Breast core biopsy with 8 cores. There are multiple breast lesions. Try you diagnosis one by one.

Lesion 1 20x and 400x

 Thank Dr. Chiang' s interpretation.

Lesion 2: Apocrine metaplasia or change with micropapaillary or papillary pattern. The nuclei are very uniform, small, evenly spaced, located the botton of the cells. I do not appreciate any cytologic atypia in this case. Cystic papillary apocrine changes are commonly seen in the breast pathology specimens. Generally people will ignorred the lesion even though mild cytologic atypia is present in the apocrine change. True atypical apocrine metaplasia is rare.

 Compared Rosen fig 11.11 (page 298 in the third edition) with the above lesion 3, we can appreciate the difference in term of cytology, uniform without atypia in lesion 3 and moderate cytologic atypia in Rosen's fig 11.11.

It is very good for the disagreement. I hope more pathologists join in the diacussion.

_ from Rosen Breast Pathology.   Compare with lesion 3, just for learning.

 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。

 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

 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

 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.

 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!

 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

 good case!

good discuss!

 同意赵老师的分析和诊断。

图5还不能说有不典型性。图7的大部分应该是平坦型上皮非典型性（FEA），但如果FEA上皮增生到最后一张图的程度时，我更愿意诊断非典型导管上皮增生(ADH)。