Breast Pathology. Helge Stalsberg MD University Hospital of North Norway
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1 Breast Pathology Helge Stalsberg MD University Hospital of North Norway
2 Major classes of breast disease Normal breast Benign breast disease Carcinoma in situ Invasive carcinoma
3 Normal breast Lobule and duct Lobule
4 Benign Breast disease: Elements of fibrocystic disease Cyst Ductal Apocrine metaplasia hyperplasia Sclerosing adenosis
5 Benign breast disease: Intraductal papilloma Fibroadenoma
6 Carcinoma in situ Ductal carcinoma in situ. DCIS Lobular carcinoma in situ. LCIS
7 The distribution of carcinoma in situ Ductal carcinoma in situ Lobular carcinoma in situ
8 Invasive carcinoma: The pathology report The definite diagnosis The local/regional extent of the disease Data relevant to prognosis Data relevant for the choice of treatment
9 The Pathology report, Ca. resection MAIN DIAGNOSIS: Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE: 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE: 3 DCIS MIN. DIST. TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative (2+ by immunohistochemistry, negative by FISH) ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
10 The Pathology report MAIN DIAGNOSIS: Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE: 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE: 3 DCIS MIN. DIST. TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative (2+ by immunohistochemistry, negative by FISH) ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
11 Types of invasive carcinoma Ductal Ductal Lobular Tubular Mucinous Medullary
12 Inflammatory carcinoma The diagnosis is based on clinical features: Diffuse erythema, peau d orange, tenderness, induration, warmth, enlargement And carcinoma confirmed by biopsy: In most cases an invasive ductal carcinoma grade 3 with tumor in dermal lymphatics
13 The Pathology report MAIN DIAGNOSIS: Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE (1-3): 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE: 3 DCIS MIN. DIST. TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative (2+ by immunohistochemistry, negative by FISH) ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
14 Tumor grading Feature Score Tubule formation 1-3 Nuclear atypia 1-3 Number of mitoses 1-3 Grade Sum of scores Grade Grade Grade 3 8-9
15 Tumor grades Grade 1 Grade 3
16 The Pathology report MAIN DIAGNOSIS: Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE: 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE: 3 DCIS MIN. DIST. TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative (2+ by immunohistochemistry, negative by FISH) ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
17 Orientation of the specimen
18 Inking of resection margins
19 The inked surface as seen in the microscopic slide
20 Examination of resection margin Skin Section 1 Section 2 Inked margin
21 The Pathology report MAIN DIAGNOSIS: Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE: 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE: 3 DCIS MIN. DIST. TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative (2+ by immunohistochemistry, negative by FISH) ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
22 Vascular invasion Tumor tissue Lymph vessel
23 The Pathology report MAIN DIAGNOSIS: Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE: 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE (1-3): 3 DCIS MINIMUM DISTANCE TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative (2+ by immunohistochemistry, negative by FISH) ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
24 MAIN DIAGNOSIS: The Pathology report Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE: 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE: 3 DCIS MIN. DIST. TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative (2+ by immunohistochemistry, negative by FISH) ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
25 Axillary lymph nodes Breast cancer spreads through lymphatic channels to axillary lymph nodes. When axillary content is removed, all nodes are searched and embedded for microscopy
26 Micrometastasis Micrometastasis spotted in otherwise negative sentinel node
27 Tumor deposits in lymph node Size Designated ptnm class > 2 mm Metastasis pn1 2 mm; > 0.2 mm Micrometastasis pn1(mi) 0.2 mm Isolated tumor cells pn0 (i+)
28 The Pathology report MAIN DIAGNOSIS: Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE: 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE: 3 DCIS MIN. DIST. TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative (2+ by immunohistochemistry, negative by FISH) ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
29 Immunohistochemistry: Estrogen receptor Negative: No benefit from hormone therapy Positive: Will benefit from hormone therapy
30 The Pathology report MAIN DIAGNOSIS: Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE: 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE: 3 DCIS MIN. DIST. TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
31 Immunohistochemistry Her-2 Her-2 positive. Will benefit from Herceptin therapy
32 The Pathology report MAIN DIAGNOSIS: Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE: 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE: 3 DCIS MIN. DIST. TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative (2+ by immunohistochemistry, negative by FISH) ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
33 The Pathology report MAIN DIAGNOSIS: Local resection (lumpectomy) of breast with invasive ductal carcinoma OTHER FEATURES: TUMOR SIZE: 3 cm LOCATION: Upper inner quadrant, right breast TUMOR GRADE: 2 RESECTION MARGINS, MINIMUM DISTANCE TO TUMOR: 4 mm from dorsal margin, 32 mm from ventral margin TUMOR INVASION OF SKIN, MUSCLE, PAGET S DISEASE OF THE NIPPLE: Absent. VASCULAR INVASION: Present DCIS: Present DCIS GRADE: 3 DCIS MIN. DIST. TO RESECTION MARGIN: 1 mm to dorsal margin NO. OF LYMPH NODES EXAMINED: 13 NO. OF LYMPH NODES WITH TUMOR: 5 HORMONE RECEPTOR STATUS: Positive for estrogen receptor Negative for progesteron receptor Her-2 STATUS: Negative (2+ by immunohistochemistry, negative by FISH) ptnm CLASSIFICATION: pt1n2mx EXTRA-TUMORAL BREAST: Fibrocystic disease
34
35 Is Breast pathology in Ghana similar to that in the industralized countries? A comparison of non-inflammatory pathology diagnoses in Ghana (KATH) and Norway (UNN)
36 The relative frequency of major pathology diagnoses in breast specimens from KATH and UNN Diagnosis Ghana, KATH (162) Norway, UNN (2173) N % N % Fibroadenoma % % Fibrocystic dis % % Atypical hyperpl 0 0 % 28 1 % Carcinoma in situ 6 4 % % Carcinoma % %
37 The relative frequency of main types of invasive breast carcinoma Type Ghana, KATH (92) Norway, UNN (1012) N % N % Ductal and NOS 85 92, ,3 Lobular 1 1,1 97 9,6 Tubular 0 0,0 10 1,0 Mucinous 3 3,3 25 2,5 Medullary 1 1,1 3 0,3 Papillary 2 2,2 3 0,3
38 Tumor grade in Core biopsies of Breast cancer Tumor grade Preliminary data 2009 Ghana (25 cases) Norway (93 cases) Grade 1 16% 33% Grade 2 28% 44% Grade 3 48% 16% E. Adjei
39 Hormone receptors in Core biopsies of Breast cancer Preliminary data 2009 Hormone receptor Estrogen receptor Progesteron receptor Ghana (25 cases) Norway (93 cases) 48% positive 89% positive 12% positive 62% positive E. Adjei
40 Her-2 overexpression in Core biopsies of Breast cancer Preliminary data 2009 Ghana (25 cases) Norway (93 cases) 32% positive 12% positive E.Adjei
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