—  SPECIALTY CONFERENCE HANDOUT  — Breast Pathology Monday, February 28, 2011, 7:30 PM CC BRA Clinical histories are printed below. Click on the case numbers for text and references of each case. Click on each slide thumbnail image for an enlarged view Unusual Breast Lesions Moderator: STUART J. SCHNITT Beth Israel Deaconess Medical Center Boston, MA Disclosure: In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose. Panelists: PUAYUAY-HOON TAN, Singapore General Hospital, Singapore J. JORDI ROWE, Cleveland Clinic, Cleveland, OH FERNANDO SCHMITT, Porto University and IPATIMUP, Porto, Portugal MELINDA E. SANDERS, Vanderbilt University Medical Center, Nashville, TN JAMES L. CONNOLLY, Beth Israel Deaconess Medical Center, Boston, MA Clinical histories are displayed below. For the fastest viewing of virtual slides, click: under each thumbnail image below. You must have Aperio ImageScope installed on your PC. If you do not already have Aperio ImageScope, Windows users with administrator privileges may download and install a free version in order to view USCAP Virtual Slides. Click the icon on the right to get your free copy:   Or, click on slide thumbnail images to view each slide in a Web-based slide viewer, which is somewhat slower. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 - Click here for Text and References Submitted by: Puay Hoon Tan - Singapore General Hospital, Singapore Clinical Summary: 55 year old Chinese female underwent an ultrasound guided core biopsy of a left breast lesion at the 0300-0400 location, radiologically described as an 'ill-defined, predominantly hypoechoic area approximately 7x6 mm with dense shadowing - possible malignancy'. Case 1 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 1 - Figure 1 Low magnification of the breast cores showing fibroadipose stroma with sparsely scattered lobules. Case 1 - Figure 2 Pale histiocyte-like cells are seen within the fibroadipose tissue. Case 1 - Figure 3 A benign lobule with a few acini/ductules containing several plump rounded cells. Case 1 - Figure 4 Pale histiocyte-like cells juxtaposed to benign ducts. Case 1 - Figure 5 The abnormal cells show ample pale, sometimes finely vacuolated cytoplasm. An occasional cell shows an intracytoplasmic vacuole. Atypical lobular hyperplasia is noted. Case 1 - Figure 6 The abnormal cells show central and eccentric, dark to sometimes vesicular nuclei, with mild to moderate pleomorphism. Percolation into fat is present. Case 1 - Figure 7 The histiocyte-like cells stream around a lobule in a vaguely targetoid fashion. Atypical lobular hyperplasia is present. Case 1 - Figure 8 Cytoplasmic outlines appear indistinct in some of the cells that seemingly fade into the background stroma. Cytoplasmic vacuoles are again discerned in occasional cells. Case 1 - Figure 11 Immunohistochemistry for AE1/3 shows positive reactivity in the histiocytoid cells, confirming an epithelial origin of the histiocytoid cells. Case 1 - Figure 12 E-cadherin is negative in the abnormal cells within the stroma supporting a lobular phenotype, while adjacent benign ductal epithelial and myoepithelial cells are positively highlighted. Lobular neoplastic cells within ductules are also negative for E-cadherin. Case 1 - Figure 13 GCDFP15 is positively expressed in the abnormal histiocytoid cells. Case 2 - Click here for Text and References Submitted by: J. Jordi Rowe - Cleveland Clinic, Cleveland, OH Clinical Summary: A 44 year old woman underwent a mammogram for a palpable breast mass. In the right breast a mass is identified at 1 o'clock which corresponds to the palpable mass. In the left breast a mass is identified at 10 o'clock. No other masses or calcifications are seen in either breast. The patient underwent bilateral ultrasound guided needle core biopsies. The following images are representative of both masses. Case 2 - Figure 1 Increasing magnifications of the tumor (4x, 10x, 40x). Note the clear spaces around the tumor nests, the nuclear grade, and the lack of tubular/alveolar pattern. Case 2 - Figure 2 Increasing magnifications of the tumor (4x, 10x, 40x). Note the clear spaces around the tumor nests, the nuclear grade, and the lack of tubular/alveolar pattern. Case 2 - Figure 3 Increasing magnifications of the tumor (4x, 10x, 40x). Note the clear spaces around the tumor nests, the nuclear grade, and the lack of tubular/alveolar pattern. Case 2 - Figure 4 Lymphovascular invasion, 40x. Case 2 - Figure 5 Estrogen receptor. Case 2 - Figure 6 EMA staining pattern in invasive micropapillary carcinoma, 20x. Case 2 - Figure 7 EMA staining pattern in ovarian papillary serous carcinoma, 20x. Case 2 - Figure 8 GCDFP-15 staining pattern in ovarian papillary serous carcinoma, 20x. Case 2 - Figure 9 PAX-2 staining pattern in ovarian papillary serous carcinoma, 20x. Case 2 - Figure 10 WT-1 staining pattern in ovarian papillary serous carcinoma, 20x. Case 3 - Click here for Text and References Submitted by: Fernando Schmitt - Porto University and IPATIMUP, Porto, Portugal Clinical History: 74-year old woman presented with a breast lump. No previous history of breast disease. Ultrasound and mammography were inconclusive. She was submitted a core-biopsy (Figures 1 to 4) and after the lesion was excised (Figures 5 to 9). Case 3 - Figure 1 Core biopsy sampling composed of two fragments of breast tissue with glandular proliferation. Case 3 - Figure 2 Round small glands lined by a single layer of cuboidal cells infiltrating fatty fibrous stroma. Case 3 - Figure 3 Glands showing variation in size and shape, lined by a pseudostratified epithelium with some tufts and micropapillae. Case 3 - Figure 4 Absence of myoepithelial cells showed by negativity for P63. Strong positivity for S100 protein. Case 3 - Figure 5 Low magnification of the lesion on excised specimen. Case 3 - Figure 6 Glandular lumen filled by proliferative epithelium. Case 3 - Figure 7 Low-power view of areas of coalescent growth of atypical cells. Case 3 - Figure 8 Area of solid (Grade 3) invasive ductal carcinoma. Case 3 - Figure 9 High magnification of invasive ductal carcinoma showing numerous mitosis, solid growth and high nuclear grade. Case 4 - Click here for Text and References Submitted by: Melinda E. Sanders - Vanderbilt University Medical Center, Nashville, TN Clinical Summary: The patient is a 56 year old female who is status post left lumpectomy and sentinel node biopsy followed by radiation therapy for invasive breast cancer in 2003, who presented in 5/2010 with a 2 month history of left breast enlargement, hyperpigmentation and multiple hard, painful skin nodules. Mammography at that time revealed a non-palpable spiculated nodule in the right breast suspicious for carcinoma and a suspicious thickening/mass of the left breast parenchyma and skin involving the anterior, inferior and medial aspects. Clinically, the left breast was described as having a peau d' orange appearance. Bilateral core needle biopsies were performed. The right needle core biopsy revealed invasive mammary carcinoma, no special type (ductal), low combined histologic grade, low proliferative rate. The biopsy on the left was read as fat necrosis and considered non-diagnostic. The decision was made to proceed with an incisional biopsy of the left breast for definitive diagnosis. Case 4 - Figure 1 Case 4 - Figure 2 Case 4 - Figure 3 Case 4 - Figure 4 Case 4 - Figure 5 Case 4 - Figure 6 Case 4 - Figure 7 Case 5 - Click here for Text and References Submitted by: James L. Connolly - Beth Israel Deaconess Medical Center, Boston, MA Clinical Summary: This is a biopsy of a breast mass in a 71 year old African American woman. The patient was in an automobile accident, with breast trauma, 8 months prior to the biopsy. Pertinent Laboratory Data: The lesional cells were positive for actin and vimentin and negative for keratin coctail(Ae1-Ae3 & Cam 5.2) Case 5 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Handouts for all Specialty Conferences will be accessible via the "Educational Materials" section on the homepage the morning after each respective conference. Printed copies of the handout will not be available at the meeting.