Tutorial on Breast Pathology Part I: Ductal and Lobular ...€¦ · Part I: Ductal and Lobular...
Transcript of Tutorial on Breast Pathology Part I: Ductal and Lobular ...€¦ · Part I: Ductal and Lobular...
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Tutorial on Breast Pathology Part I: Ductal and Lobular Neoplasias
Thomas J Lawton MD, Director Seattle Breast Pathology Consultants, LLC
Seattle, WA
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• There are two main types of epithelial cells in the breast: Ductal and Lobular.
• The distinction is based on how the cells look and how they grow, not necessarily on their location in the breast.
• So ductal cells can travel into the lobules and lobular cells can travel up the ducts.
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Normal breast duct and lobules
lobule
duct
lobule
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Let’s start with ductal….
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There are three main ductal lesions: 1) ductal hyperplasia, usual type; 2) atypical ductal
hyperplasia; and 3) ductal carcinoma in situ Ductal hyperplasia Atypical ductal hyperplasia Ductal carcinoma in situ
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Ductal hyperplasia, usual type
• This basically means there are too many ductal cells in the ducts but they are not atypical.
• Often graded as mild, moderate, or severe (florid). • Studies show there is an increased relative risk
(1.5-2 times) for the subsequent development of invasive carcinoma with moderate to florid ductal hyperplasia.
• This risk applies to both breasts.
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Ductal hyperplasia: What does it mean if my biopsy shows this? • If found on core needle biopsy and the
findings are concordant to the radiologist, no need for surgical excision.
• If found on a surgical excision and nothing more significant is found, no need for the pathologist to comment on margins and no need for surgical re-excision.
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Atypical ductal hyperplasia • This term describes a proliferation of ductal cells
that has “some, but not all” of the features of low grade ductal carcinoma in situ.
• Studies show there is an increased relative risk (4-5 times) for the subsequent development of invasive carcinoma.
• This risk applies to both breasts.
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Atypical ductal hyperplasia: What does it mean if my biopsy shows this? • If found on core needle biopsy, surgical excision
is warranted because of an approximate 20-30% chance of finding carcinoma in situ or invasive carcinoma based on most studies.
• If found on a surgical excision and nothing more significant is found, no need for the pathologist to comment on margins and no need for re-excision in the vast majority of cases.
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Ductal carcinoma in situ • This term refers to a neoplastic proliferation of
ductal cells that has not invaded beyond the confines of the duct.
• Studies show there is an increased relative risk (8-10 times) for the subsequent development of invasive carcinoma.
• This risk applies to both breasts. • However, ductal carcinoma is situ is also felt to be
a precursor lesion, unlike atypical ductal hyperplasia and usual type ductal hyperplasia.
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• Risk lesions imply a relative increased risk for the development of invasive carcinoma which applies to both breasts, not just the breast involved by the diagnostic risk lesion.
• A precursor lesion is thought to also be able to proceed to invasive carcinoma in the same part of the breast if it is not treated appropriately.
• This is why surgeons try to get clear margins around ductal carcinoma in situ and often patients receive radiation therapy and/or endocrine therapy. The reason is to try to reduce the risk of this precursor lesion proceeding to invasive carcinoma at a later time.
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Ductal carcinoma in situ: What does it mean if my biopsy shows this? • If found on core needle biopsy, surgical excision is
necessary. • If found on a surgical excision, the size of DCIS,
nuclear grade, presence of necrosis, and distance from all surgical margins should be reported by the pathologist.
• If margins are close, additional surgery may be needed. • Radiation therapy may also be needed. • In many cases, a medical oncologist may ask the
pathologist to determine if the DCIS is estrogen receptor positive.
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Now on to lobular…
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Lobular hyperplasia
• Not a well-defined pathologic term • Diagnosis not generally used
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Atypical lobular hyperplasia • A proliferation of small cells that begin to fill up
but do not expand the milk-producing glands in the lobules.
• Studies show there is an increased relative risk (4-5 times) for the subsequent development of invasive carcinoma, similar to atypical ductal hyperplasia.
• This risk applies to both breasts.
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Atypical lobular hyperplasia: What does it mean if my biopsy shows this?
• If found on core needle biopsy, most doctors will recommend a surgical excision but this is somewhat controversial.
• If found on a surgical excision and nothing more significant is found, the pathologist does not need to comment on surgical margins, and no surgical re-excision is needed.
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Lobular carcinoma in situ
• A proliferation of bland cells that fill up and expand at least 50% of the milk-producing glands in the lobules.
• Studies shows there is an increased relative risk (8-10 times) for the subsequent development of invasive carcinoma.
• This risk applies to both breasts.
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Lobular carcinoma in situ
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Lobular carcinoma in situ: What does it mean if my biopsy shows this?
• If found on core needle biopsy, most doctors will recommend a surgical excision but this is somewhat controversial.
• If found on a surgical excision and nothing more significant is found, the pathologist does not need to comment on surgical margins, and no surgical re-excision is needed.
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Stay tuned for Part II which will cover invasive carcinomas…