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- B2229breast 髓样癌, yes or no?(cqz-26) 9-1-2009
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标签：乳腺不典型髓样癌 基底细胞样乳腺癌
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本帖最后由 于 2009-09-26 08:24:00 编辑
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| 以下是引用Elizabeth在2009-9-4 8:36:00的发言：
Dr.Zhao, It's very nice to learn your cases. Many thanks! I think this is case of medullary carcinoma. Syncytial growth pattern, absence of glandular structure,lymphocyte infiltrate, moderate nuclear pleomorphism and well circumscribed, all features support medullary carcinoma. |
| 以下是引用cqzhao在2009-9-5 1:22:00的发言：
Interesting. Most of people would sign out as 髓样癌. Questions: How often did you sign out 髓样癌 in your daily work? If you have 100 breast ca, how many cases are diagnosed as 髓样癌by you or your colleaques? |
- 博学之，审问之，慎思之，明辨之，笃行之。
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本帖最后由 于 2009-09-06 20:09:00 编辑
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Find some original paper abstrats about classification systems for medullary carcinoma (MA). They are similar, but with some difference. I am pasting some paper abstracts for some ones who have good English and are interested to this area.
Cancer. 1977 Oct;40(4):1365-85.
Medullary carcinoma of the breast: a clinicopathologic study with 10 year follow-up.
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Hum Pathol. 1988 Nov;19(11):1340-6.
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Medullary carcinoma of the breast: a clinicopathologic study with appraisal of current diagnostic criteria.
Department of Pathology, George Washington University Medical Center, Washington, DC 20037.
Fifty-three cases of mammary carcinoma originally diagnosed as medullary carcinoma (MC) or infiltrating duct carcinoma (IDC) with medullary features were reviewed and reclassified using the strictly defined histologic criteria applied a decade ago by Ridolfi et al. Our study interval (1961 to 1982) allowed for a minimum follow-up of 5 years for each patient, with a mean follow-up period of 7.2 years. When reclassified, 24 tumors fulfilled the criteria for MC, 16 tumors were determined to be atypical MC, and ten tumors were found to be IDC; the observed 5-year survival rates were 95%, 80%, and 70%, respectively. These findings confirmed those of other investigators, that when specific criteria are applied, MC proves to be a form of mammary carcinoma with a favorable prognosis. However, we also found that when tumors were excluded from the MC category solely on the basis of in situ carcinoma, focal marginal infiltration, or a sparse mononuclear infiltrate, the survival rate of these patients was similar to that of patients in the medullary category. Thus, we propose that one of these criteria alone should not suffice to exclude the diagnosis of MC. On the other hand, tumors with two or more of these atypical features, or with extensive marginal infiltration, no mononuclear cellular infiltrate, and/or less than 75% syncytial growth, should be classified as IDC with medullary features. Typical MC with bland nuclei or a focal microglandular growth pattern only were not observed in this series; however, these findings should probably also cause a tumor to be classified in the IDC category. By dividing our cases into two rather than three groups, we found a statistically significant difference between the survival rates of 94% and 64% for MC (34 tumors) and IDC (14 tumors), respectively. Although the latter figure probably exceeds the survival rate for IDC without medullary features, the difference does not appear great enough to warrant a separate diagnostic category.
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Mod Pathol. 1995 Jan;8(1):31-8.
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Medullary carcinoma of the breast: interobserver variability in histopathologic diagnosis.
Department of Pathology, University of Virginia Health Sciences Center, Charlottesville, USA.
To assess the interobserver reproducibility for the diagnosis of medullary carcinoma of the breast (MC), 53 previously diagnosed MCs were independently assessed by six observers for growth pattern, nuclear grade (NG), inflammation, tumor margin, intraductal component, and glandular features. Tumors were reclassified as MC, atypical MC, or infiltrating ductal carcinoma according to the histopathologic criteria of Ridolfi et al. (Cancer 40:1365, 1977), Wargotz and Silverberg (Hum Pathol 19:1340, 1988), and Pedersen et al. (Br J Cancer 63:591, 1991). NG was the most reproducible parameter, and tumor margin was the least, with consensus agreement by four of six observers for 49 (92%) and 26 (49%) of cases, respectively. Utilizing the histopathologic criteria proposed by Ridolfi et al., Wargotz and Silverberg, and Pedersen et al., consensus diagnoses were achieved in 37 cases (70%), 46 cases (87%), and 51 cases (96%), respectively. A consensus diagnosis of MC in all three systems was unassociated with tumor size, axillary lymph node status or overall survival (median follow-up: 89 mo). The consensus (or better) reclassification of 44/53 (83%), 35/53 (66%), and 27/53 (51%) previously diagnosed MC as atypical MC or infiltrating ductal carcinoma by the criteria of Ridolfi et al., Wargotz and Silverberg, and Pedersen et al., respectively, suggests that MC was previously over-diagnosed. While the scheme of Pedersen et al. is the most reproducible, additional follow-up information is necessary to determine the biological significance of this classification system. To minimize these difficulties in practice, pathologists should carefully adhere to published criteria and indicate the classification system utilized.
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Breast Cancer Res Treat. 1989 Oct;14(1):91-9.
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Inter- and intraobserver variability in the histopathological diagnosis of medullary carcinoma of the breast, and its prognostic implications.
Department of Oncology ONA, Finsen Institute, Rigshospitalet, Copenhagen.
One hundred thirty-one breast carcinomas with medullary features, registered in the Danish Breast Cancer Cooperative Group from 1977-1982, have been histopathologically reviewed by two senior pathologists and classified as typical medullary carcinoma (TMC), atypical medullary carcinoma (AMC), and non-medullary carcinoma (NMC). Diagnostic criteria were based on those put forward by Ridolfi et al. and Fisher et al. The procedure was repeated with an interval of about one year by both pathologists. The diagnostic interobserver agreement was 72% with a Kappa of 0.55. The intraobserver agreement was 77% and 63% with Kappa values of 0.64 and 0.44, respectively. To see whether the observed inter- and intraobserver variability had any prognostic implications, diagnostic subgroups for both pathologists were analyzed with Kaplan Meier plots for recurrence-free survival (RFS) and with log rank tests. In the first evaluation pathologist 1 segregated a group of TMC with a significantly better RFS than for the NMC group, and pathologist 2 segregated a group of TMC with a corresponding strong trend. These findings could not, however, be reproduced in the second evaluation. The study indicates that the criteria of TMC and AMC as proposed by Ridolfi et al. need to be sharpened and simplified in order to reduce inter- and intraobserver variability. Larger studies with a control group of infiltrating ductal carcinomas are mandatory to elucidate the clinical importance of the diagnoses of Typical and Atypical Medullary Carcinoma of the breast
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本帖最后由 于 2009-09-06 20:21:00 编辑
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Medullary carcinoma of the breast, proposal for a new simplified histopathological definition. Based on prognostic observations and observations on inter- and intraobserver variability of 11 histopathological characteristics in 131 breast carcinomas with medullary features.
Department of Oncology ONK, Rigshospitalet, Copenhagen, Denmark.
In a previous study of 131 breast carcinomas with medullary features, we evaluated the diagnostic inter- and intraobserver variation and its prognostic implications using the criteria of typical (TMC) and atypical (AMC) medullary carcinoma of the breast put forward by Ridolfi et al. (1977). We found a considerable interobserver variation as well as intraobserver variation, with significant implication on prognosis, and concluded that the histopathological definition of MC must be sharpened and simplified in order to increase the diagnostic reproducibility. In the present study of the same population of 131 patients with breast carcinomas with medullary features we have examined inter- and intraobserver variation concerning 11 histopathological characteristics. Furthermore, we have analysed the prognostic importance of these 11 histopathological features, and the prognostic implications of the observed inter- and intraobserver variation. Based on the observations, we have eliminated criteria with poor inter-/intraobserver agreement as well as those implying no or minimal impact on the prognosis. We propose a new simplified histopathological definition of medullary carcinoma of the breast (MC), retaining reproducible, prognostically significant criteria (syncytial growth pattern and diffuse, moderate or marked mononuclear infiltration). The prognosis of MC, based on this definition, is significantly better than those of infiltrating ductal carcinomas grade II + III.
This is the important paper. In the past almost 20 y, people use this criteria for MA
Br J Cancer. 1991 Apr;63(4):591-5.
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Eur J Cancer. 1994;30A(12):1792-7.
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Medullary carcinoma of the breast, prognostic importance of characteristic histopathological features evaluated in a multivariate Cox analysis.
Department of Oncology R, Herlev Hospital/University of Copenhagen, Denmark.
In this study of 136 breast cancers with medullary features (MC), registered in the Danish Breast Cancer Cooperative Group (DBCG) from 1982 to 1987, we confirmed the prognostic importance of a new definition of medullary carcinoma of the breast (MC newdef) which was recently proposed by us, deduced from a previous study of a corresponding tumour material (DBCG 77-82). However, the individual histological criteria did not have the same prognostic importance as in our previous study, although prognostic trends were the same. To further improve and validate the diagnostic criteria, we combined the two populations and performed a multivariate Cox regression analysis. In the final Cox model, four histological parameters retained positive prognostic importance: (1) predominantly syncytial growth pattern, (2) no tubular component, (3) diffuse stromal infiltration with mononuclear cells and (4) sparse necrosis. We propose that these criteria are emphasized in the histological diagnosis of medullary carcinoma of the breast.
| 以下是引用笃行者在2009-9-5 22:06:00的发言：
非常好的病例！主要是两种意见：髓样癌；基底细胞样型乳腺癌。 我的观点是：诊断基底细胞样型乳腺癌应该有免疫组化结果的支持；诊断髓样癌必须1、形态典型。2、排除基底细胞样型乳腺癌。 |
Also for wfbjwt :Your reading is so fast.
Basically basal-like ca and medullary ca are two different calssification systems. We cannot say the dx of MA should exclude basal-like ca.
In fact most cases of MA belong to the category of basal-like ca.
I am pasting some related abstracts here.
Semin Diagn Pathol. 2004 Feb;21(1):65-73.
Medullary carcinoma, provocative now as then.
James Homer Wright Pathology Laboratories, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA. JEICHHORN@PARTNERS.ORG
The recent observation that studies of BRCA1-associated tumors contain a high proportion of medullary carcinomas and ductal carcinomas with medullary features has re-introduced pathologists to an old diagnostic problem. The term "medullary carcinoma" dates to the 19th century, but the modern entity was introduced in 1949 by Moore and Foote, who described a carcinoma with a lymphoid infiltrate, a favorable prognosis, and low frequency of metastasis. Almost three decades later, Ridolfi et al proposed specific criteria for diagnosis, resulting in an entity with an even more favorable prognosis and a lower incidence. The reproducibility and clinical relevance of the diagnosis have been questioned recently, and new criteria have been proposed and compared. The tumors typically express cytokeratin 7, often vimentin and S100-protein, but not cytokeratin 20. The usual ones are positive for p53 and negative for estrogen receptor, Her2/neu, and bcl-2. Medullary carcinomas express e-cadherin and beta-catenin more often than ordinary high-grade ductal carcinomas, and the former have genetic differences from the latter. The lymphoid infiltrate of medullary carcinomas is related to beta-actin fragments exposed by apoptotic cells. The present review discusses historical and recent developments and emphasizes diagnostic criteria.
