50-55 y/f breast lesion

Fig 1-3 H&E

Fig 4 myoepithelial stain (p63)

You dx or differential dx

谢谢cqzhao老师！

瘤细胞呈小腺管或梁梭状排列，浸润脂肪组织，感觉有菊形团样结构，梁梭和间质之间有点裂隙（看不太清），P63阴性，考虑恶性，1、需要标记鉴别神经内分泌的肿瘤，小腺管太密集了2、微腺管腺病是不是可以排除？

是否请cqzhao再给点高倍图，并期待免疫组化和老师的精彩讲解！

 上皮源性恶性肿瘤——癌；

就近的原则：考虑乳腺癌的继发灶，其他的转移癌尚未能除外。

 实性或近似实性，夹杂粘液样成分--->提示实体型乳头状癌，见脂肪浸润灶。可有神经内分泌分化。

已有浸润则不存在鉴别诊断问题，否则需要鉴别其它类型的乳头状肿瘤和导管内增生性病变。

谢谢Dr.cqzhao，期待您讲解！

 http://www.ipathology.cn/forum/forum_display.asp?keyno=106223

又学习链接的一例，通过对比，觉得是实体型乳头状癌。

 abin提到的：需要鉴别其它类型的乳头状肿瘤和导管内增生性病变。

复习陈国章教授的资料：

To 天山望月 , Abin and 197:

Thank for your analysis.

 I got these photos from one of our GYN/breast fellows who took the figures for publication. I do not have high power photos. Please open the second and third H&E photos to see if there are some similarities to and difference from the photos in my third cases.  Then please think about your diagnosis or differential dx. In term of discussion, differential diagnoses are very important.

In fact it is a very interesting and rare case. Wonder why so few people join the discussion.   Do not know I should share with you some interesting cases or just normal or common cases. I do not know how good our pathologists' diagnostic skills are in China.  

 赵老师请在关注疑难罕见病例的同时,为我们推出一些基本的基础的病例好吗?由易到难,大家慢慢学习.

我们没有机会出国接受正规培训,但是我们很幸运能够在网络中跟赵老师学习.这机会非常难得!感谢赵老师~!真希望如赵老师这样的好老师多一些,再多一些.那我们病理人就太幸福了.

Agree with Abin, in addition to invasive carcinoma, the adjacent solid component with well rounded nodule, relatively uniform cells and fibrovascular core + lack of myoepithelial staining...indicating

'solid papillary carcinoma". I have never seen a papillary solid carcinoma associated with invasive carcinoma (only heard about mucinous carcinoma association before).  What about ER/PR and neuroendocrine marker profile? Beautiful case! Thanks.  

 神经内分泌癌要考虑，看不清核分裂相，似有小灶坏死------不典型类癌？

看不到乳腺结构，转移癌也应排除

Collagen IV stain:  Collagen IV became somewhat disrupted adjacent to the focus of invasive carcinoma.

I quickly reviewed the discussion above. I think most comments are very reasonable for this case. 

Final diangnosis: EPC with focal frankly invasive ductal carcinoma. The photos try to demostrate the EPC with focal invasion. They do not show the EPC with high power, which make the diagnosis difficult. I discussed EPC in my case 3 and solid papillary ca in other case. Please check to see the details if you want to.

EPC can be present alone or associated with focal DCIS in the surrounding breast tissue. Sometimes frankly invasive carcinoma is present in association with EPC like this case. Mostly the invasive ca is ductal ca. In clinical practice the key question is how to report the size of invasive ca. Most people think we should report only the size of the frankly invasive component (not include the EPC part) as the tumor size for staging to avoid over treatment.

Neuroendocrine stains were negative for this case. In fact neuroendocrine positive tumors are not common.

Thank for review this case.

cqz