—  SPECIALTY CONFERENCE HANDOUT  — Breast Pathology Tuesday, March 23, 7:30 PM Salon 1 and Balconies 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 Uses and Limitations of Adjunctive Studies for Solving Problems In Breast Pathology 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: CAROL A. REYNOLDS, Mayo Clinic, Rochester, MN TIMOTHY W. JACOBS, Virginia Mason Medical Center, Seattle, WA SANDRA J. SHIN, Weill Cornell, Medical Center, New York, NY IAN O. ELLIS, City Hospital, NHS Trust, Nottingham, UK GELAREH FARSHID, BreastScreen South Australia & South Australian Pathology, Adelaide, South Australia 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 Clinical Summary: 55 year old woman with a small nodule noted by ultrasound in the left breast. Ultrasound-guided core needle biopsy performed. Case 1 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 1 - Figure 1a Ultrasound of left breast. Case 1 - Figure 1b Low power image of infiltrating tumor composed of solid, irregular nests separated by intervening dense fibrous stroma. The tumor borders appear well-delineated. Case 1 - Figure 1c Medium power image of variable sized solid nests composed of tumor cells with mild pleomorphism. Tumor nuclei round to oval with stippled (salt-and-pepper) chromatin pattern. Case 1 - Figure 1d High power image of large distended duct with rosette-like lumen formation. Case 1 - Figure 2 Chromogranin. The tumor cells demonstrate strong chromogranin expression. Synaptophysin and NSE showed similar staining result. Case 1 - Figure 3 Calponin stain. The infiltrating tumor cells and the distended ducts with rosette-like lumen formation lack a basal layer of myoepithelial cells. Calponin highlights the vessels in the stroma. Case 1 - Figure 4 CDX2. The tumor cells demonstrate diffuse nuclear staining against CDX2. Case 2 - Click here for Text and References Submitted by: Timothy W. Jacobs - Virginia Mason Medical Center, Seattle, WA Clinical Summary: A 39 year old woman underwent prophylactic mastectomy. The nipple was unremarkable clinically, as well as on gross pathologic examination. Images are from a routine section of the nipple. Case 2 - Figure 1 Case 2 - Figure 2 Case 2 - Figure 3 Case 2 - Figure 4 Case 2 - Figure 5 Case 2 - Figure 6 Case 2 - Figure 7 Case 2 - Figure 8 Cytokeratin 7 Case 3 - Click here for Text and References Submitted by: Sandra J. Shin - Weill Cornell Medical Center, New York, NY Clinical History: 51 year-old female with new onset 2.5 cm retroareolar mass. Needle core biopsy is performed. Case 3 - Figure 1 Needle core biopsy: A small glandular proliferation with angled contours and an infiltrative growth pattern. Case 3 - Figure 2 Needle core biopsy: Tissue core containing a small glandular proliferation in a background of moderately heavy lymphocytic infiltrates. Case 3 - Figure 3 Needle core biopsy: Higher magnification of a small glandular proliferation with associated cellular stroma. Case 3 - Figure 4 Needle core biopsy: Extremely infiltrative growth pattern of glandular structures between benign mammary glands and in fat. Case 3 - Figure 5 Needle core biopsy: Extremely infiltrative growth pattern of glandular structures between benign mammary glands and in fat. Case 3 - Figure 6 Needle core biopsy: Glandular structures are cytologically atypical. A rare mitosis is identified. Case 3 - Figure 7 Excisional biopsy: Traits of squamous differentiation in participating glandular structures, in this case, by an increase of glassy eosinophilic cytoplasm in some foci. Case 3 - Figure 8 Excisional biopsy: Associated stromal cellularity in a lamellar pattern and imperceptible blending with adjacent stroma also known as "spindle-cell metaplasia". Case 3 - Figure 9 Immunohistochemical stain Smooth muscle actin: Strong staining of stromal myofibroblasts give the illusion of a myoepithelial layer in this invasive tubular carcinoma. Case 3 - Figure 10 Immunohistochemical stain p63: Variable circumferential staining around glandular structures. Some areas show diffuse or sporadic positivity while other areas are completely negative. Case 3 - Figure 11 Immunohistochemical stain p63: Some glandular structures show more diffuse staining of basal and luminal epithelium, likely foci with squamous differentiation. Case 3 - Figure 12 Immunohistochemical stain smooth muscle myosin heavy chain: Variable staining like p63 but in addition, closely apposed to glandular structures are stromal spindle cells demonstrating a lamellar and "wispy" staining pattern. Case 3 - Figure 13 Immunohistochemical stain K903: Shows diffuse but variably intense staining of glandular structures. Stromal cells are negative. Case 3 - Figure 14 Immunohistochemical stain K903: Some glandular structures demonstrate a "core" staining pattern where the luminal epithelium shows notably more intense staining than adjacent basal cells in the same gland. Case 4 Submitted by: Ian O. Ellis - City Hospital, NHS Trust, Nottingham, UK Clinical Summary: An 83 year old woman who presented symptomatically with a lump in her left breast. Clinical examination showed a small illdefined lump in the upper outer quadrant. Imaging with ultrasound and mammography showed an partly circumscrbed mass lesion. An ultrsound guided needle core biopsy was taken. 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: Gelareh Farshid - BreastScreen South Australia & South Australian Pathology, Adelaide, South Australia Clinical Summary: A 54 year old women presented with an inoperable 10.5cm mass in the left breast. Core biopsy showed an infiltrating ductal carcinoma, ER+ve, PR +ve, HER2 not amplified. Staging investigations were clear. She was treated with neoadjuvant chemotherapy, an aromatase inhibitor and radiation therapy. Proceeded to mastectomy, axillary clearance and a TRAM reconstruction. She made an uneventful recovery with a good cosmetic result. Pertinent Laboratory Data: No discrete mass found on gross inspection. An ill defined, diffusely edematous region with prominent ducts,140x70x25mm, merges with the central breast disc. The axillary clearance specimen showed very small lymph nodes, largest 5mm. Case 5 - Figure 1 Fibrotic breast parenchyma with a sprinkling of inflammatory cells. Case 5 - Figure 2 Rare enlarged atypical cells admixed with inflammatory cells. Case 5 - Figure 3 Small groups of larger, atypical cells. Note absence of normal breast ducts and lobules. Case 5 - Figure 4 A breast duct showing enlargement and atypia of its lining epithelium. Case 5 - Figure 5 Atrophic axillary lymph node showing capsular edema and fibrosis. Case 5 - Figure 6 Treatment effect in an axillary lymph node. Case 5 - Figure 7 Immunohistochemistry for CD68, demonstrating reactivity of histiocytes, but not the scattered larger, suspicious tumour cells. Case 5 - Figure 8 Immunohistochemistry for the cytokeratins AE1/3, highlighting small numbers of residual cancer cells. 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.