoptosis Apoptosis is the process of programmed cell death. Biochemical events lead to characteristic cell changes (morphology) and death. These changes include blebbing (irregular bulge in the plasma membrane of a cell), loss of cell membrane asymmetry and attachment, cell shrinkage, nuclear fragmentation, chromatin condensation, and chromosomal DNA fragmentation. Unlike necrosis, apoptosis produces cell fragments called apoptotic bodies that surrounding cells are able to engulf and quickly remove before the contents of the cell can spill out onto surrounding cells and cause damage. 15 axilla The axilla is the area directly under the joint where the arm connects to the shoulder. 2, 3, 8 basement membrane The basement membrane is a thin sheet of bers that underlies the epithelium, which lines the cavities and surfaces of organs. 1, 9 chromatin Chromatin is the combination of DNA and other proteins that make up the contents of the nucleus. 5, 6 cryostat A device used to maintain cold cryogenic temperatures. 2 embolus An embolus is any detached, itinerant intravascular mass (solid, liquid, or gaseous) carried by circulation, which is capable of clogging arterial capillary beds (create an arterial occlusion) at a site distant from its point of origin. 9, 14, 15 eosinophilic Eosinophilic means loves eosin. Eosinophilic describes the appearance of cells and structures seen in histological sections that take up the staining dye eosin. This is a bright-pink dye that stains the cytoplasm of cells. 6 epithelial Epithelial tissues line the cavities and surfaces of structures throughout the body, and also forms many glands. Functions of epithelial cells include secretion, selective absorption, protection, transcellular transport and detection of sensation. Epithelial tissue lies on top of connective tissue, from which it is separated by a basement membrane. It is composed of tightly clustered cells connected by tight junctions and desmosomes. Epithelial tissue is avascular, so it must receive nourishment via diusion of substances from the underlying connective tissue, through the basement membrane. The cells in epithelium are very densely packed together, leaving very little intercellular space. All epithelial cells rest on a basement membrane, which acts as a scaolding on which epithelium can grow and regenerate after injuries. Epithelial tissue is innervated, but avascular. Thus epithelial tissue must be nourished by substances diusing from the blood vessels in the underlying tissue. The basement membrane acts as a selectively permeable membrane that determines which substances will be able to enter the epithelium. 13, 68, 13, 14, 17 exeresis Surgical removal of any part or organ, roughly synonymous to excision. 5, 6, 9, 10, 14, 15

Mammary Pathology

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hyperplasia Hyperplasia (or hypergenesis) means increase in number of cells/proliferation of cells. It may result in the gross enlargement of an organ and the term is sometimes mixed with benign neoplasia/benign tumour. Microscopically cells resemble normal cells but are increased in numbers. Hyperplasia is considered to be a physiological (normal) response to a specic stimulus, and the cells of a hyperplastic growth remain subject to normal regulatory control mechanisms. This stands in contrast to neoplasia (the process underlying cancer and benign tumours), in which genetically abnormal cells proliferate in a non-physiological manner which is unresponsive to normal stimuli. 68 mastectomy A mastectomy is the surgical removal of one or both breasts, partially or completely. 3, 8 metaplasia Metaplasia (Greek: change in form) is the reversible replacement of one dierentiated cell type with another mature dierentiated cell type. The change from one type of cell to another may generally be a part of normal maturation process or caused by some sort of abnormal stimulus. In simplistic terms, it is as if the original cells are not robust enough to withstand the new environment, and so they change into another type more suited to the new environment. If the stimulus that caused metaplasia is removed or ceases, tissues return to their normal pattern of dierentiation. 6, 13 necrosis Necrosis is the premature death of cells and living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death. Cells that die due to necrosis do not usually send the same chemical signals to the immune system that cells undergoing apoptosis do. This prevents nearby phagocytes from locating and engulng the dead cells, leading to a build-up of dead tissue and cell debris at or near the site of the cell death. For this reason, it is often necessary to remove necrotic tissue surgically, a process known as debridement. 5, 6, 14 neoplasia Neoplasia (new growth in Greek) is the abnormal proliferation of cells. The growth of neoplastic cells exceeds and is not coordinated with that of the normal tissues around it. It usually causes a lump or tumour. Neoplasms may be benign, pre-malignant (carcinoma in situ) or malignant (cancer). Pre-malignant neoplasms do not invade and destroy the surrounding tissue but, given enough time, will transform into a cancer. Malignant neoplasms are commonly called cancer. They invade and destroy the surrounding tissue, may form metastases and eventually kill the host. 8 neuroendocrine Neuroendocrine cells (neurosecretory cells) are cells that receive neuronal input (neurotransmitters released by nerve cells) and, as a consequence of this input, release message molecules (hormones) to the blood. 6 papillary A papillary tumour is a benign epithelial tumour forming a rounding mass. 2, 6 parenchyma The parenchyma are the functional parts of an organ in the body. This is in contrast with the stroma which refers to the structural tissue of organs. 3, 4 periductal Around a duct. 3 phyllode tumour Large, fast growing masses that form from the periductal (around a duct) stromal cells (connective tissue) of the breast. 3 sagittal Sagittal plane is a vertical plane which passes from front to rear dividing the body into right and left sections. 4 stroma Connective tissue. 3, 13 tamoxifen Tamoxifen is an antagonist of the oestrogen receptor in breast tissue via its active metabolite, hydroxytamoxifen. It has been the standard endocrine (anti-estrogen) therapy for hormone receptor-positive early breast cancer in pre-menopausal women, although aromatase inhibitors have been proposed. Some breast cancer cells require oestrogen to grow. Oestrogen binds to and activates the oestrogen receptor in these cells. Because of this competitive antagonism, tamoxifen acts like a key broken o in the lock that prevents any other key from being inserted, preventing oestrogen from binding to its receptor. Hence breast cancer cell growth is blocked. 14 tumourectomy A tumourectomy is the removal of the tumour. It is a surgical operation performed at the operating block. 24, 8