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- B1581Breast lesions cqz (12) (2-16-2009)
图1
图2
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Breast core biopsy with 8 cores. There are multiple breast lesions. Try you diagnosis one by one.
Lesion 1 20x and 400x
标签：LCIS CCC FEA ADH 导管内乳头状肿瘤 放射状瘢痕
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本帖最后由 于 2009-03-19 23:29:00 编辑
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×参考诊断
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shn-821128 离线
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Thank every one for giving dx for this case.
1. Lobular carcinoma in situ (immunostains support the diagnosis.
2 Micropapillary apocine change or metaplasia. Uniform nuclei, micropapillary growth pattern. It is completely benign. Papilary or micropapillary apoccrin changes are very common. It is part of fibrocystic changes (FCC). Generally I just call FCC and d not mention the apocrine cmetaplasia. If they are ductal epithelial cells without apocrine change. The lesions with the same cytomorphology need to be diagnosed as ADH or low grade DCIS with micropapillary pattern. This is why I pasted this photo here.
3. Columinar cell change (CCC): Single layer of columnar cells lining the dilated acini with secretion. I do not see atypia even though some nuclei are round. It is not enough to call flat epithelial atypia even though the lining cells are not classic columinar cells.
4. Intraductal papilloma.
6. Radial scar. It is not a wrong diagnosis if you call sclerosing diangosis. They are in the same categry of the lesions.
In our hospital if diagnosis is radial scar in breast core biopsy, breast surgeons will do an excisional biopsy. So we are cautious for this diagnosis if no other severe lesions in the breast core. I think there were some studies which indicated tha radial scars increase the risk of cancers. But I am really not sure it is true. So if it is not a typical radial scar, I generally will not call it. I may call sclerosing adenosis. For this case I think it is reasonable to call radial scar.
OK, I have to do sth now. We will discuss the photo 5 and 7.
You can write your oppinion about the 5 lesions if you do not agree with me.
I f you agree, we can concentrate on the other two lesions now.
Thanks,
cz
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本帖最后由 于 2009-03-19 23:44:00 编辑
赵大夫讲的非常好，受益匪浅，译文如下：Thank every one for giving dx for this case.感谢大家给本例的病理诊断。1. Lobular carcinoma in situ (immunostains support the diagnosis).1、小叶原位癌，免疫组化支持该诊断。2 Micropapillary apocine change or metaplasia. 2、微乳头大汗腺化生或大汗腺改变。Uniform nuclei, micropapillary growth pattern. 一致的细胞核，微乳头排列。It is completely benign.完全是良性。 Papilary or micropapillary apoccrin changes are very common. 乳头状或微乳头性的大汗腺改变是非常常见的。It is part of fibrocystic changes (FCC).这是纤维囊性变的一部分(FCC)。 Generally I just call FCC and do not mention the apocrine cmetaplasia.一般情况下我们说纤维囊性变而不说大汗腺化生。 If they are ductal epithelial cells without apocrine change. 如果纤维囊性变的导管上皮细胞没有大汗腺改变，The lesions with the same cytomorphology need to be diagnosed as ADH or low grade DCIS with micropapillary pattern. 而这种改变有相同的细胞形态，应该被考虑为非典型导管增生或有微小乳头的低级别导管原位癌，This is why I pasted this photo here.这就是我为什么要贴本例的原因。3. Columinar cell change (CCC): Single layer of columnar cells lining the dilated acini with secretion. 3、柱状细胞改变(CCC)：单层柱状上皮细胞衬复在有硬化扩张的腺泡上，I do not see atypia even though some nuclei are round.虽然其核圆，我没有看到异形性， It is not enough to call flat epithelial atypia even though the lining cells are not classic columinar cells.虽然内衬上皮细胞不是典型的柱状细胞，不能称之为扁平上皮非典型性。4. Intraductal papilloma.4、导管内乳头状瘤。6. Radial scar. 6、放射状疤痕，It is not a wrong diagnosis if you call sclerosing diangosis.如果称为硬化性腺病，也不错。 They are in the same categry of the lesions.这是同一范畴的病变。In our hospital if diagnosis is radial scar in breast core biopsy, breast surgeons will do an excisional biopsy. 在我们医院，粗针活检如果诊断放射状疤痕时，乳腺外科医生会做切取活检。So we are cautious for this diagnosis if no other severe lesions in the breast core.因此如果乳腺粗针活检没有其它严重病变时，我们诊断放射状疤痕非常慎重。 I think there were some studies which indicated tha radial scars increase the risk of cancers.我看到许多文献提出放射状疤痕增加了癌肿危险。 But I am really not sure it is true.但我不确定确实如此。 So if it is not a typical radial scar, I generally will not call it. 因此如果不是典型的放射状疤痕我们也不诊断。I may call sclerosing adenosis.我们称为硬化性腺病。 For this case I think it is reasonable to call radial scar.本例，有理由认为它就是放射状疤痕。OK, I have to do sth now. We will discuss the photo 5 and 7.以后会讨论图5-7.You can write your oppinion about the 5 lesions if you do not agree with me.如果谁不同意以上5种意见也可以写出自己的意见。I f you agree, we can concentrate on the other two lesions now.如果同意，这两例讨论总结至此。Thanks,cz谢谢大家。赵大夫。
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Seem most of you agree the interpretation of F 1-4, 6. You can give your reasons if you do not agree.
F 5, 7involve columinar cell change, 平坦型上皮非典型性（FEA) and related lesions. FEA is a very controversial term. There are many issues which are not clear, such as dx criteria, managment: present in in core biopsy, in excisional bx, .in surgical margins. In fact even in the US, many general surgical pathologists do not know the term or do not know how to make the diagnois. Of cause most of surgens know nothing about FEA. We have alot of consult cases from other hospitals. Often we need to talk with primary pathologists. This is why I know a lot of general pathologists do not know the term well.
Interesting to know that our pathologists in China use this term or not. Please share your knowledge about FEA with ours.
Thanks
Yes, We use the terminology of columnar cell lesion in diagnosis.
The columnar cell lesion especially flat cell atypia is related to some low grade carcinoma such as tubular carcinoma, tubulobular carcinoma etc. However, I am puzzled about FEA accompany with structure complex, should it be diagnosed as atypic duct hyperplasia or FEA, just as figures shown in lesion 7? According to the definition of FEA there should not have structure complex.
Interested in the topic very much.
Thanks!
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本帖最后由 于 2009-03-12 12:14:00 编辑
Fig 5.
Right: CCC
Left: Clearly we can appreciate the difference ducts in the right from the right duct. If these are the only few atypicla ducts in a breast core biopsy, I will relactant to call FEA. If there are more ducts with similar features, I may call FEA.
CCC-FEA are a continuous lesion. The cut point is difficult.
Fig 7 is a very good example showing the spectrum of CCC-FEA-ADH. Focal monotonous proliferation with cribriform pattern shows the features of ADH. Few glands surrounding the focus of ADH demonstrate atypical CCC or FEA. It is not easy to find the good area. Today I joined one day of breast long clourse. There are 8 excellent speakers (pathologists, oncologists, surgeons) from England, austrlia, the US talked about ADH, DCIS, FEA, bx, et al. There are many new and converoversial issue about breast pathology. There are also some difference between contries. I may find a time to review some talks with you in future.
Ok. You can mention your oppinion if you do not agree with my interpretation about this case.
Thanks, cz
Lesion 1:lobular neoplasia,the diagnosis must be established by immunostaining for CK 34BE12.
Lesion 2:atypical ductal hyperplasia ,apocrine.
Lesion 3:cystic hypersecretory carcinoma,DCIS
Lesion 4:sclerosing adenosis with focal atypical ductal hyperplasia ,apocrine
Lesion 5:columnar cell chang,mild cytologic atypia
Lesion 6:complex sclerosing lesion
Lesion 7:columnar cell change,with severe atypia and low-grade DCIS
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Glad to see Dr. Ciang's input and diagnosis. Different interpretations were noted in lesions 2, 3, 4, and 7. Wish other share your oppinions. Also welcome Dr. Chiang to describe the reasons for the diagnoses. We can understand more by discussion. Thanks, cz
Lesion 2:大汗腺化生也存在一个谱系，良性---------恶性。该例大汗腺化生表现导管内增生，形成微乳头，细胞异型明显，核增大，核质比增加，核仁明显。但是这种改变在切除标本中未必有不同的临床意义。
Lesion 3:囊性高分泌性导管原位癌，表现导管高度扩张，腔内有分泌，被覆细胞简单，可有微乳头结构，细胞核增大，其余细胞学较温和，容易漏诊，要结合整体组织学，本例给出的图像值得怀疑和商榷。
Lesion 4：基本结构是腺病，导管有旺炽型增生，增生的导管上皮成分复杂、间质硬化，结构类似硬化性腺病，整体图像不支持导管内乳头状瘤，最多可以诊断adenosis with florid ductal hyperplasia。
Lesion7：这是一例柱状细胞变化很好的例子，显示了柱状细胞变化的形态学谱系，形态学表现延续了良性和非典型性，局灶性DCIS（需要免疫标记证实），但是这样的例子和诊断定会有争议，因为柱状细胞变化的研究还在继续
谢谢楼主提供这么好的病例。
