—  SPECIALTY CONFERENCE HANDOUT  — Breast Pathology Wednesday, March 11, 2009, 7:30 PM Convention Center 302 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 Diagnostic Dilemmas 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: NOUR SNEIGE, Anderson Cancer Center, Houston, TX LAURA C. COLLINS, Beth Israel Deaconess Medical Center, Boston, MA DAVID G. HICKS, University of Rochester medical Center, Rochester, NY EDI BROGI, Memorial Sloan-Kettering Cancer Center, New York, NY GARY TSE, Prince of Wales Hospital, Hong Kong, China 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: Nour Sneige - Anderson Cancer Center, Houston TX Clinical Summary: A 74 year old women presented with 1.3 cm left breast mass. Excisional biopsy was performed. Case 1 - Figure 1 Case 1 - Figure 2 Case 1 - Figure 3 Case 1 - Figure 4 Case 1 - Figure 5 Case 1 - Figure 6 Case 2 - Click here for Text and References Submitted by: Laura C. Collins - Beth Israel Deaconess Medical Center, Boston MA Clinical Summary: A 43 year old female presented with a 2.5 cm right breast mass Overlying skin dimpling was present On imaging the lesion appeared as a well circumscribed, lobulated mass Due to the superficial location of the lesion an excisional biopsy was performed Immunostains for ER, PR and HER2 were negative Neuroendocrine markers were negative Case 2 - Figure 1 Low power view of several irregular nests of tumor cells embedded in a fibrotic stroma. Case 2 - Figure 2 Higher power view showing a solid nest of basaloid appearing cells characterized by large cells with round to oval, hyperchromatic nuclei with scant eosinophilic cytoplasm. Nucleoli are inconspicuous. Case 2 - Figure 3 High power view showing a cribriform area. On high power the basaloid cells show moderate to marked nuclei atypia. Around some of the lumens the cells appear to have more abundant eosinophilic cytoplasm and normochromatic nuclei. Other lumens contain homogeneous, eosinophilic material. Case 2 - Figure 4 Low power view showing another area of the tumor which has the appearance, at this power, of having fibrotic material within the solid tumor cell nests. Case 2 - Figure 5 CK 5/6 Case 3 - Click here for Text and References Submitted by: David G. Hicks - University of Rochester Medical Center, Rochester, NY Clinical History: An 80-year-old Caucasian male with multiple chronic medical problems presented to his primary care physician for routine health maintenance exam Family history was significant for: Daughter who developed a fallopian tube carcinoma at the age of 45 followed by breast cancer Family history of pancreatic cancer and cardiovascular disease Physical Exam & Imaging: Physical examination: unremarkable with the exception of an inverted left nipple with a palpable 2 x 2 cm retro-areolar mass Clinical laboratory evaluation: unremarkable except for an elevated serum PSA (2.3 mg/L) Mammography: irregular focal area of asymmetry in the left retro-areolar region measuring 2.5 cm without associated micro-calcifications Ultrasound: left retro-areolar region showed an irregular hypo-echoic area measuring 1.6 cm without significant posterior enhancement or shadowing Core biopsies of this mass were obtained Case 3 - Figure 1 Case 3 - Figure 2 Case 3 - Figure 3 Case 4 - Click here for Text and References Submitted by: Edi Brogi - Memorial Sloan-Kettering Cancer Center, New York, NY Clinical Summary: A 44 year old woman underwent excision of new mammographic calcifications in the left breast. The diagnosis was "intraductal carcinoma, solid type with comedonecrosis and calcifications, close to the margin". Re-excision yielded the findings shown in Figures 1-5; the findings in figure 6 were not noted. More surgery followed, showing "multifocal LCIS, extending into ducts, with foci of comedonecrosis, present at two distinct foci of the inked resection margin." The patient received no radiotherapy. Case 4 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 4 - Figure 1 Extensive solid carcinoma in situ is present, centered in the TDLU. Some of the acini show massive distention and central necrosis. Case 4 - Figure 2 Extensive solid carcinoma in situ is present, centered in the TDLU. Some of the acini show massive distention and central necrosis. Case 4 - Figure 3 Massively expanded acini with central necrosis abut the inked margin. Case 4 - Figure 4 The carcinoma consists of a monotonous proliferation of small cells, with central nucleus. Few large histiocytes are admixed with the carcinoma in situ. Case 4 - Figure 5 The carcinoma in situ consists of small cells, with scant cytoplasm and inconspicuous nucleoli. Rare binucleate cells are present. Intracytoplasmic vacuoles indent some of the nuclei, with resulting signet ring morphology. Case 4 - Figure 6 Scattered tumor cells admixed with few lymphocytes are present in the stroma adjacent to in situ carcinoma. This focus, not present in the original slides, was unveiled only in a deeper section. Case 5 - Click here for Text and References Submitted by: Gary Tse - Prince of Wales Hospital, Hong Kong, China Clinical Summary: A 50 year old lady presented with a 4.7 cm mass in the right breast. There was no nipple discharge. There was also a previous history of breast lump removed from the same breast 2 years ago. Physical examination showed the mass to be hard to palpation, but was not adherent to the skin or underlying tissue. There was no axillary lymphadenopathy. The breast lump was excised and the section is a representative sampling of this breast mass. Case 5 - Figure 1 Case 5 - Figure 2 Case 5 - Figure 3 Case 5 - Figure 4 Case 5 - Figure 5 Case 5 - Figure 6 Case 5 - Figure 7 Case 5 - Figure 8 If there are glass slides for a conference, they will be available for study in the microscope room in the Convention Center Room 313 for participants who wish to review them prior to the evening session. 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. A booklet containing an agenda for each Specialty Conference symposia and a list of speakers is provided at the meeting.