赵澄泉老师分享 | 三个乳腺经典病例

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赵澄泉老师分享 | 三个乳腺经典病例

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来源：美国匹兹堡大学医学院赵澄泉

整理：慧馨

病例一

50 y/f with breast mass 1.5 cm.

U/S guided breast core biopsy

40x ，400x

网友回复：

1、颗粒细胞瘤

2、同意颗粒细胞瘤

3、颗粒细胞瘤，浸润性生长，边界不清，细胞核有一定的异性，考虑为恶性，要能找找分裂象就更有依据些。

Above should be the answer from pathologists.You are wrong if you called GCT directly even though this case were a GCT . I mentioned many times in this web that we are pathologists and we cannot guess dx.

In fact this is a very easy and unusual case which I had when I was at AFIP. I first saw the case. Clearly it was granular cell tumor by cytomorphology. Tumor cells show small round and nuiform nuclei and abundent and granular eosinophilic cytolasm, classic features of GCT. Surprisingly IHC stains indicated the tumor cells were strongly positive for CK7, AE1/AE3, and negative for S-100, CD68. So it is histiocytoid carcinoma, a variant of lobular carcinoma.

Of cause I am sure all of us know that these two tumors have much different prognosis.

The lession for this case is that pathologists must rule out all other possible differential diagoses before we make our final diagnosis in our clinical practice. This priciple should be used for all cases even though we think we know the dx of the cases.

病例二

I transfer this case from previous breast lesion. Hope more people see and join in the discussion:

50 year women with breast mass

Fig 1 is a low power view of the lesion, where the overlying skin adjacent to the nipple is seen overlying a well-circumscribed mass.

Fig1 is a low power view of the lesion ,where the overlying skin adjacent to the nipple is seen overlying a well-circumscribed mass.

（图1低倍，乳头附近的皮肤下方见界清肿块）

Fig2 mid power

Fig3 high power

Fig4 p63 stain

您的诊断和鉴别诊断？

网友讨论：

Lili0321：按标记结果，考虑浸润性乳头状癌。

故乡：p63染色阴性，细胞有异型，考虑导管内乳头状癌。

LiLI：另外，还要除外皮肤汗腺发生的腺癌。

Abin：组织学和IHC符合囊内乳头状癌。这些图未显示浸润。同意楼上，要排除皮肤附件来源的癌。

Now I share a second case with same diagnosis as above case.

H&E and p63 stain.

Whoever saw the case please write down what you think and join in the discussion.

These photos will be published soon. Please do not copy them for your publication.

How can I add a marker to the photos like in the lecture photos? Then others cannot copy them.

Abin: Can u help to do it ,thanks.

cz

P63

网友讨论：

第3楼也是囊内乳头状癌，p63染色有小灶DCIS。

是，我现在也同意第一例为囊内乳头状癌，但第二例似乎不同，囊壁无内衬上皮，乳头是实体型的。请教赵老师。

赵澄泉老师： Great. Most of u got the answer. Both of the cases are intracystic papillary carcinoma.

The H&E slide in the second case is not very good. You can see it more clearly in the p63 stained slide, which demonstrates papillary glandular structure. The pattern is not like solid papillary ca. I discuss a lot about the features of solid papillary ca (SPC) in one case recently. But I cannot find it now.

Intracystic papillary ca is called encapsulated papillary ca (EPC) now. Microscopically, it is characterized by one nodule of papillary ca surrounded by a thick fibrous capsule. The histologic apperance of the papillary proliferation can have any of the features of papillary DCIS. Myoepithelial cells are not present in the papillae of EPC, same as in papillary DCIS. However, in contract to papillary DCIS, myoepithelial cells are also absent in the periphery of the tumor nodule of EPC. This is the most important feature of EPC. See my above two cases. Currently most people consider the lesion is a vaiant of papillary DCIS, even though some think it may represent a low grade invasive carcinoma. Studies have demonstrate that EPCs have excellent prognosis with adequate local therapy alone. One of our fellows recently demonstrated that collagen IV stain may be useful for differential dx of EPC. The stain is positive in EPC, but negative for invasive carcinoma.

Two cases of EPC with collagen IV stain (periphery of the tumor nodule).

病例三

50-55 y/f breast lesion

Fig 1-3 H&E

Fig 4 myoepithelial stain (p63)

You dx or differential dx

网友讨论

abin：这个很难，我再想想，呵呵。谢谢cqzhao老师！

天山望月：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！该例，abin都说难了，一定有名堂，期待ing。

197: 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！

赵老师： Sorry I do not have photos in high power

天山望月：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：

单纯的乳头状病变：中心出现肌上皮并且ER阳性不均质支持良性病变

具有实性或筛孔状区域的乳头状病变：要评估是否为UDH、ADH 或 DCIS；CK5和ER染色有帮助（ADH 和 DCIS 为 CK5-, ER+）。

赵澄泉老师：

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.

Abin：谢谢Dr.cqzhao提醒，果然很难，我再好好考虑一下。我猜大家正是觉得难，才很少有人发言。本例发表一周以来，浏览人次超过140啦！

stevenshen: would guess this is infiltrating breast carcinoma with neuroendocrine features. Looking forward to hearing the final answer and comment. Great case! Thanks.

赵澄泉老师： Sure there is component of invasive carcinoma. What is the other component?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.

xxrn: 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

赵澄泉老师：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

VI型胶原纤维染色

赵澄泉 | 美国匹兹堡大学医学院病理学教授。主要科研方向为妇科肿瘤的病理诊断、分子生物学、妇科宫颈细胞学及HPV的研究。现有2个NIH-R01研究课题作为共同研究者。已发表医学论文近160篇，论文摘要110篇。会议宣读科研和受邀讲课90余次。

来源：美国匹兹堡大学医学院赵澄泉

整理：慧馨

病例一

50 y/f with breast mass 1.5 cm.

U/S guided breast core biopsy

40x ，400x

网友回复：

1、颗粒细胞瘤

2、同意颗粒细胞瘤

3、颗粒细胞瘤，浸润性生长，边界不清，细胞核有一定的异性，考虑为恶性，要能找找分裂象就更有依据些。

Above should be the answer from pathologists.You are wrong if you called GCT directly even though this case were a GCT . I mentioned many times in this web that we are pathologists and we cannot guess dx.

In fact this is a very easy and unusual case which I had when I was at AFIP. I first saw the case. Clearly it was granular cell tumor by cytomorphology. Tumor cells show small round and nuiform nuclei and abundent and granular eosinophilic cytolasm, classic features of GCT. Surprisingly IHC stains indicated the tumor cells were strongly positive for CK7, AE1/AE3, and negative for S-100, CD68. So it is histiocytoid carcinoma, a variant of lobular carcinoma.

Of cause I am sure all of us know that these two tumors have much different prognosis.

The lession for this case is that pathologists must rule out all other possible differential diagoses before we make our final diagnosis in our clinical practice. This priciple should be used for all cases even though we think we know the dx of the cases.

病例二

I transfer this case from previous breast lesion. Hope more people see and join in the discussion:

50 year women with breast mass

Fig 1 is a low power view of the lesion, where the overlying skin adjacent to the nipple is seen overlying a well-circumscribed mass.

Fig1 is a low power view of the lesion ,where the overlying skin adjacent to the nipple is seen overlying a well-circumscribed mass.

（图1低倍，乳头附近的皮肤下方见界清肿块）

Fig2 mid power

Fig3 high power

Fig4 p63 stain

您的诊断和鉴别诊断？

网友讨论：

Lili0321：按标记结果，考虑浸润性乳头状癌。

故乡：p63染色阴性，细胞有异型，考虑导管内乳头状癌。

LiLI：另外，还要除外皮肤汗腺发生的腺癌。

Abin：组织学和IHC符合囊内乳头状癌。这些图未显示浸润。同意楼上，要排除皮肤附件来源的癌。

Now I share a second case with same diagnosis as above case.

H&E and p63 stain.

Whoever saw the case please write down what you think and join in the discussion.

These photos will be published soon. Please do not copy them for your publication.

How can I add a marker to the photos like in the lecture photos? Then others cannot copy them.

Abin: Can u help to do it ,thanks.

cz

P63

网友讨论：

第3楼也是囊内乳头状癌，p63染色有小灶DCIS。

是，我现在也同意第一例为囊内乳头状癌，但第二例似乎不同，囊壁无内衬上皮，乳头是实体型的。请教赵老师。

赵澄泉老师： Great. Most of u got the answer. Both of the cases are intracystic papillary carcinoma.

The H&E slide in the second case is not very good. You can see it more clearly in the p63 stained slide, which demonstrates papillary glandular structure. The pattern is not like solid papillary ca. I discuss a lot about the features of solid papillary ca (SPC) in one case recently. But I cannot find it now.

Intracystic papillary ca is called encapsulated papillary ca (EPC) now. Microscopically, it is characterized by one nodule of papillary ca surrounded by a thick fibrous capsule. The histologic apperance of the papillary proliferation can have any of the features of papillary DCIS. Myoepithelial cells are not present in the papillae of EPC, same as in papillary DCIS. However, in contract to papillary DCIS, myoepithelial cells are also absent in the periphery of the tumor nodule of EPC. This is the most important feature of EPC. See my above two cases. Currently most people consider the lesion is a vaiant of papillary DCIS, even though some think it may represent a low grade invasive carcinoma. Studies have demonstrate that EPCs have excellent prognosis with adequate local therapy alone. One of our fellows recently demonstrated that collagen IV stain may be useful for differential dx of EPC. The stain is positive in EPC, but negative for invasive carcinoma.

Two cases of EPC with collagen IV stain (periphery of the tumor nodule).

病例三

50-55 y/f breast lesion

Fig 1-3 H&E

Fig 4 myoepithelial stain (p63)

You dx or differential dx

网友讨论

abin：这个很难，我再想想，呵呵。谢谢cqzhao老师！

天山望月：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！该例，abin都说难了，一定有名堂，期待ing。

197: 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！

赵老师： Sorry I do not have photos in high power

天山望月：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：

单纯的乳头状病变：中心出现肌上皮并且ER阳性不均质支持良性病变

具有实性或筛孔状区域的乳头状病变：要评估是否为UDH、ADH 或 DCIS；CK5和ER染色有帮助（ADH 和 DCIS 为 CK5-, ER+）。

赵澄泉老师：

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.

Abin：谢谢Dr.cqzhao提醒，果然很难，我再好好考虑一下。我猜大家正是觉得难，才很少有人发言。本例发表一周以来，浏览人次超过140啦！

stevenshen: would guess this is infiltrating breast carcinoma with neuroendocrine features. Looking forward to hearing the final answer and comment. Great case! Thanks.

赵澄泉老师： Sure there is component of invasive carcinoma. What is the other component?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.

xxrn: 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

赵澄泉老师：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

VI型胶原纤维染色

赵澄泉 | 美国匹兹堡大学医学院病理学教授。主要科研方向为妇科肿瘤的病理诊断、分子生物学、妇科宫颈细胞学及HPV的研究。现有2个NIH-R01研究课题作为共同研究者。已发表医学论文近160篇，论文摘要110篇。会议宣读科研和受邀讲课90余次。

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