WHO Classification of Tumours of bie Jest hii Sea eS eS a UCU A To)World Health Organization Classification of Tumours Preura, Thymus and H IARC Press: Lyon 2004 ISBN 92 832 24183 JW, Reich: LeBoit PE. Burg G., Weedon D. ): World Health Sarasin A. (Eds,); World He: fication of Organization Classification of logy and Genetics of | Tumours. Pathology and Genetics of Head and Neck Tumours (21d editon). Skin Tumours (3rd edition, IARC Press: Lyon 2005 IARC Press: Lyon 2006 ISBN 92 832 24175 ISBN 92 832 2414 0 Fletcher C.D., Unni KK. Delellis R.A., Lloyd A.V, Heitz, PLU, Mertens F. (Eds.}: World Health Eng C. (Eds }: World Health Organization Classification of Organization Classification of Tumours. Pathology and Genetics of Tumours. Pathology and Genetics of Tumours of Soft Tissue and Bone Tumours of Endocrine Organs (31d (31d edition} edition). IARC Press: Lyon 2002 IARC Press: Lyon 2004 ISBN 92 632 2413 2 ISBN 92 832 2416 7 +i H., Wiestler 0.0. ‘World Health n Classification of val Nervous SH. Campo S., Harris, ES. Plier S.A. Stein H, man JW. (Eds): World th Organization Classification of Tumours of the Haematopoietic and Lymphoid Tissues (ath edition) IARC: Lyon 2008 ISBN 92 832 2431 0 Bosman FT. Carneiro F, Hruban RAH, Theise ND. (Eds.): World Health Organization Classification of ‘Tumours of the Digestive System (4th edition} IARC: Lyon 2010 ISBN 978 99 €32 24927 This book and all other volumes of the series can be purchased from: From all countries WHO PRESS: World Health Organization CH-1211 Geneva 27 Switzerland Tol. +41 22 791 9284 Fax +41 22701 4857 bookorders@uho.int \wontzwno intfocokorders! From USA, STYLUS PUBLISHING, LLC 22883 QUICKSILVER DRIVE PO Box 605, Hetndan, VA 20172-05 Tel. +1 800 232 0223 Tel. +1 703-661 1581 Fax. +1 703 661 1501 siylusmaildipressivarehouse.com wenn.styluspub.com From Canada Renout Publishing Compa 41-8389 Canoiek Road Ottawa, Ontario K1J 943 Tel, +1 618 745-265 Fax. +1 613 745-7660 order dept@ren waw.rendutbooksWorld Health Organization Classification of Tumours (aS & International Agency for Research on Cancer (IARC) 4th Edition WHO Classification of Tumours of the Breast Edited by Sunil R. Lakhani lan O. Ellis Stuart J. Schnitt Puay Hoon Tan Mare J. van de Vijver International Agency for Research on Cancer Lyon, 2012World Health Organization Classification of Tumours Series Editors T. Bosman, MD Elaine 8. Jaffe, MD Sunil R, Lakhani, MD Hiroko Ohgaki, PhD WHO Classification of Tumours of the Breast Editors MD, PhD. nical Editors Heidi Mattock, PhD Purcell, PhD Layout Pendue, France International Agency for h on Cancer (ARC) 69372 Lyon Cedex 08, FiThis volume was produced with support from the MEDIC Foundation The WHO Classification of Tumours of the Breast presented in this book reflects the views of a Working Group that convened for a Consensus and Editorial Meeting at the International Agency for Research on Cancer (IARC), Lyon September 1-3, 2011. Members of the Working Group are indicated in the List of Contributors on pages 196-202Published by the inernational Agency for Heseerch on Cancer (IARC), +150 cours Albert Thomas, 69372 Lyon Cedex 08, France ‘© International Agency for Research on Cancer, 2012 Distiouted by WHO Press, World Health Organization, 20 Avenue Appia, 1211 Genova 27, Switzerland (Tel +44 22 791 8264; Fax: +41 22 781 4857; exmal!: Dookordierstath int. Publications of the Werld Heslth Organization enjoy copytight protection in accordance ‘sth tho provisions of Protocol 2 of the Universal Copyright Convention Al rights reserved. ‘The designations employed and the presentation of the materia inthis publication do not imply the ‘expression ol any opinion whatsoaver on the part of the Secretariat ofthe World Health Organization concerning the egel stu of any country, erilory, cy, oF area or of is authors, or concering the delimitation of ils Konters or boundaries, ‘The mention of specific companies or of cerain manufacturers products does not imply tat they are ‘endorsed or recommenced by the World Health Organization in preference to oiners ofa similar ature that are nat mentioned. Errors and omissions excepted, the names of proprietary products are istinguished by initial capital letters. “The authors alone are responsible forthe views expressed in this publication. “The copyright of figures and charts remains withthe authors. (See Sources of fgures, pages 202-204) ‘Secon pint run (16,000 copies) Format for bibliographic citations Lakhani S.A, Elis }O., Schnitt S.J. Tan PH,, van de Vier MJ. (Eds. WHO Classification of Tumours of the Breast. IARG: Lyon 2012 IARC Library Cataloguing in Publication Data WHO classification of tumours of the breast edited by Sunil A Lekhani... [et al] - 4” edition (World Health Organization classification of tumours) 4. Breast Neoplasms ~ genetics 2. Breast Neoplasms ~ classification 3 Breast Neoplasms - pathology I. Lakhani, Sunil R. Il. Series ISBN 978-92-899-2433-4 (NLM Classification: Wi 1)Contents WHO classification of tumours of the breast ‘TNM classification of tumours of the breast 1 Introduction and general features: 2 Invasive carcinoma of no special type 2. Special subtypes invasive lobular carcinoma Tubular carcinoma and cribriform : Carcinoma with medullary features Metaplastic carcinoma Carcinoma with apocrine differentiation Salivary glandiskin adnexal type tumours Adenoid cystic carcinoma Mucospidermoid carcinoma Polymorphaus carcinoma Mucinous caroinoma and carcinoma with signet-ring-cell diferentiation Carcinorna with neuroendocrine features Invasive papillary carcinoma Invasive micropapllary carcinoma Inflammatory carcinoma Bilateral breast carcinoma and non-synehronous breast carcinoma Exceptionally rare typas and variants Secretory carcinoma Oncooytic carcinoma Sebaceous carcinoma Lipic-rich carcinoma Glycogen-rich clear coll carcinoma Acinic cell carcinoma 4 Lobular neoplasia 5 Intraductal proliferative lesions Introduction and overview Usual ductal hyperplasia Columnar cell lesions Atypical ductal hyperplasia Ductal carcinoma in situ 8. Microinvasive carcinoma 7 Intraductal papillary lesions Intraductal papilloma Intraductal papitary carcinoma Encapsulated papillary carcinoma Solid papillary carcinoma Introduction Adenos's, sclerosing adenosis and ‘apocrine adenosis Microglanciular adenosis, atypical microglandular adenosis and mmicroglandular adenosis with carcinoma Radial scar and complex sclerosing lesion Tubular aclenoma Lactating adenoma Apocrine adenoma Ductal adenoma Pleomorphic adenerna @ 10 13 8 46 48 53. 55 56 58 59 60 62 64 65 a 7 nm 2 7 74 4 5 7 at 82 84 88 99 100 103 708 108 mt 112 112 113 14 115 116 116 117 117 9 10 1 2 13 14 16 Myoapithelial and epithelial-myoepithelial lesions Myoepithelial and epithelia-myoepithelial lesions Adenomyoepithetioma and adenomyoepithelioma with carcinoma Mesenchymal tumours Nodular fascitis Benign vascular lesions Pseudoangiomatous stromal hyperplasia Myofibrobiastoma Desmoid-tyoe fibromatosis Inflammatory myoiibroblastic tumour Lipoma Granular cell tumour and benign peripheral nervye-sheath turrour Angiosarcoma Liposarcoma Rhabdomyossreoma Osteosarcoma Leiomyora and leiornyasarcama Fibroepithetial tumours Fibroadenoma Phyliodes tumour Harartoma, Tumours of the nipple Nipple acienoma Syringomatous tumour Paget ciseast Lymphoid and haematopoietic tumours Introduction Diffuse iarge B-cell lymphoma Burkitt lymphoma Fell lymphoma Extranodal marginal zone lymphomas of Mucosavassociated iymphoid tissue Follicular lymphoma Metastases of extramiammary ‘malignancies to the breast ‘Tumours of the male breast Gynaecomastia Carcinoma of the male breast Genetic susceptibility: inherited syndromes Introduction and historical perspectives Inherited syndromes associated with an increased risk of breast cancer: Introduction BRCAt and BRCA2 syndromes, Li.Fraumeni syndrome Ataxia telangiectasia syndrome Cowden syndrome Lynch syndrome Other breast cancer-predisposing genes Contributors Sources of figures References ‘Subject index 161 165, 166 168 a7 172 174 178 183 186 188 192 194WHO classification of tumours of the breast EPITHELIAL TUMOURS Microinvasive carcinoma Invasive breast carcinoma Invasive carcinoma of no spacial type (NST) 8500/3. Pleomorphic carcinoma 8022/3 Carcinoma with osteoclast-like stromal giant cells 8035/3 Carcinoma with choriocarcinomatous features Carcinoma with melanotic features Invasive lobular carcinoma 8520/3 Classic lobular carcinoma Solid lobular carcinama Alveolar lobular carcinoma Pleomorphic lobular carcinoma Tubulolobular carcinoma Mixed lobular carcinoma Tubular carcinoma 8211/3 Cribriform carcinoma 8201/3 Mucinous carcinoma 4a0/3 Carcinoma with medullary features Medullary carcinoma 8510/3 Atypical medullary carcinoma 8513/3 Invasive carcinoma NST with medullary features: 500/38 Carcinoma with apocrine differentiation Carcinoma with signet-ring-cell differentiation Invasive micropapillary carcinoma 8507/3" Metaplastic carcinoma of no special type 8575/3, Low-grade adenosquamous carcinoma 8570/3 Fibromatosis-like metaplastic carcinoma 8572/3 Squamous coll carcinoma 8070/3, Spindle cell carcinoma 8032/3 Metaplastic carcinoma with mesenchymal differentiation Chondroid differentiation 8571/3 Osseous differentiation 8571/3 Other types of mesenchymal differentiation 8575/3 Mixed metaplastic carcinoma 8575/3 Myoepithelial carcinoma e982/3 Rare types Carcinoma with neuroendocrine features Neuroendocrine tumour, well-differentiated 8246/3 Neuroendocrine carcinoma, poorly differentiated (small cell carcinoma) 8041/3 Carcinoma with neuroendocrine differentiation 8574/3 Secretory carcinoma 8502/8 Invasive papillary carcinoma Acinic cell carcinoma Mucoepidermoid carcinoma Polymorphous carcinoma ‘Oncooytic carcinoma Lipid-rich carcinoma Glycogen-rich clear cell carcinoma Sebaceous carcinoma Salivary gland/skin adnexal type tumours Cylindtoma Clear cell hidradenoma Epithelial-myoepithelial tumours Pleomorphic adenoma ‘Adenomyoepithelioma Adenomyogpithelioma with carcinoma Adenoid cystic carcinoma Precursor lesions Ductal carcinoma in situ Lobuler neoplasia Lobular carcinoma in sit Classic lobular carcinoma in situ Pleomorphic lobular carcinoma in situ Atypical lobular hyperplasia Intraductal proliferative lesions Usual ductal hyperplasia Columnar cell lesions including flat epithelial atypia Atypical ductal hyperplasia Papillary lesions Intraductal papilloma Intraductal papilloma with atypical hyperplasia Intraductal papilloma with ductal carcinoma in situ Intraductal papilloma with lobular carcinoma in situ Intraductal papillary carcinoma Encapsulated papillary carcinoma Encapsulated papillary carcinoma with invasion Solid papillary carcinoma In situ Invasive Benign epithelial proliferations Sclerosing adenosis, ‘Apocrine adenosis Microglandular adenosis 8430/3 8525/3 8299/8 8314/3 8315/3 8410/3 8200/0 8402/0" 2940/0 8983/0 8983/3" 8200/3, 8500/2 520/02 8519/2" 8503/0 8503/0 8503/2" 20/2 8503/2 a504/2 8504/3 es0g/2 8509/3,Radial scar/complex sclerosing lesion MALIGNANT LYMPHOMA ‘Adenomas Diffuse large B-cell lymphoma ge20/2 Tubular adenoma 8211/0 Burkitt lymphoma 9687/3 Lactating adenoma 8204 —— T.cell lymphoma Apocrine adenoma 8401/0 Anaplastic large cell lymphoma, Ductal adenoma 85080 ‘ALiCnegative 970218 Extranodal marginal-zone B-cell lymphoma MESENCHYMAL TUMOURS of MALT type 9629/3 Nodular fasciitis 8828/0" Follicular lymphoma 9690/3 Myofibroblastoma, 8825/0 Desmoidi-type fibromatosis 8821/1 METASTATIC TUMOURS, inflammatory myotibroblastic tumour 8825/1 Benign vascular lesions Haaren i299 TUMOURS OF THE MALE BREAST Angiomatosis, Gynaecomastia Atypical vascular lesions Carcinoma Pseudoangiomatous stromal hyperplasia Invasive carcinoma 8500/3 Granular cell tumour 9580/0 In situ carcinoma eso0/2 Benign peripheral nerve-sheath tumours Neurofibroma 9540/0 CLINICAL PATTERNS meet see [flammatory carcinoma 8530/3 eae berg. Bilateral breast carcinoma Liposarcoma 885013 Angiosarcoma 2120/3 Rhabdomyosarcoma 89003 Osteosarcoma 9180/3 Leiomyoma 8890/0 Leiomyosarcoma 8890/3 FIBROEPITHELIAL TUMOURS Fibroadenoma 9010/0 Phyllodes tumour 9020/1 Benign 9020/0 Borderline 9020/1 Malignant 9020/3 Periductal stromal tumour, low grade 9020/3, Hamartoma ‘TUMOURS OF THE NIPPLE Nipple adenoma 8506/0 Syringomatous tumour 8407/0 Paget disease of the nipple 8540/3 phology codes are fom the Internationa Classification of Diseases for Oncology ((CD-0) [4638]. Behaviour is coded 0 for benign IS, for unspeciied, borderline or uncertain behaviour, #2 fr carcinoma in stu and grace Il inkraepthelal neoplasia, and /8 for malig- ani tumouts; * The classifeation is modtiea trom the previous WHO histological c'ssiication of tumours (1413] taking into account changes our understanding of thasa lesions. Inthe case af nauroendoorine neoplasms, the clasfcation has beon simpiliad to be of mare practical ty in morphological classication; “These new codes were aproved by the IARCMWHO Corritie for IOD-O.TNM classification of tumours of the breast Primary tumour % Primary tumour cannot be assessed 70 'No evidence of primary tumour Ts Carcinoma in stu Tis(OCIS) Buca carcinoma in sits Tis (LCIS)Lobular carcinoma in sit Tis (Paget) Pagot disease ofthe ripple not associated with inva ‘sive carcinoma andor carcinoma in sity (DOS andor LIS) inthe underying breast pareneriyma. Note: Carcrorasin the breast parenchyra associated wth Paget dase » calogorzed based onthe sige and characteris of the parenchymal 80, alhough he presence of Paget disease should sil be note. qn ‘Tumour 2 em oy less in gteates!cimension Timi Microinvasion 0.1 em or less in greatest simension* Neto “Mersinvason sto extension of cancer cols beyend the basement ‘rombrane nfo he adjacent issues wih ro focus mor han 0.1 em n goat ‘=timansion When tore ara uli foo cf mcronwasion the io of only he ages foe i used to clans the ercinvation. (Do nat ee the sum ft inv The prosonce of rip fc of miroinvasion shoud bo note. ait' won mutipl ager invasive carcinomas Tia More than 01am but ot math 0. om in reatot Tie Mors hans om tot mor than 1G In rein Re sew ait ee tae ae ce eee Pe) wrerrest vee et estenrer eae ae era er attra 14 Turf ny sz wih rect extent fo chest wal andlor to skin (ulceration or skin nodules) Note nvsin ofthe drs lone dows ot cusy as T4, Chas wal incluces , mercosta muscles, ard seats amr muse but nt peceralmuscla 4s Extension fo chest wal (dogs not incude pactoras muscle invasion only) Tub Ueration, ipsiletoral satelite skin nodules, or skin ‘edema (including peau orange) Tée Both da and 4b, above 14d Infiammatory carcinoma Note: nflamvatory carchera of th braast Is characterized by citus, ay inauraten ofthe sen with an ersipseid edge, usually wih no UN ering masse skin biopsy negative and there eno localized meas Leable primary canco, the Tealegory is pIX when pahoogicaly staging a Infammatery carcinoma (Ti). Oimpling ef he skin nipple action, or ter stn changes, exoant thse in Tab and Tad, may accu in, T2,0¢ TS winout atecing he ctasstoaton N—Regional lymeh nodes NX gional ympn nodes removed) NO Noregional iympn-coas met Ni Meiastasis in movabie ipsiatera! lev node(s) N2 Metastasis in slates! eve! are clinically ned or mate latera nigeria mammary lnically evident axliary hrsph-node N2a Metastasis in axillary lymph node(s) fx (matted) orto other structures N2b_ Metastasis only in clinically Iymon node(s) and in the allary ymor-noce metastasis INQ Metastasis in iosiaieainiracavoutr (le odes} with or without ‘ment: in cinically catectes” ipsiatral lymph noda(s) with cinically even sillary Iyenph-node metastasis: or met tral sur clavicularlymon node(s) win cr wincut axilary or internal mammary lymph node iveherrent Ne Metastasis in inraclavicular lyon N3b_ Metastasis in nterel mamma Nc Metastasis in supractavicularlyrnon node\s) "2 another el mammary aly Cotectod asitary) lymph nade invoWe mammary Note“ “Ciicaly detecies is dete as by imaging sicies(exclucing bones highly euspicious for malignancy or mmactorta:aes bssec on frenaasie sep ‘mination. Coteraton of okay detects metas de axpraton wihout excisen bps) © sat. ‘Excisional Bopsy ofa ymph rode oF Sons ‘once of aeegnment ofa pf laa a bogeal cassteaton (pt) suse ey excise ar cen inconizction wit a patologca T aseonren 4 serene noo nthe a ent, Patho biopsy M— Distant motastasis MO No distant metastasis. MT Distant metastasis,pN~ Regional ymph nodes aeation requis the resection and examina nodes (level), Such a rese0- the low axiery moh Regional lymph nodes cannot bo assessed 0.9. prov fF not removed for study) than 02 rm n gre Miorometastasis asis in 1-8 axilary ipsietoral ‘ymph nades: andlor n intemal mammary nodes wit nelasiasis detected by sentinel lymph-node biopsy ba not clinically detected SNimi Micrometastais (agar than 0.2 mm ener more than 200 cals, ut none larger than 2.0 pNia Metastasis in 1-3 axllany lymph node(s) including atleast 1 larger than 2 menin great est dimension Internal mammary lymph nodes with mic ‘scopic oF macroscopic met by sentin! Ioh no fe biopsy but nt cin catecit pNic Metastasis in 1-3 axillary lymph nodes enct informal mammary lymph nodes with micro scopic or mac ected scopic metastasis de by sentin! lymph-node biopsy but not ically detected Metastasis as described below: N22 Malas n 4. axilary hh nodes, nclusing atleast ane tht is lerger then 2 mm N22 Metastasis in clinically detected internal ‘mammary lymph node(s), in the absence of lary lym Motastasis as desos below Na Metastasis in 10 or more axillary Iymeh rodes ne larger than 2 mm) or metastasis ut the THM cassleation i avaliable 6) Cancer Staging Manual ihe (UCC, THM cleseation of maligna infractavicular mph nodes PNG Metastasis in clinically detected internal Ipsilateral mammary lymph nado) nthe pres fence of positive axillary Wymon node(e), or o than 3 axillary iymph rod: and in internal mammary lymph nod meta biopsy but not 40 years. Invasive br 4101 Mamograntic pearance of histalagialy andotedarwihcaeicalons 17% ceeatons ony 19% be 102 Spactum of hill dogosis ssparing o mammographic crulrtva lecions Meco caronama m% raps panilary 5% “uta earcnoma ” ‘vive bar earcnoma o ar ingroses 18% Alcohol he consumption of alcohol has been consistently associated with a moderate increase in the risk of breast cancer {1345, 1886}. According to the dose-response relationship (number of drinks per day), even a low level of consumption was as- sociaied with an increase in risk. Evidence Suggests that high intake or high blood levels of folate may decrease risk (1624) Cigarette smoking cording to the USA Surgeon Ge 2004 report on the health consequanc Of smoking, the evidence suggested no 1usal relationship between active smok- ing and breast cancer | 1394). Similar the combined data from 53 epidemiolog- ical studies showed no relationship be- tween smoking and breast cancer among women who do not drink alcoho) (538) cancer is most commonly marifested on mammography a& an il-defined or spicu lated mass, with or without associated calcifications, but can also present as er chitecturel distortion, foos! asymmetric density or calcifications alone. Urasound can be added to improve sensitivity in women with mammographically dense breasts Mammography is rely helptlin younger women and its use in women aged <40yoars is confined to those with proven breast cancer. Ultrasound alone is the method of choice for imaging the breast in women aged < 40 years, Mag- nelic resonance imaging (MRI) is the most sensitive method for detecting breast cancer, but is use is confined to screening women at very high risk (8.9 carriers of mutations in the BRCAT oF BRCA2 genes) and local staging of cer- tain breast cancers (see below). Further assessment and staging Imaging snould always be used to as- sess both breasts before any treatment is implemented. Mammography and ul: tresound are complementary for the pre treatment assessment of the size, extent and presence of multfocality of breast cancer. The vast majority of breast can: cers should be diagnosed without the However, substantial additional evidence has accumulated in the past decade, and ‘a review conducted in 2009 by a Can dian task force concluded that active smoking is causally related to both pre- and postmenopausal breast cancer. Fur thermore, this task foree concluded that second-hand smoke (“passive smoking") is causally related to premenopausal breast cancer, but that the data were suficient to allow a conclusion to be made for postmenopausal breast cancer {287} ‘Single-nucleotide polymorphisms Recent studies have included advanced methods to scan the whole genome for ‘genetic changes (GWAS) that may convey an increased risk of breast cancer. Ro- sulls ta date do nat show any applications for inese methods to either demarcate risk cr offer strategios for prevention (1101) . Wilson P.Brttan need for eurgical biopsy using imaging. directed needle sampling; ultrasound. Quided core biopsy is the method of choice. Ultrasound is also used routinely to assess the axilla at the time of pres- entation, with biopsy of any abnormal Iymph nodes. MRI can be used to im: prove pretreatment staging of the breast where there is doubt about the extent of disease after mammography and ultra: sound (e.g. in the denge breast) and rou: tinoly for invasive lobular carcinoma. Fig. 1.02 Diglal manmogram shoning 2 ypca sll peal rest cancer wth associated caeoatenClinical features inversion, A Total commonly, noma will present as enlargement o he axillary lymph nodes in the of any aby hs sym caused by benig evaluation wit samp piration cyto! ablis siagnostic mammography placed over the lesion 10 that itis visualized on the film, A spiculated mass is th pear hitectural distortion or nmogram, The majority o identified with target 2 ket ‘combined mam: und is quite low, Fig. 103 Aged ‘nance imaging (MR) is not a sub: fora histological diagnosis: ne negative pre M, Morrow E Rute % . se Localized benign / 60 Fibrosdenoma o---% <0 2a at 41-50 Age (years) 5160 >60 enol benon is presenting wih adscrte rest 6, jeterrining that present. Magnet in one study, ive value of MAL was 952,153}. Unless 85.4% (95% Cl, 81. 1-89.0%) |152}. When he results of the physical examination, mammography, and needle biopsy ara all benign and concordant, the risk of —y Fig, 1.04 Maninogtphic demonstaton of the eveion of por derentted nase lens inthe silary tal ofthe gt bres, undelete at seeing, B 18 appeal be al lymph rods are seen inthe sla, CLje caronama, A Manmagran ef pera Grading asive carcinomas of no special type 1d all alher invasive breast carci mas are routinely graced based on an sgment of tudulel r pleomorphism af ent of histological grade has be- 1ore objective as the by Patey & Scerf 1077] and Bloom & ardson |151| have been modified by Bision & Elis (977), Aller the adoption of 2 changes, many studies have demon- ated a significant association betwoen slogical grace and survival of patients ive breast carcinoma (1136, Grade is @ powerful prognostic fac- id should be included as & compo: 16 minimum dataset for histological Table 1.03 Seni-quantatve mead assessing “ubule and gland formation joy of umour (> 75%) 1 Moderate dare (10-75%) a Lie or none (< 105) 3 Nuclear pleomorphism Sal regular untorn cos 1 Nedsrate ncrease nse ‘and varity 2 Marked vation 3 totic counts Dependent on microscay ona P18 soe Table 104 Final grading sors for gland fomaton, a pleomorphism and oc count Grate 1 “alse, 3-5 ate? Toll sxe, 67 Gate Talal sore 89 sive catenama, cal cut reporting of breast cancer (1091 and is @ key component of clinical decision-mak- ing tools such as the Nottingham Prog: nostic Index [46] and Agjuvart! online Hope Method of racing Three tumour characieristios are evalu: ated: tubule for of glandular differentiation; nuclear ple: isn; and mitotic counts. A numeri ‘ring system of 1 to 3 is used to censure that each factor is assessed inde- pendently (Table 1.03). Glandular form: lion is assessed over the whole tumour and is a low-power assessment. Nucla pleomorphism is evaluated for the showing the worst degree of pleomor- phism, and mitotic counting is performed for the area exhi 1¢ most prolifer tion When evaluating tubules and glandula acini, only structures exhibiting clear ce’ tral lumina surrounded by polarized neo plastic cells are counted; cut-off paints o 75% and 10% of glandular/tumour are: are used to allocate the score, Nuclear picomorphism is ce 10 the regularly of nu 36 of normal enithe! ing regularity of n ar oulines and the number and size of rucleai are useful additional features in al: locating scores for pleomorphism. Score 1 nuclei are vexy similar in size (< 1,5) to those of benign pre-existing epith cells and show minimal plet and even chromatin pattern and fare not visible or vary inconspicuous. Score 2 ouclei are larger (1.6-2xsize of benign epithelial cell nuclei), with mild to moderate pleomorphism and visible but morphisr 2x size of De rign epithelial cell nuclei) with vesicular chromatin, vary markedly in size and shape and olen show prominent nucieol Evaluation of mitotic figures requires care. d relies on optimal tissue fixation anc good preparation of sections, Observers Table 1.04 Score breshlds for mtotccourts Field diameter Mitotic count (sore) ee = 2 3 am ss =10 ast 210 aa 38 at a5 Bt om ss 22 os ss 22 os 6 za oa 58 23 058 aM a 58 zi os? 215 oss? 215 os? 216 0558 21 ot 58 21 058 218 os 8 218 os 39 os 8 om 58 os a <0 ag sit ott aati as st os tz on att oe et og etsmust count oniy definite mitatic figures; hyperchromatic and pyknotic nuciel are ignored since they are more likely to rep- resent apoptosis rather than cells in mito sis. Mitotic Counts require standardization to a fixed field area. The total number of mitoses per 10 HPF is recorded. Cu-oft points for scoring depend on field area. Thereior, for milote counting itis essential ‘o calibraie the microscope by measuring the diameter ofthe HPF ( 40x objective, see ‘Tabi 1.04). Field selection for mitotic scor- ing should be from the peripheral leading ‘edge of the tumour to find the area with ‘most mitotic activity. If there is heterogene- ity, regions exhibiting @ higher frequency of ‘mitoses should be chasen. Field selection is by rancom meander through the chosen area. Only fields with a representative tu- ‘mour-cell burden should be assessed. The three values are added together to produce scores of 3 to 9, to which the grade is assigned as follows: Staging ‘Tumour staging The most widely used system for staging breast carcinoma is the TNM system pub- lished by the American Joint Committee ‘on Cancer (AJCCVUnion for International Canear Control (UICC). The most recent criteria described in the seventh edition ‘of the TNM system are provided at the be- ginning ofthis chapter (S66). This system ‘captures information about the extant of cancer at the primary site (tumour or T), the regional lymph nodes (nodes or N), and spread to distant metastatic sites (metastases or M). Special techniques for Classification are not required and com- Parable information can thus be collected over time and in diverse locations. T.N, and M are combined 10 create five stages (stages 0, | I Il, and IV) that sum- rmarize information about the extent of re- gional disease (lumour size, skin or Cchest-wall invasion, and nodal involve ment) and metastasis fo cistant sites. For individual patients, this information is im- portant for making decisions conceming the control of lacal disease, as well as to dotermine the value of systemic therapy. Determining tumour stage is also essen- tial for organizing groups of similar pa: tients for comparison in clinical trials, $3.5 points: grade 1, welkliferentiated 6-7 ponts: grade 2, moderately ferrite *8-9 points: grace 3, poorly ditfeentiated For the purposes of quality assurance, it is recommended that the individual score ‘components be reported in addition to the ‘calculated grade. Graging of small tissue samples such as needie-core biopsy specimens is possi- ble, but should be recognized to have lim- itations particularly due to the inherent reduced abt 10 assess mitotic frequency accurately. This may lead to underestima- ‘ion of truo grade in such soecimens (552), Molecular genetics of histological grade “Tumours of uifferent histological grades show distinct molecular profiles at the ‘genomic {204,970,1228), transcriptornic (1178,1358) and immunchisiocherical le: cls (4). These studios suggest that most high-grade tumours are unlikely to stem from the progression of low-grade cancers epidemiological studies, or other types of investigations. Biological tests, such as ‘gene-expression profiling, may comple ment information on stage by estimating the risk of future metastasis or recurrence cr by predicting the likely response to treatment Both clinical staging and pathological staging are used for patients with breast cancer, Clinical stage depends an physi- cal examination and imaging studies, with ‘or without confirmation by fine-needle as- piration cytology. Pathological classifica. tion of T and N primarily relies on the {Gf0ss and microscopic examination of surgically excised specimens. Tis based (on the size of the invasive carcinoma in the majority of patients. If multiple areas of invasion are present, T classification is based on the largest focus, A small ca: cer is sometimes best evaluated measuring size on glass slides. Ofter telation between gross, microscopic imaging findings is necessery to imine the best T category. Lyman should be evaluated by thinly sicin examining all nadal tissue in Identity all macrometastases (me! > 0.2. cm), M classification is prin: tetmined by the results of and that grade 1 and 3 breast tumours are probably two different diseases that may have distinct molecular origins, patho- genesis and behaviour (970, 1230, 1358]. Gene-expression studies have demon- strated that histological grade reflects the molecular makeup of breast cancer bet ter than lymph-node status or tumour size 834,1615} It should be noted, however, that recent meta-analyses of microarray-based ex- pression-profling studies have demon- strated that the prognostic impact of the signatures investigated stems from the Proliferation-related genes (392,1589) and these studies are discussed in detail ‘elsewhere in this book. Most importantly, in some stuces using molecular signatures, histological grade remained an independ- tent prognostic factor for estrogen-receptor- positive tumours even after the inclusion of gene signatures in the multivariate models (1059, 1568} S.Lester G,Csemi D. Weaver S. Tuzlal M. Morrow studies, with pathological confirmation after biopsy in some cases. ‘An important change in the seventh edition Of the TNM system is the introduction of a new stage IB for patients with T1 carcino- mas (20cm or less) and only micro- metastases 10 axilary nodes (pNimi. ‘Although these metastases have statistical significance [515.1125,1561}, the effect on prognosis s So smal that itis rare appro- priate to classify them separately rather than together with stage Il patients having macrom The commen practice of ini ‘ore definitive surgical adjuvant or presurgical ‘a combination of infor ‘examination, imaging, ination to deter T.N, and M classifi- ii Posttreatment tions are determined Determining stage reatment provides formation (221 ic and blood-vessel invasion nwvascular invasion (also termed vascular invasion, angiolymphatic,ascular invasion, or LVI) is the cinoma within email vessels main tumour mass, most fre- the periphery of an invasive 2 (peritumoral LVI) Although LVI <0 with lymph-node metasta- : so an independent prognostic oy ocal and distant recurrence and pin clinical decision-making guidelines www.necn.orgiprofes ysician_gls/t_guidelines.asp) +505 772.1108}. The presence of both ‘metastases confers a worse than either alone, Vascular- Jement can serve as a rosor- sumour cells in the skin or chest cannot be removed by conven y. Inaddiion, intravascular tu- be less susceptible to treat- ciemionstrated by renorted cases cancer presentoniy as LVI after nt chemotherapy, Germis is @ particularly poor < factor owing to frequent asso- th local recurrence and distant ssiases |10], When extensive, LMI in often causes the skin changes tic of inflammatory carcinoma, uently noted when multiple je metastases are present, a ot inthe unusual cases in which servation of LV is hindered by the characteristics of the carci ‘or example, LVI is rare in lobular 88, possibly because ofthe lack n ofthis tumaur type to vessal ther cases, extensive LVI may to diagnose if the tumour cells fill vascular spaces and mimic 2) carcinoma in situ (DCIS). Con sey, LVI is present in approximately * patients without axillary nodal and itis more important as a © factor in this group of patients, (© drainage for some cancers © to other nodal basins Sreratvely, some subtypes of cancers are sied with a lower incidence of ie metastases and may metasta: ovmatly via blood vessels {980.931}, =remple, “triple-negative" carcinomas 1 for estrogen, progesterone, and ‘eceptors), often do not involve F nades, bul frequently spread to dis- 58s {467.1581}. In general, the in- vessels are the size of capilaries ses in larger blood vessels with 2 walls are excoodingly rare. € of LVI as a prognostic factor has nampered by the lack of universal ‘consensus on how to define its presence and whether there is a naed to separate lymphatics from blood vessels or meas: ure the extent of LVI. In the majority of cases, LVI can be reliably identified on haematoxylin-and-eosin (HE) slides by using strict histological criteria (1203) Immunohistochemical stuies can bo Used to distinguish lymphatics frorn small capillaries and, in some cases, additional subtle foci can be identified (929,930), However, the currently available markers are not completely specific or senstive. In daily practice, itis not necessary to dis tinguish the vessel type, as both have prognostic significance. It is not yet clear if the foci only seen by special studies have sufficient prognostic significance to justify their routine use or whether they will dilute the overall significance of LVI as a prognostic variable, Lymph-node status The status of the axillary lymph nodes is the most important single prognostic fac- tor for all except a small subset of broast carcinomas. Nodal metastases are strongly corelated with tumour size and the number of invasive carcinomas (213,280,1451, 1881]. Disease-froc survival and overall survival diminish with each adsitional pos- itive node (920,976,1521}. The ratio of pos- itive to negative nodes also provides prognostic information and can adjust for differences in surgical and pathology prac- tices that result in variable numbers ot nodes evaluated |1522,1596). Positive odes are a marker of distant dissemina- tion, as surgical removal of nodes does not appear to have a major effect on sur vival 495}, Macrometastases, defined as being >0.2.0m in size, have been shown in mul tiple studies to have prognostic signifi= cance. They can be reliably detected by thinly sectioning nodes (into slices of 0.2em), embedding all sices in paraffin blocks, and examining @ representative HE slide from each block. However, fail- Ure to examine all nodal tissue can result in missing macrometastasas in up to 40%, of positive nodes |149, 1343}. Detection of emaller metastases may require addi- tional levels into paralfin blacks andlor i= munohistochemiical studies. Although these small metastases, classi- fied as either micrometastases (> 0.02 om, up to 0.20m, or > 200 cells in a single nodal cross-section) or isolated tumour- coli clusters (ITCs; no larger than 0.02 cm, ‘or < 200 cells ina single nodal cross-sec- tion) do havo statistical significance, the actual impact on prognosis (after all ‘macrometastases have boon excluded) is < 8% at § and 10 years when compared with node-negative women |515,1125,1560, 1861}. In addon, the presence of micro- ‘metastases or ITCs on addtional deeper levels is not a discriminatory variable for predicting recurrence or survival. More than 80% of these wornen survive without recurrence at a median follow-up of 8 years (1561). Thus, there is litle value in performing additional levels or immuno- histochemical studies that will find some but not all of these deposits |1560} Incurrent practice, there is wide variation in how nodes are evaluated intraopera- tively and on permanent sections (297, 298,1862}. The role of molecular app- roaches, such as reverse-transcriplase polymerase chain reaction (RT-PCR), in routine practice is unclear since the size of the metastasis is uncertain and both false- positive and false-negative results can ‘occur (366 839}. In selected cases in which lesger metastases may be dificultto detect, such as lobular carcinomas, immunohisio- chemical studies may be helpiul (209, 4490) Neither palpation nor ready available im- aging techniques are reliable for the oxclu- sion of nodal metastases, as most pationts Present with only a few nodes involved fy ‘small metastases. Cancers drain to one or two sentinel nodes in the axilla, or rarely to ‘other nodal basins, which can be identi- fied intraoperatively by sither dye or ra- Gioactive tracer. If cancer is not detected in the sentine! nodes), < 10% of patients will have other nodes involved. Intramam- maty nodes are rarely sentinel nodes; however, when involved by cancer, they are included with axillary nodes for stag- ing {68,1126}. Sentinel-node biopsy has proven to be a useful technique to sepa- Fate node-positive from node-negative patients with recuced morbidity [74,682 829}. A completion axillary dissection is Not required for patients with negative ‘sentinel nodes and may not be necessary for selected patients with only limited ‘nodal involvement {495,721}, In the setting of prosurgical or necadju: vant therapy, small nodal metastases are indicative of an incomplete respanse to systemic therapy and have the samo sig- nificance as larger metastases [699). A ‘complete response in known lymph-node ‘metastases is more predictive of ultimate a‘outcome than is the response in the pri- mary carcinoma {350,1226). Thus to ob- tain the most information, itis preferable ta document positive nodes before ther. apy by fine-needle aspiration or needle- ‘core biopsy, rather than surgical removal Sontinel-node biopsy can be employed after treatment, although the false-nega- tive rate is slightly higher (198, 1050}, Although negative nodes are a very favourable prognostic factor, 10-20: patients will eventually develop cistant metastases. In some cases, the cancers will have spread to other nodal groups that are not routinely evaluated, such as internal mammary nades (641). There is also a small group of cancers that aopear to metastasize hasmaiogenousiy without Molecular testing for estrogen receptor, progesterone receptor, and HER2 Introduction Three molecular biomarkers are used in the routine clinical management of pat- ienis with invasive breast cancer: estrogen receptor (ER), progesterone recepicr (PR) ‘and HER2, Since all are targots andi or in- dicators of highly effective therapies against invasive breast cancer in various clinical settings, accurale assessments essential ‘and mandatory (33,242, 360}. Its the re- sponsibility of every pathology laboratory evaluating these biomarkers to provide accurate and reproducible results ER ER is a nuclear transcription factor that, when activated by the hormone estrogen 22 i x slimulates the growth of normal reast epi- thelial cels (272}. Proliferation may also be activated in the cells of invasive breast cancers expressing ER which, of course, is detrimental (1274). ER expression has been measured in invasive breast cancers by various methods for simost 40 years. Today nearly all testing is performed by in munohistochemistry, a sensitive, specific, ‘easy and inexpensive technique that can be performed an rautinely prepared histo- logical sampies, primarily formalin-fixed parefin-embedded (FFPE) tissue sectons, Slained slides are evaluated microscop cally to determine the proportions and in tensity of positive cells. By immunohisto- chemistry, about 80% of invasive breast nt of nodes, For example, bassl-ike carcinomas are a poor group, this is the molecular st Ikely to exhibit extensive fement (1681}. For these pa- prognostic markers will be ant than nodal staging, ©. Allred E. Brogi K Miller J. Isola Viale cancers express nuclear ER, in a propor- ton ranging from < 1% to 100% positive cells (558), Many clinical studies, including large ran- domized clinical trials, have demonstrated that ER isa strong predictive factor for res pponee to hormonal therapies such as ta- rmoxéten |360, 1274); this is the main reason. for routine evaluation. Tamoxfen binds ER and blocks estragen-stimulated growth, resulting in significantly longer disease- free and overall survival in patients with ER-positiva invasive breast cancers, com pared with those that are ER-negative. The Clinical response to newer types of hor ‘monal therapies, such as the aromatase inhibitors (that suppress the production of, a Fi 06 Exrossen of oop ear (ER) mas wos crc, as dbrnned by unison Ata ee > outa cacinonainstu(0CS) cigrass ER in tumour ud wibha ange « 1% 10 100% (AO; BAprox. 1k; C Approx 10%; D Apex. 20%; EAporox 60%; F Approx. 10%) Apc, 65% express progesterone ecapir (PR) with a sina broad rage. The eran turers are enrey negate (0% f cols A), Aclrcay postive test fo both receptors is dened as rules staning nz 1% oltuour cls anda nega esas «1% Adal tam (343,nt on ER status; are positive for ER re- is a direct corre cad of response the level of ex- tumours express- ER show signficant # that of entirely negative nally uneespon- The results of many immuno provide strong ‘ng "ER positive’ clinically staining tumour cells 'g0 been endorsed by @ ‘ernational experts in re £720 guidelines (541). Those many other recommen- promote accurate 10- Its, such as mandatory unlikely negative results = e tuaular carcinomas, tu: gical grade), and the n of comprehensive quailty grammes, inely assessed by immuno- y in invasive breast cancers gulates the expression of © presence of PR usualy indi- 2 estragen-ER pathway is in- 2 functional {272}. Once expressed, cd by the hormone proges- also stimulates the growth of ' (46, 242, 1274], Very ike ER, sssed in the nuclei of 60-70% sive breast cancers, with expres- fries on a continuum ranging 100% positive cells. There is a ‘lation between lavels of ex- on and response to hormonal thera- and even tumours with very lov =5 (2 1% positive cells) have a signiti- ‘ance of responding (932, 1274) coh the expression of PR is highly with thatof ER, the correlation is, resulting in four possible pheno- of combined expression. Each com- ons associated wth significantly df rates of response to hormonal oy, which would not be apparent if ring ER of PR only (103). The phe- 08 ER-posilive/PR-posiive is most fro- (70%), and is associated with the rate of response (60%). ER-nega- PR-negative is the next most common nbination (25%) and these tumours are entilly unresponsive (0%). The re- ing two discordant phenotyoes are .clated with intermediate response A Fig 1.07 HER2iesingin invasive beast cancers, Inmunehistochenisty (HC) and Woresance insu hybidzaton (FISH) ae the most comoreiensvey valle assay fuse in cue cnc pace. A clncaly postive IC tes iste a song cruferenta membrane sizing n> 20% of nour oa (A, white anogave es i rad ‘as neak oeielyateet staring A postive FISH results dofnod as a HER guna: chromosome 17 ratio of > 22 (B), wile negaive real is dened as <1 8. Bath assays may rolun equvecl sul, and HER satus inthe ‘mous mustbeconfmadby test using the semaive method (0, FISH by MC, and HC by Fi) rates, although there is debate as to whether ER-negativorPR- positive tumours actually exit ‘Several new molecular methads for deter. mining the status of hormone recentors, 28 wall as other important biomarkers, which may be more powerful than immunohisto- chemistry in predicting response to hor- ‘monal therapy and prognosis, are being developed (840, 843,1024, 1059, 1359} HER2 oncogene and oncoprotein ‘The HER2 gene (standard nomenclature, ERBBQ, located on chromosome 17, en: ‘codes 2 growth factor receptor on the sur- face of normal breast epithelial cells (383), HER? expression has been evaluated in invasive breast cancers for about 25 years. Studies demonstrate that the gene is amplified in approximately 15% of tu- ‘maursin patients with primary breast can- cer, and that amplification is highly correlated with elevated protein expres: sion (33,242,383}. The reported frequency of HER2-positive invasive breast cancers was higher in the past, before widespread screening mammography; later detection may have allowed more time for genatic alterations to accumulate as tumours evolved (713), HER? status is primarily determined by immunohistochemistry and/or fluores- cence in sity hybridization (FISH) on FEPE ‘samples, providing results that ere essen: tially equivalent, and occasionally com: plementary, in terms of clinical efficacy [983.1891]. Other chromogenic methods of in situ hybridization that can accurately determine gene copy number using rau- tine brightfeld microscopy are becoming popular {1087A]. As with hormone recep: tors, guidelines have been developed to promete accurate testing for HER, and ft 'S prudent for laboratories to folow the principe established 1591) The relatonship Detwoon HER? status and cinical outcome is complex and varies writ setting (242,191), Recent studies demonstrate that HER2-posive invasive breast cancers respond favourably to therapies that specrfcally target the HER2 proiein (e.g. tastuzumab and lapatinib) {112.389}. The main reason for assessing HER2 siaius today is to identily cand datos for this type of targeted thorapy. HER2 postive tumours are defined e3 those tumours that show erong circum enial staining elerredto a8 3+ staining) n > 30% of cells by immmunohistochenisty, andlor HER2gere amplification detected by in stu hybridization; or tumours that show modersiely strong circumferental membrane staining (relerted to as 2+ Staining) and HER2gene amoiticaion dtactod by in situ hybridization (642 1591), These HER2-postive tumours show the best response fo HERD targeted thae apy in any clinical setting (112,326). Tu- ‘ours that show iia or na protein exp- tession by immunchistochemistry (referred 10.480 of 1+ slaining) most always have thenormal number of copios of tho HER2 gene as assessed by in stu hybridization and are reported as HER2-negative 23Post-therapy effects Definition In the widest sense, post-therapy effects include morphological and biological al- {erations in cancers and normal tissue alter any treatment, However, the term is ‘most commonly used to describe changes seen after neoadjuvant therapy (also termed “primary systemic therapy” or ‘presurgical therapy’), in which treatment (chemotherapy, endocrine therapy, and OF targeted therapy) is administered be- fore surgical excision. Observed alter- ations in cancers are used to evaluate the response in vivo. ‘Morphological characteristics of carcino- ‘mas after treatment Based on the results of maging and needie- core biopsy findings (grade, histolagical type, necrosis, proliferation rate, harmano- receptor status, and HERE status), any pa- tient who is eligible for systemic therapy ‘can be treated with neoadjuvant therapy. Although neoadjuvant therapy does not provide survival benelil, response to troat- ‘ment is a strong prognostic factor and is Useful for inclvicual patient care, and also represents a short-term end-point for clin~ ical trials (162,441, 599,727, 849.1105). In Addition, some patients with large cancers may consequently become eligible fcr breast conservation [163,175] Post-therapy specimens The residual carcinoma oF tumour bed must be found in order to evaluate res- pponse to therapy, and this facilitated by the placement of clips before treatment In large specimens, lack of such markers may lead to difficulty identifying the tu- mour bed, which may render a statement about pathological completo response (PCR) problematic, In cases of pCR, the tumour bed can often be identified macroscopically as a fibrous, ruabery area. However, gross changes may be sublle, making pretreatment clip place- ment valuable. Residual cancers typically become softer and more cifficult to pal- pate, except in cases af absent or mini- mal response, The macrascopie size of identifiable residual tumour or multiple tu- mour foci, as well as distances from the resection margins, should be recorded ‘Changes in the residual tumour cells, i present, are very variable in degree. In therapy-resistant cancers, no morpholog- ical alteration may be detected. More SE. Pinder J. Kulka nly, carcinomas become lass cel- and are often present as scattered nests across the tumour bed. The size and celiviity of foci of the overall residual cancer should be recorded, since the extent of residual invasive car- cinoma, together with lymph-nede status, Is 2 powerful predictor of long-term sur vival 221}. n a few casos, the remaining cancer cellsbecome bizarre, possessing large and irregular nuclei. The cytoplasm of the residual tumour cells may become vacuviated in about 40% of cases [999] In some cases, the only residual cancer is in lymphatic spaces and this finding has been associated with recurrence after neoadjuvant therapy [250A]. The mitotic ‘count is often lower in the residual carci- noma, Nevertheless, histological grade remains a prognostic factor after neoad- juvant therapy and should be reported [179}. after a complete response, only a loose, oedematous, vascularized fibro alastotic area of connective tissue with chronic inflammatory cells and macro- phages may mark the tumour bed, When only small foci of atypical cells are pres- cent, immunchistochemical studies may be helptul to distinguish cancer cells rom Table 1.05 Comparison of systems fr evaluating reponse fo necadivat heap) fr bess cancer: ahoegcl ovation fy tae eon ina No invasive carcinoma Yareuedlagt 1 CChvaler (262) Prosencn ons carcinoma with Noinvasheorinstu Yes 1 seri or frais ‘arin Salat (1265, Presence of invasive carcinoma “lal ornesrtoisl —Yos, + retmont oft 2 Presence of rasimentefert, tnorapout eect Nilo: Payne 1023) Prasenc fines crcinoma No invasive carcinoma No 3 Celery ROB (residual cancer {1980} Se oftunourbedin two dimensons __Nainvasvecarcnona Yes, umber nd sae of 2 burden) Celdaiy of resivalinvasive carcinoma lage depos (vhs scores ‘uated foreach case) ce ty) 221) Sic ofimasve carcinoma No invasive carcinoma Yes, number Upiog (dopendert onthe init AIC and Nalapoes) [UNPI (Mode Notingham {11} Sie of ina carcinoma No invasive carcinoma Yes, number a Prognostic nx) Tur grade Pinder {1109} "of tumouramaing beat No invasive carcinoma Yes, reaenono! avseree Sreat 2 response ‘ump res 1tiocytic cells and invasive car- sm careinoma in situ, ocrine therapy may be used, ‘sults in pCR. The treated can- == ~2y nave a contral area of fibrous 1432) ‘cinoma in situ (OCIS) may be the absence of residual inva. ‘oma. Ths finding does not ex assification as a pCR and these 2 good prognosis | 162,449, teeoh nodes ‘he maximum amount of infor- m neoadjuvant therapy, the or ncdes should be evaluated belore Enlarged nodes, or those iden- ultrasound, may be sampled ©: ~v=-nzeale aspiration or needle-core es) | no metastatic carcinoma is tinal node can be biopsied. In 128 removed following neoad|u- ~srapy, areas of fibrosis (somotimes s=22=-shaped) oF large collections of phages, can be seen and are inter- a8 representing response of ic disease to the neoadjuvant As in the breast tissue, immuno- -mistty for keratins can be helpful can completely resolve without 3 Nistological evidence of prior clvement. Without pretreatment =-2v2i0n, the distinction between nega- "0988 before treatment and a nodal not be made with certainty, The =scose in the nodes has more prog- portance than does response in -ast (726), Small motastases after including isolated tumour cells, enlatve of an incomplete fatho- response, In the setting of neoad- = therapy, the presence of isolated ~our cells seen by H&E should be in- with caution, and ae node-pos- studies, 10-30% of patients have 5. 10-18% of pationts have no oF i= onse, and the majority has a par- = "=s00n8¢ to therapy. The extent ofthis Sense is associated with outcome, = ran eight systems have been pro- == 10 classify the degtee of tumour res- therapy. Some systems compare =onomas pre- and post-therapy (0. 2yne, Pinder) |1023,1109}, whereas others quantify the amount of residual ear- cinoma (e.g. AJCC: and RCB, residual cancer burden) {221.1390}. Identifying AJCC stage before and after treatment is important and pravides additional prog- nostic information (650) ‘Morphological changes in normal tissues after treatment Normal breast epithelial structures may show atypia, inthe form of enlarged and ‘occasional pleomorphic nuclei, after neo- adjuvant therapy. These may be present fal some distance from the site of the in- vasive tumour and can be present throughout the specimen rather than in the vicinity ofthe tumour bed; care should ‘be taken not to over-diagnose these as in situ disease Radiation can cause the stroma to be dense and hypocellular. The epithelial cells of ducts and lobules may show slightly regular and hyperchromatic nuc- lei, and lobules may become sclerotic. Radiation fibroblasts may be seen and bizarre stromal cells may also be present,is important that these changes are not ‘sported as signs of sui generis atypia or rent malignancy (1263). Atypical ular proliferations can occur in the in, and sarcomas, particularly angiosar- coma, may arise in the radiated skin lor breast years after radiotherapy. Fig. 110. A Residual (ravascular tumour calls showing marked pleomorphism folowng neoadjuvant tery. B Th rosiual tizare tumour clin he miele of he fld bears alge nracyopasmicvacule. Classification using needle-core biopsy and fine-needle aspiration Fine-needie aspiration (FNA) and needle coe biopsy (NCB) have been extensively sed for years in the diagnosis of breast lesions and have good sensitivity for the lagnosis of malignancy in pelpable lesions 704,966). There is evidence that NCB is ‘more sensitive for the detection of impalpa- 'e lesions and is recommended for the luation of microcaleifications and FNA indings that are suspicious [187]. Its es- sential that these techniques are used in smibination with clinical and radiological assessment. the “tiple approach” (186) Iris not possible to distinguish between in uu and invasive carcinoma using FNA. False-positive diagnosis of adenocarct noma is uncamman with FNA (< 1%). By NOB, 2 false-positive diagnosis of invasive carcinoma or ductal carcinoma in situ (DCIS) is rare (1139). Furthermore, in pa- tients with microcalctications detected at mammography, about 20% of ciagnoses of ee Paes, DCIS made by NCB are upgraded to inva sive carcinoma on excision, Preoperative agnosis using FNA or NCB can allow de- ‘intive decisions regarding reatmant to be made botore surgery and may affect sur- gical autcome (1578, 1580). In other in- stances, such information can help avoid unnecessary surgery in patients with be nign lesions. The rate at which malignan- cies are missed with NCB is rare, witha low impect on patient management [1143] Classification using FNA A dofinitve diagnosis of carcinoma is ‘made when the aspirates display high cel- lutarty, 2 monomorphic cell population, conspicuous loss of cell cohesion with nu- ‘merous isolated single epithelial ces, and aniso-nucleosis. Some carcinomas, such as lobular, tubular, papilary invasive carci nomas or invasive carcinomas of low nu- ‘lear grade may be dificult to recognize on sue i ann F Schmit, N. Sneige A.Leo FNA and should be confirmed by NCB. (966!, The distinction of metastases to the breast from primary cancers elsewhere may be possible using NCB or FNA i there are distinctive feetures andior pertinent clin- ical history {1000}. Ciassification using NCB Experience to date has indicated that there ‘excellent coretation between the findings of NCB with those of open biopsy (805, 1593). Furthermore the level of diagnostic agrooment among pathologists in the inter pretation of NCB specimens is extremely high 285]. The use of strict agnostic ri teria, coupled with immunohistochemisty is uselul to avoid a mischagnosis. However, a defniive diagrosisis not always possible and aclassfication that includes borderline categories euch as “suspicious,” “equivo- cal" or “uncerisin malignant polenta” is sot in patient management {1142}. The Fig. 1.41 Sceretng ison. A Sdeotng sen on needa bopy, hugh tobe suspicious for imaie carcinoma, & Inmunosrin fr sooth muse ain highs an cist lye of moeptheal cls suounding the bul structures, supporting the agnosis of noninvasive canes. . er asal ductal hyperpasia lobular neoplasia, aca sk lesion on NCB has aisa with varabio rates of main Re subsequent su 9178.54, 088), As ares eragerent of such les osisby NCB has been con rot however hat he carina 2 of biopsy eves used es obaned the gauge of 3, and the percentage ot he 98824), Exc Is ofon ar NCB diagnosis of over fr some Ind Ul colon of maging Tacings f concordant maghete resonance rag ral loweup rthout urge ay appropri 1223) and predictive markers ade can be assessed on : ut 70% of agroernent wth the ined inthe surgical specimen NA and NCB can give an stological ype, but neithar is ause of the existence of xed types, Estrogen roceptor 2 status can be relably as- with agreements of about ). The analysis of prognos- > factors using FNA should of distant metastasis lable tissue material Jr2s0und-guided NCB or FNA of ‘odes can be helpil in the ve carcinoma, forthe grass of metastases [300] Fig. 143 A fucocal-it eson 01 nooo biopsy, mista a uchcus carcinoma, The races of gs ober eptetn which rgresent the ning of autre ost space an he absence ol in bee vessdseoesing he mciouslakes shoud be the key oh gas Contrast his nage wth hat mucinous carcino (8). woking alae nt misinrreled as lobular ype. B Ducal carcrama in iu mnunctning for -cachern shows stong menrarcusexresion, he presance of uta ferentaten . aMolecular pathology overview Breast cancer is a heterogeneous cis: cease with mutiple subtypes, variable siz, grade, metastatic potential and with vary- ing prognosis. Hence, the choice of ther- apy for patients with breast cancer is to some extent defined by information pro- vided by the pathological assessment. The examination of the standard haema- toxylin and eosin (H&E)-stained section is siilan ficient, cost-effective and power- {ul mode of providing information to inform Classification and hence clinical manage- ment [1146]. The pathological subtype (69. tubular versus metapiastic) grade (1 versus 3), size, vascular permeation and nodal status wil provide informative data to define he likeliest outcome for patients with breast cancer and the need for agju- vant systemic therapies. Nonetheless, de- vvelopments in our understanding of the molecular and celular basis of cancer ini- tition and progression are providing tools for tefining the texonomry of beast cancer ‘ang opening up new avenues ior the clas- sification and treatment of breast cancer {941,1080] ‘The Use of immunohistochemistry for df= {orentiating benign from in situ and inva sive malignancy using a variety of cell ‘end tissue-specific molecules, such as koratins (keratins 5/6, 14), 963 and base- ment-memiorane markers (collagen W, Breast-cancer genomics and next-generation sequencing ‘Comparative genomic hybricization and microarray-based comparative genomic hybridization have demonstrated that breast cancers are remarkably neteroge- neous at the genomic level (15B,262C, 2620, 463,574,664,970A), and that there is ‘a correlation between the patterns of gene copy-number aberrations and histological grade and estrogen receptor (ER) expres sion in both ductal carcinomas in situ (DCIS) and invasive carcinomas of no special type (NST) [15B,204,205,2738,, 574,664,970,970A,970B. 1520). Grade 1 invasive carcinomas NST are usually diploid or neardiploid, and have been shown to harbour recurrent deletions of 16a (> 86%), gains of 14 (60%) and gains of 16p (40%), which may result from an 28 vasive b laminin) has had a significant impact on clinical management. This is particularly important in breast-screening practice, where small amounts of tissue removed sing core biopsies have to be evaluated subsequent to the detection of an abnor- ‘mally on radiological examination. Scle- rosing lesions pose particular diagnostic, difficuties. Staining for estrogen receptor (ER), prog- testerane receptor (PR) and HER? is be coming standard practice and increasingly, gene-amplification studies for HER2 (ERBB2) have also been incorporated into testing, Guidelines for the assess- ment of hormone receptors have been published by the American Sociely of Clinical Oncology (ASCO) and thresholds for positivity have been established (541, 1591}. The use of tamoxifen or an aro- matase inhibitor and the addition of chemotherapy with or without trastue Zumab are dictated by the results of these studies; tis Important thatthe information, derived from the analysis is robust with 900d quality contrals in the pre-analytical, analytical and postanalylical stages Quality assurance programmes exist to help standardize protocols and it is tecom- mended that laboratories engaged in the analysis should participate [107]. These simple molecular tests already help us to unbalanced chromosomal translocation involving chromosomes 1 and 16 in up to 40% of cases (451,831,970,*466A\, Grade 8 cancers, on the other hand, are remark ably heterogeneous, and often frankly aneu- ploid. Despite the greater number and ‘complexity of copy-number aberrations found in grade 3 carcinomas, deletions of 116q are found in only approximately 30% of cases, and are almost restricted to ER- nogative lesions |970}. In fact, approx! rmatoly 50% of grade 3 ER-positive cancers, harbour the typical pattern of gene copy. number aberrations found in grade 1 tu mours (2. deletion of 18 and gain of 1q) 231,970), This information has led to the hypothesis that progression from low 10, high-grade breast cancer is an uncommon on and general features SR. Lakhani 4S. Reis. Md. van de Vier sttatily breast cancers into meaningful groups for determining prognosis and treatment Recently, genomic and exprescion micro- array technology, enabling us to simulta- neously examine changes in thousands of genes, has been used to subclassily breast cancer and establish “signatures” ‘or the prediction of "good versus bad! and “responsive versus non-responsive’ cancers (1486) Proteomic methods are also available and a number are suitable for use with paraifin-embedded material Proposals for identifying and substratiy- ing patients using more clinically useful grading systems (1.9, stratifying interme- late grade into low-risk/grade 1 and high-risk/grade 3) [1868) and those with tumours that are likely to recur (recur fence scores) {1409] have been sug- gested. Much remains to be done in terms of standardization of platforms, use of appropriate quality controls, statistical methods for analysis and cut-offs used to separate cancers into different groups. Nevertheless, the technology holds much promise for adding to and extending the current classification of breast cancer 10 help optimize patient management, US. Reie-Filho SR, Lakhani P.Devilee biological phenomenon, which may be ro- stricted to tumours of ER-positive pheno- typo [970.9704), Intermediate-crade DCIS and grade 2 invasive carcinoma NST hat- bbour more complex genomes than grade 1 lesions; however, deletions of 16q and gains of qe found in a substantial num- ber of cases. These observations suggest that these lesions are the result of pro gression of grade 1 DCIS and invasive Ina way akin to low-grade DCIS and inva sive carcinomas NST, lobular carcinomas also harbour deletions of 169, gains of tq and 16p [26A,258,520A,827,1173}. There is evidence to suggest thatthe diferences between low-grade ductal and lobular proliferations is the target gene of 16qin low-grade ductal prolif. = 12rget gene of 18q deletions be identified (613,704, the target gene in lobular as been shown to be CDM (128, 4.1826}. This gene encodes E- an adhesion molecule that me- mophylic and homatypic ad- enithelial cells; loss of E-cad- sion has been shawn to lead istic diseohesiveness ang nd metastasis of lab- 331B,1868) CDH? lass of function type, additional gena- correlations have been cancers, For instance, cnomas (1442) and adenoid > 1092,1577A) have been vr recurrent chromosornal aly 12:18) and 6:9), translocations lead 10 of the chimaeric: fusion ETE NTRKG (1449) and MYB-NFIB sthermore, micropapillary mucinous |739} carcino- own to harbour distinct jene copy-number aberra- eared to grado- and ER. sive carcinomas NST. clations beiween the 2) characteristics of DCIS and pression profiling 6 body of literature on the jene alterations or changes expression of one or af a of genes with prognosis fo therapy in breast cancer Although many statistically art associations have been ident helming majority are not h to be clinically useful. This surprising because many of 8 already correlate with known vogen receptor, ER: HER2; 2 behaviour of cells or tu- determined by the coordinated =sscon of many genes, making it un- the analysis of one or a few accurately predict clinical be- fond what is already known, =wide analysis of gene expression microarrays is used in tranele- invasive carcinomas NST and the pat- terns of gene copy-number aberrations in breast cancer, there is stil a great degree of heterogeneity in grade 2 and grade 3 lesions. Furthermore, although the “inti sic” subtypes as defined by gane-oxp- ression array analysis have distinctive patterns of gene copy-number aberre- tions, each sublype comprises a rather heterogeneous group of tumours in terms of the patterns of genetic aberrations 0b- served (19B,118A,262C, 2620, 483,574, (664,970A, 1242A) With the advent of next-generation so- ‘quencing, it has become possible to char- acterize the entire genome, transcriptome and epigenome of a tumour {63A). Com- plete genomic sequencing studies of breast cancers have demonstrated that breast cancers are incredibly heteroge- neous in terms of the mutations, structural variations and copy-number aberrations they harbour [343A,676A,970C, 12974, 1375). In fact, few mutations have been shown to be highly recurrent (e.g. TPS3, PIKSCA and PTEN) in invasive carcino- mas NST |519A, 676A, 1374,19744). With the clinically defined subgroup of breast cancers (i.e. ER-positiveyHER2-negative, HER2-positive and ER-negativeMER2- negative), a great degree of heterogeneity in torms of the natterns and types of gene tional research to identify novel prognostic and predictive factors, and a number ofc agnostic tests based on the assessment of patterns of gene exprassion in tumours are ‘commercially available, The use of micto- array analysis makes it possible to assess the lovel of expression of all genes in the human genome. Tumour-cell behaviour is determined by the coordinate expression pattern of genes involved in the regulation, cf cell growth and other important aspects of cell behaviour. Therefore, the analysis of global gene-expression patterns may faci itate the preciction of tumour behaviour, n= cluding the risk of developing distant metastases and response to speciic ther- apies. In most studies, gene expression has been analysed using RNA isolated from frozen tumour material, without attempting to envich for tumour cells. The expression ee ‘copy-number aberrations, mutations and somatic rearrangements has been docu- mented. Next-generation sequencing has also revealed the existence af a “mutator” phenotype [1375], which is characterized by the presence of multiple tandem du- plications and is reported to be found more frequently in. ER-nogative/HER2. ogative breast cancers. In addition, com- Plete sequencing of matched primary and Metastatic breast cancers have demon- slrated that turiours are lkoly to be com- posed of mossics of subclones of cancer cells that harbour genetic aberrations in addition to the founder genetic events, and that breast-cancer metastasis may stem from genetically distinct subelones from the primary tumour (349A, 12974) With the combined efforts of The Cancer Genome Atias (TOGA), the International Cancer Genome Consortium (ICGC) and numerous individual academic projects, > 25000 cancer genomes will be seq- enced in the next 5 years (7038). These data will undoubtedly unravel the com- plete landscape of mutations in different types of breast cancer and lead to the identification of novel “crivers" of the dis ease, which can be exploited therapeut cally MJ. van de Viver D. Hayes CM. Perou C. Sotirou JS. Reis-Filho pattern of a tumour is also determined by gene expression in the many other cell types that are present in the clinical tu- mour mass (e.g, fibroblasts, endothelial cells, and inflammatory cells) and thus these non-tumour cells may also can: tribute to tumour behaviour. Technical principles of microarray analysis ‘A microarray is an ordered arrangement of known DNA molecules of predeter- mined sequence (the “probes") attached to‘ solid support. One array may contain ‘many thousands of probes and can be obtained by a number of cifferent manu- facturing methods. The probes attached to the solid support can be complemen- tary DNAS (CDNAS), cligonucleotides of varying length, or genomic sequences (ie, bacterial arificial chromosomes, BACs), The atray may be formatted by Expression profiing 29applying the DNA (cDNA, oligonucieo- tides) 10 the array by pins or inket tech- nology, by in sity photolthographic synthesis of oligonuctecties, or by bead- based methods. The target sequence hy- bridized to the probes on the array may be racioactively or fluorescently labelled The isolation of FINA, which is then con- verted io cDNA, jolowed by high-hrough- put sequencing of all CDNAS, can now also be used for the analysis of gene-exp- ression patterns. The result of each ofthe techniques used to assay gene-expression proies is that the expression level of each gene on the array is measured quantitatively for each tumour sample. Bioinformatics techniques The combination of clinical and microar- ray studies produces a database of gene- expression data and clinicalipathological ata; each patient or sample Is repre- sented by thousands of data-points that then have to be analysed. Of the many analytical techniques that can be used to correlate gene-expression data with clin- ical and pathological parameters, unsup- enised hierarchical cluster analysis is very important, as are supervised classi fication methods, and the use of existing gene-expression signatures, Unsupervised hierarchical cluster analysis ‘When an unsupervised approach is used to analyse gone-expression data for a se ries of tumours, the clinical or pathology information available for the tumour sam- ples is not used. For the analysis of micro- array data, the mast frequently used method has been hierarchical cluster analysis. This a mathematical algorithm that can be used to order gene-expres- sion data, Thus gene-expression analysis ‘can be used in selected circumstances to subolassify tumours on the basis of hier- archical cluster analysis into specific sub- ‘groups |416, 1090, 1356}, Supervised classification To find gene-expression patterns that can predict the clinical behaviour of tumours, itis more appropriate to use a supervised method that specificaly searches for ‘genes that correlate with a given clinical parameter, such as survival or response to therapy. Fundamental to this approach is the identification of the patterns af ex- pression of a combination of genes that can predict tumour behaviour (2.9. risk of 30 inormas development of distant metastases, re sponsiveness to specific forms of chamo: therapy), ‘An essential step is to validate a predic- tive gene-expression pattern in an inde- pendent series of tumoursfpationts. It is. ‘obvious that the robustness ofthe predic- tive gene-expression profiles will improve with increasing sample size. Existing gene-expression signatures ‘A major advantage of microarray analysis Is that specific properties of cells can be recognized by the expression level of a large set of genes. This has been opera. tionally defined as “expression signatures” or ‘multigene predictors’. A gene-expres- sion signature can be defined by the cell ‘ype in which its component genes are ex- pressed (e.g. "T-cell signature’) or by the biological process in which its component genes are known to function (e.g, “prolif. eration signature” or "wound signature") ‘Studies of gene expression in clinical ‘samples of breast cancer For the clinical use of gene-expression profiling, the main aim is to Identify pro- files associated with spocitic cinical and- points and to implement gene-expression profling in the diagnostic process for pa- tients with breast cancer. The frst step to- ‘wards this goal is fo obtain tumour tissue that is suitable for use in gene-expression profling, At present, studies of gene-exp- ression profiing mainly employ RNA iso- lated from frozen tissue. To this end, lumaur samples from a representative part of the surgical specimen must be pro- ‘cessed within 30-60 minutes after surgory. ‘The tumour sample is most commonly snap-frozen in liquid nitragen and stored at -70°C or in liquid nitrogen, but com- mercial reagents are also available In which tissu can be stored for up to 7 days, preserving the quality of the RNA. ‘The tissue compostion ofthe frozen sam> ple, including the percentage of tumour cells, should be assessed under the micro soope. The source of RNA is usually surg cakexcision specimens, but RNA isolated from fine-needle aspirates and needle ‘pote biopsies can also be used for micro array analysis. tis also possible to perform ‘gene-expression studies using RNA from formalin-fixed, paratin-ombodded (FFPE) tissue sections; however, the methods volved require painstaking design and lesting of individual gene-expression probes, thus precluding the use of the global microarray-type format for FFPE material ‘Subgroups of breast cancer as defined by gene-expression profiles When unsupervised hierarchical cluster analysis is used to analyse series of breast carcinomas, a striking division of the tumours into ER-postive and ER-neg- alive categories is observed (1080, 14986}. The ER-positive group is characterized by tho expression of many genes specitic to breast luminal cells, whereas most of the ER-negative tumours express genes characteristic of myoepithelial cals, Based on the subgroups that are ob- served using hierarchical cluster analysis, several subgroups of breast carcinomas, can be categorized with distinct clinical outcomes: basal-like type tumours (ER negative tumours expressing myoepithe- lial"basal” genes such as keratin 5, 14, and 17); HER2-Ike tumours (ER-negative tumours that overexpress the HER2 gene); urinal A and luminal 8 (ooth ER- positive tumours clustering together) {1090}. Other dominant subgroups that Can be recognized are normal epithelial- like tumours and claudin-iow tumours, the latter of which show features of stern cells (1123), Gene-expression profile-defined signa- tures predicting olnics! outcome The supervised approach of classifying tumours has identilied a 70-gene and a Té-gene prognosis signature (1080, 1486, 1549). “Activated” and "quiescent" sub- {groups of tumours can be recognized on the basis ofa nound-Ike signature (241); while “genomic high grade" and a “ge- nomic law grade" groups of tunours can bbe recognized on the basis ofa histolog- ical grade-telated signature {1958}. in ac dition, @ reverse transcription polymerase chain reaction (RFPCR) 21-gene expres sion proie for prognosis in patients with tamoxitensreated node-negative breast cancer has been identified {1069}. Prob- ably the most promising and clinically Lsetul area forthe application of microar- ray analysis s the prediction of response to treatment, including chemotherapy {629}, normonal therapy (846), and racia tion; there are fewer of these predictive signatures, but many are under develop- ment. The prognostic gene-expression profiles that can be used in clinical prac tice are listed below.sis signature has been 2 microarray-based test ‘9 determine the prog- h stage 1 or 2, node- breast cancer of tumour requites fresh or frozen » 2 tumour-cell content of ‘otomous test classifies goed" oF “poor” prognosis, pendent predictor of cis 1486,1496). The prog- the 70-gene prognosis, jpported by level Il ovi- 4. 703A,944A,1486). Consis- ion that the prognostic ovided by the 70-gene sig- ns from the expression 0 and proliferation-re- 1173A,1177A, 1589}, the ‘mation provided for ER- 31s limited or non-exis- 20 index (GGl) prognostic signature that was ‘ed on the evidence that grade is a strong prognostic. postive disease and that re- of tumour grade by histolog- 25's suboptimal. A microarray- (nature that could classify si Cancers into GGI grades | 2s Gerived |1958), This signature ately classified histological 2 3 tumours into GGI grade | ctively, but was also shown stological grade 2 cancers, ke, which have a low fre- [stant relapses, and grade Ih ‘ave a clinical behaviour of histological grade 3 can- {Gl was initaly developed as based test that required fresh ples |1358}; a quantitative OR (QRTPCR} version of this as been recently developed and validated (1452A). There is level Ill ‘evidence to demonstrate that GGI is a prognostic factor for ER-positive breast cancers [331A}. In a way akin to histo- logical gracie and the 70-gene prognosis signature, the prognostic information pro- vided by GG primarily stems from the ex- pression levals of prolteration-rolated genes. "Intrinsic" subtypes Hierarchical cluster analysis of genes thal vary more between tumours than between repeated samples of the same tumour (.e. “intrinsic genes") revealed the exis- tence of at least five molecular subtypes Of breast cancer, namely luminal A, lumi- ral B, HER2-onriched, basal-tike and nor- mal breast-like. Importantly, the most stable separation was shown to be be- tween basallike tumours and tumours Classified as of another “intrinsie" subtype (17264, 15694) Different ists of intrinsic genes" and sin. gle-sample predictors to classify breast ‘cancers into the “intrinsic” subtypes have been described: however, it has been demonstrated that different methads may assign the same pationts into cifforont “in trinsic” sublypes and only the basal-ike ccancers can be reproducibly identfied re- gardless of the analysis methods em- ployed |3564,8384,8494, 1089A, 1355A, 469A), The lack of standardization and reproducibility was in part addressed by the devotopment of PAMSO (10734), @ 50- Gene set that classifies invasive breast Cancers into luminal A, luminal B, HER2- ‘enriched and basal-ike subtypes. A prog- ‘nostic test based on the expression levels cof these 60 genes assessed by GRT-PCR has been developed and is applicable to FFPE archival sampies. Love! Il evidence for its prognostic impact has been demon strated in retrospective analyses of pros- pective clinical trials (976A.997A) Itmust be emphasized thal the classtication cof tumours into luminal A urinal B, HER2- ‘enriched and basal-lks types by PAMEO and the classification of breast cancers on the basis of immunohistochemical analy- sis of ER, PR and HER? isnot equivalent When the results of PAMSO and iremuno- histochemical analysis of ER, PR and HER? aro discrepant, pationts should be managed according to the current im- munohistocherical markers, Additional molecular sublypes of tu- ‘mours that are preferentially ER-nogative have boon proposed, including the mo- lecular apocrine [348A,422) and claudin iow [1122] tumours. The biological and clinical relevance of these navel sub- "ypes remains to be determined 21-gene recurrence score The 21-gene recurrence score is a gAT: PCR-based signature based on the ex: pression of 21 genes (16 cancer-related and 6 reference genes) that can be ap: plied to RNA extracted from FFPE tissue samples (1058). The 21-gene recurrence score is a mathematical function devel 98d to predict the risk of distant relapse at 10 years for patients with ER-postve lymph nede-negative broast cancers 1050). It is @ continuous variable (rang- ing fram 0 to 100) thats associated wth the risk of distantrelapse within 10 years, and an independant prognostic factor for ER-positve, node-negative patents with breast cancer trated with adjuvant en- ocrine therapy (i.e. tamoxifen and aro- matase inhibitors) (353A, 1058, 16994) ‘On the basis of the 21-gene recurrence score, patients can be classified into three categories, inclucing low risk (re currence score [7S] < 18), intermediate tisk (RS 18-81) and high risk (RS 31), which equate with 10.year relapse rates Of 7%, 14% and 30%, respectively. The 21-gene recurrence score also correlates with benefit from chemotherapy in ER- positive breast cencers {10594CHAPTER 2 Invasive carcinoma of no special typeInvasive carcinoma of no special type Definition Invasive breast carcinoma of no special type (NST), commonly known as ductal carcinoma NST, comprises the largest (group of invasive breast cancers. It is not ity as it ropresonts the heterogeneous group of tumours that fail 0 exhibit sufficient characteristics to ‘achieve classification as a specific histo: logical type, such as lobular or tubular ICD-0 code #50013 ‘Synonyms and historical annotation Invasive carcinoma of no specific type (ductal NST); Invasive carcinoma, not oth vise specified (ductal NOS): infitrating ductal carcinoma. Many other names have been used historicaly for this form of breast carcinoma, including scious car- cinoma, carcinoma simplex and spher. oidal coll carcinoma. "Infitrating ductal carcinoma’ has been used in the past, but \Was revised in the last edition of the WHO Classification of Tumours (1413) to recog- nize the non-specific nature of this term Use of the term “ductal” perpetuates the traditional but incorrect concept that these umours are derived exclusively trom mammary ductal epithelium in distinction from lobular carcinomas, which were deemed to have arisen from within lobules, for which thero is also no evidence. In ad- dition it as been shown that the terminal= duct lobular unit {TDLU) should be regarded as a single entity from the point of view of the site of origin of most breast carcinomas (84, 1673). Some groups [445) have retained the term *cuctal” but added the phrase “not otherwise specified”, while others (1052) prefer to use “no special type” to emphasize the distinction from specific-type tumours. “Carcinoma of no special type' is increasingly accepted in- ternationally and preferred, but since "duc~ tal” is sill widely used, the terms “duct: NST." “ductal NOS," or “invasive ductal ‘carcinoma’ are alternative terminology op- tions. G. MacGrogan Epidemiology Invasive carcinoma NST forms a large pro- orion of mammary carcinomas and its epidemiological characteristics are similar to those of the group as a whole (see Chapter 1: Epidemiology). It is the most common "type" of invasive carcinoma of the breast, comprising between 40% and 75% of cases in published series. This wide range is largely attributable to the lack of application of strict criteria for in clusion in the special types and alsa the fact that tumours with a combination of in- vasive carcinoma NST and spaciabtype Patterns are nol universally recognized as a separate mixed category, but may bo in cluded with tumours of "no special type’ Invasive carcinoma NST, like all forms of breast cance, is rare below the age af 40, years, but the proportion of tumours clas: sified as such in young wornen with breast cer is in general similar to that in older women {708}. There are no well-recognized differ ences beiween the known risk factors Fig.204 Invasive carcinoma oro spec ype, grad 1, A Fst sco: Itamarmarylnph node (ow) and smal (<5 mm} nen-spece density B Second seron, 20 mnths ‘ho densty has grown a ite Thr scren, ater arate 29 mons: he 10 mm mous more covious but sl not palpablehy, culturaiifestyle factors, les) for breast cancer uctal NST cancers in par- ‘8 tumours develoaing iagnosis of conditions > increased risk of breast pial ductal hyperpla: woplasia, invasive carck $ frequent than tumours, , namely tubular and clas- ‘oma [1085, 1056} ‘ave no specific macro Thore is a marked varia- ‘< 101mm to > 100mm ean treguiar, stellate outine iQuration, The tumour edge rately of il-detined and umscziption. Classically in sa NST is firm or even hard may have a “grilly” feel « knife, The cut surface is ie with yellow streaks. ay 5 this histological type of essentially through a clusion of recognized spe- As a consequence, morpho- 6 vary considerably from 2, Alllypes of tumour margins =rved, from highly infiltrative, permeating the lobular stroma and dis. rupting the normal lobular units, to con- \inuous pushing margins. Architecturally, the tumour cells may be arranged in cords, clusters and trabeculae, whilst some tumours are characterizes by a pre- dominantly solid or syncytial infiltrative pattern with litle associated stroma. In a proportion of cases, glandular differentiae tion may be apparent as tubular struc tures with central lumina in tumour-call groups. Occasionally, areas with single- file infiltration or targetoid features are seen, bul these lack the cytomorpholog= cal characteristics of invasive lobular car- cinoma, The carcinoma cells also have a variable appearance. The cytoplasm may be abundant and eosinophilic. Nuclei may be regular and uniform or highly pleomorphic with prominent, often mult ple, nucleoli, Mitotic activity may be viru. ally absent or extensive. In up to 80% of cases, foci of associated ductal carci- noma in sity (DCIS) will be present. Any associated DCIS is usually of same nuc- lear grade as the invasive carcinoma, ‘Some histopatnologists recognize a sub: type of invasive carcinoma NST, “infilrat ing ductal carcinoma with extensive in situ component." The stramal component is ‘extremly variable. Thore may be a highly callular fibroblastic proliferation, a scanty element of connective tissue or marked Fig. 202 lnvasive carcinoma of no special type. A ‘mastectomy specimen rom a patel aged 84 yeas, hyalinization, Foc! of elastosis may also bbe present in a periducial or pervenous distribution, Focal necrosis may be pres ent and this is occasionally extensive with secondary formation of cysts. In a mi- norty of cases, a distinct lymphaplasmna: cytoid infiltrate can be identified. = invasive carcnoma of no special ype (NST), arade |B Invasve carcinoma NST, rade. C Invasive carcinoma NST, grade I, wih no eedenceof andar dferentation, umerou as ios, wh sor abnormal rok ies pesLympho-vascular tumour emboli can be observed throughout the tumour, but only those localized outside the tumour carry a prognostic effect. Carcinoma of mixed type For a tumour to be typed as invasive car- cinoma NST, it must have a non-special- ized pattern in > 50% of its mass as judged by thorough examination of repre~ sentative sections. If the non-specialized pattern comprises between 10% and 49% of the tumour, the rest being af a roc- ognized special type, then it wil fall into one of the mixed groups: mixed invasive NST and special type or mixed invasive NST and lobular carcinoma, Apart from these considerations, there are very few lesions that chould be confused with in- vvasive carcinoma NST. Rare morphological variants of invasive carcinoma NST ‘These morphological forms of breast can- cer are not currently recognized as dis- tinct special types of invasive breast ‘cancer but as variants of invasive carcl- noma NST, Pleomarphic carcinoma ICD-0 code 8022/3 Pleomorphie carcinoma is a rare variant of high-grade invasive carcinoma NST, which is characterized by a proliferation TB OR Pa. sarcoma. B nmunostning for ertnAE")AE) corms teeta nature ote proce, 96 invasive al typ aN Pood iferentid oo without dstnctne arcitecue of pleomorphic and bizarre, sometimes multinucleated, tumour giant cells com- rising > 50% of the tumour calls in a background of adenocarcinama or ade- nocercinoma with metaplastic spindle and squamous differentiation (1321). In the original series described, the pationts ranged in age from 28 to 96 years with a median of 51 years. Most patients pres- ‘ent with @ large palpable mass (mean size, 5.4 om); in 12% of cases, metastatic tumour is the first manifestation of dis- case, The tumour giant cells in pleamarphic carcinoma account for > 75% of tumour cells in most cases, The tumours are typ- ically of grade 3 with a high mitotic fre- quenoy and central necrosis. There may be associated high-grade DCIS and lyrn= phovascular invasion. Hormone-recaptor expression is usually negative, but a proportion of cases overexpress HER2 protein (1626). Axillary lymph-node meta- stases are present in 50% of patients, with involvement of three or more lymph nodes in most of these. Many patients present with advanced cisease, One recent study found that poor outcome in these tumours. is associated with presence of a spindle cell metaplastic component (989), Carcinoma with ostecctast-tike stromal giant cells ICD-0 code 8035/3 ‘The common denominator of these carci- omas is the presence of osteaclastic giant cells (OCs) in the stroma (571) Tho giant cells are generally associated with an inflammatory, fioroblastic, hyper- vascular stroma, with extravasated ery- throcytes, lymphocytes and monocytes tt Be len kad tomisnterreicn ofthe ason as 2— monenucleated and binucle- ‘some containing haemo- t cells vary in size and number of nucle’. They the epithelial compo- nd within lumina formed by giant cells contain a non-atypical bland nu 2tcells and hypervascular (e- can be observed in fastases and in recur. einomatous part of most frequently a well- fferertiated invasive carci all the other histological observed particularly in- mi carcinoma (986,1 103), ular, mucinous, papillary {986,7103}, squamous and asic pattems (871,1323} and yorna {735} raw uniform expression and are negative for S100 tin, and negative for ker- smiorane antigen (EMA), 2nd progesterone recepiors (ER The giant celis are fe for acid phosphatase, ise and lysozyme, but = or alkaline phosphatase, which morphotogical similarity 10 is and osteoclasts (1207, 54). Ultrastructural and immuno cai studies have confirmed the ature of the osteaclastic cells, these unusual carcinomas OGCs appear in relation to hypervascular stroma around) regardiass of histology, 5 that promote macrophage mi- ngiogenesis, suc! Ber , x ve carton om pete NST) wh tonal aseoces gat ls nd Faemaseriv aden macrophages. B The invasive crcnara NST icf rade gan eels ar event in testo, ‘and MMP12, are secreted trom both tu moural and non-tumoural cells. Its likely that the OGCs are generated by syncytial fusion of macrophages, but not by mito- sis without cell division. The phenotypic resemblance of OGCs to ostecclasts in the bone has been confirmed by the ob- servation of expression of MMP, TRAP, and cathepsin K (1255,1314}. ‘About one third of the reported cases had lymgh-node metastases, The 5-year sur vival rate is around 70%, which is similar to, orbetter than, patients with ordinary in vasive carcinomas [1862]. Prognosis is related to the characteristics of the asso: clated carcinoma and does not aopear to bbe influenced by the presence of stromal giant cells Carcinoma with features Patients with invasive carcinoma NST may have elevated levels of serum human chorionic gonadotrophin (HCG) {1303} and as many as 60% of invasive carcinomas NST have been found to contain HOG-cos itive cells (596). Histological evidence of Choriocarcinomatous differentiation, how- fever, is exceptionally rare with only a few cases reported (487,518, 1250). All werein women aged between 60 and 70 years. choriocarcinematous Carcinoma with melanatie features A few case reports have described ex ceptional tumours of the mammary parenchyma thal appear to represent ‘combinations of invasive carcinoma NST ‘and. malignant melanoma (1005,1051. +237] and in some of these cases, there appeared to be a transition from one cell type to the other. A genetic analysis of one Fig. 206 Irvasie carcinomas win sroraleteocaste slant cols often have vascular stromal ssue with aocumaaton of haomosidenn pigment, giving them ‘a brown macroscopic appearance, such case showed loss of heterozygosity al the same chromesomal loci in all the Components of the tumour, suggesting an origin from the same neoplastic clone 1005}. The mere presence of melanin in breast cancer calls should not be con sirued as evidence of melanocytic difer entation, since pigmentation of carcinoma cells with melanin can occur when breast cancers invade the skin and involve the dormospidermal junction (851. In ono study, focal expression of melan A was found in 18% of breast cancers, The pres ence and extent of melan A expression was statistically significantly associated with a reduction in tumour-cel cifferentia: tion, but not tumour type, size, ymph-node metastasis, hormone-receptor stalus oF HER? expression. Expression of melano- crytic markers in breast tissue appears to bbe related to lineage infidelity (87). In ad- ditton, care must be teken to distinguish tu- ‘ours showing melanocytic differentiation from breast carcinomas with prominent cyto- plasmic deposition of lipofuscin (1309), re at fl 37x “as. Asem 8 Fig. 208 Invsiecarrema of no specal ype: corcnoma wih chorarchomlcus features. A, BMulinucleated trou cls wh srxged ruc exer he equa, on- aud coplsmic processes acund ster ofmarceyctunou ol, mimicking the bigrai growth ota of chaercroms. Note the atnonmal ito figs inti highayade ‘Most melanotic tumours ofthe breast rep- regent metastases from malignant melan- ‘omas originating in oxtra-mammary sites (1328]. Primary melanomas may arise anywhere in the skin of the breast, but an crigin in the nipple-areola complex is ex: ‘emely rare {1070}. The aiferential diag- nosis of malignant melanoma arising in the nipple-areolar region must include Paget isease, the cells of which may occasin- aly contain melanin pigment {1267} (see Chapter 12) Genetics Cases of familial breast cancer associated ‘with mutations in BRCAT are commonly of Invasive carcinoma NST type but have medullary carcinoma-lke features, ex hibiting higher mitotic counts, a grater proportion ofthe tumour with a continuous pushing margin, and more lymphocytic n= filtration than sporadic cancers [747] Cancers associated with mutations in BRCA2 are also often of invasive carci- noma NST type, but exhibit a high score for {ubule formation (fewer tubules), a higher 38 Invasive carcinoma of na proportion of the tumour perimeter with a Cconlinuous pushing margin and a lower mi- totic count than sporadic cancers (747) ‘The genetic variation seen in breast cancer ‘8s a whole is apparent in invasive carci- noma NST. Recent observations associat ing specific genetic lesions or regions of alteration with a particular histological ‘ype or grade imply that the group of breast cancers of invasive carcinoma NST type includes a number of different types of tumour that have developed via Unrelated genetic evolutionary pathways 204}, and that show fundamental ciffer- fences to some tumours of special type, including lobular 528) and tubular carc- noma {1230}. Furthermore, cDNA micro array analysis has clearly demonstrated that Invasive carcinorna NST can be clas sified into subtypes on the basis of gene- expression patterns (1090, 1356} and that ‘many of the special types of breast can- ‘cer have characteristic alterations (see Chapter 1: Expression profiing and Breast-cancer genomics and next-gerer- ation sequencing). Prognosis and predictive factors Invasive carcinoma NST forms the bulk (60-80%) of casos of breast cancer anc its prognostic characteristics and man- agement are similar or slightly worse with 4 95-50% 10-year survival [976] cor pared to breast cancer a5 a whole with ‘around a 65% 10-year survival. Prognosis is influenced profoundly by the ciassica vatiables of histological grad, tumour size, lymph-node stalus and vascular in- vasion (see Chapier 1: Grading and Stag- ing) and by predictors of therapeutic response, such as ER and HER2 status {see Chapter 1: Molecular testing for es- trogen receptor, progesterone receptor {and HER2). Approximately 70-80% of in- vasive breast carcinomas NST are ER- positive and approximately 15% of cases ‘are HER2-positive. The management of invasive carcinoma NST isalso influenced by these prognostic and predictive char acteristics.CHAPTER 3 Special subtypes Invasive lobular carcinoma Tubular carcinoma and cribriform carcinoma Carcinoma with medullary features Metaplastic carcinoma Carcinomas with apocrine differentiation Salivary gland/skin adnexal type tumours Adenoid cystic carcinoma Mucoepidermoid carcinoma Polymorphous carcinoma ‘Mucinous carcinoma and carcinomas with signet-ring-cell differentiation Carcinomas with neuroendocrine features Invasive papillary carcinoma Invasive micropapiliary carcinoma Inflammatory carcinoma Bilateral breast carcinoma and non-synchronous breast carcinoma Exceptionally rare types and variantsInvasive lobular carcinoma Definition ‘An invasive carcinoma composed of non: cohesive cells individually dispersed or arranged in a single-fle linear pattern in a fibrous stroma. It is usually associated with lobular carcinoma in situ (LOIS), ICD-0 code 8520/3 Epidemiology invasive lobular carcinoma (ILC) repre- sents 515% of invasive breast tumours (376,789,795, 1264, 1444, 1587} Since the 1980s, the incidence of ILC has increased relative to that of invasive carci- noma of no spacial type (invasive carct- ‘noma NST) {789,790}. This might be atti- butable to the increased use of hormone. replacement therapy |168,308,789,796, 1016,1162) or increased consumption of alcoho! |791,793). The mean age of pa- tients with ILC is 87-65 years, slightly higher than that of patients with invasive carcinoma NST |73,795, 1138, 1264, 1444} Clinical features Most women present with an ill-defined Palpable mass involving any part of the breast, although centrally ocated tumours were found to be slightly more common in patients with ILC than with invasive carct- norma NST in one study |1587]. Radiolog: ially, the most common mammographic findings are a spiculated mass or archi- tectural distortion. Calcification is infte- ‘quent. Compared with invasive carcinoma NST, mammography has a reduced sen. sitivity for detecting ILC (57-89%) with high false-negative rates of up to 19% (577,723,764). Ultrasound is more sensi- tive (78-95%), although the size of the tu mour can be underestimated 211,237, 243,409, 1 189,1295, 1556). Magnetic res ‘onance imaging (MRI) is more helpful in diagnosing ILC, particularly multifocal le- sions, although this technique can lead to false positives and overestimation of tu- mour size (342, 1273} ‘A high rate of multicentric tumours has been reported in some studies [341,785) bbut this has not been found in other series based on clintal {1264} or radiological 40 {764} analysis. An incidence of contralat- feral tumours, particularly synchronous tu- ours, of 5-199 has also been reported (00 Bilateral breast carcinoma), which is higher than for invasive carcinoma NST (73,190,257,941, 426, 1094, 1326), Macroscopy ILCs frequently present as iregular and poorly delimited turnours that can be dif- ficult to define macroscopically because of th aifuse growth pattern of the cell n- filtrate {1926}. The size of the ILC is also ificul to determine, athough ithas been reported to be slightly larger than that of invasive carcinarna NST in some series (1284, 1326, 1587), Fig. 3.02 Macoscopy fan invasine abr earnoma spay an nadoion. SR. Lakhani E. Rakha PT. Simpson Fig 3.01 Manmogaphy ofinvasve ool carcinoma. AAchtecurl ditorton inthe aarti corresponding 2 pablo area ofthckning, BMagifed vewo he recur ary dstorton, Histopathology ‘The classic pattern of ILC 455,885, 1555; is characterized by a proliferation of smal cells, which lack cohesion and appear in- dividually dispersed through a fibrous conneative tissue or arranged in single- file linear cords that invade the stroma These infitrating cords frequently presen concentric paltern around normal du ‘There is often lite host reaction or distr bbanee of the background architecture, The Neoplastic cells have round or natchec ‘ovoid nucle! and a thin rim of eytaplasrs with an occasional intracytoplasmic lumer [1128}, often harbouring a central mucois inclusion. Mitoses are typically infrequer’ These classic cytological features are the ssame as those seen in lobular neoplasia which is associated with ILC in 58-98% o' cases (6,341,345,964] Histological variants ‘A number of variants of ILC have be described that share either the cytolog ‘eal or growth pattem of classic ILC, bu all lack cell-o-call cohesion The solid type is characterized by the typ ical non-cohesive and small colls of lob. lar morphology but these cells grow i sheets, are often mare pleomorphic and have a higher frequency of mitoses than the classic type (427]© alveolar variant are mainly globular aggregates of at $1378} ooular carcinoma (PLC) re~ tive growth pattern of lob- a but exhibits a greater ular alypia and pleoror- er mitotic rate than c'assic 565]. This variant is frequ- ed with LCIS composed of ‘comorphie cytological features, ~specrine {996} oF histio- | diferentiaion and may be * signet ring cell ular variant is composed of a tubular growth pattern mecels aranged ina linear LCIS is observed in about joulo-Jobular carcinomas, roup is composed of cases mixture ofthe classic type ‘9 of these variant patterns classic ILC type and mixed ontrioute to the majority of lobu- comprising up to 75% of all 1187). In addition, both in arcinoma NST and lobular fea- tiation are present in about sive breast cancers {795,885] 20-type carcino) / graaing ance ofthe three-tiered Notting- ical grading system for ILC matter for debate due to the ic absence of tubule forma- inthe tubulo-lobular variant), ty of neoplastic cells and the count. Some studies report the anastie value of grading ILC while several studies sug- de is an independent pre- lent outcome (98,997, 1089, Jost (gpproximately 76%) classic ‘ade 2, whereas ILC of grade 3 of non-classic type {1043, +395}. Of the three components of tumour grading, the mitotic index is the most use- {ul predictor of outcome; a high mitotic ‘count is associated with a worse progno- sis (1137) Immunoprofle ‘Although the literature suggests that 80-95% of ILCs are positive for estrogen receptor (ER), in currant practice, classic, ILCs are almost invariably ER-positve. In comparison, 70-80% of invasive carcino- mas NST are ER-positive. Progesterone receptor (PR) positivity is found in 60-70% of both tumour types 73,1138, 1264,1617). ER was found to be exp- ressed in the classic form and in variants, bout the rate of positivity was highest (100%) in the alveolar variant (1316) and lowest (10%) in PLC |110}. HER? ampi- fication and overexpression are rare in ILC {73,1117,1138, 1231, 1954}, although ‘evident in some PLCs {922,1929). The ex pression of p53, basal markers (keratin 14, keratin 5/6, EGFR) and myoepithelial markers (smooth-muscle actin and p63) is rare in ILC (348,413, 1138). The profi. eration rate, measured by MIB1/KI67 Ia~ bling, is genorally low in ILC, although higher in the variants (1004, 1043}, One of the most consistent molecular alterations in ILC and its variants is the loss of ex- pression of the cell-cell adhesion mole- cule E-cadherin, which contributes to the Characteristic discohesive nature of bu- lar cells (922,469,938, 10321060, 1144, 1185, 1329). Most ILCs also show altered integrity of E-cadherin complex mole- cules, with loss of alpha-, bota- and gamma-catenins, and the mislocalization (f 120 catenin from the cell membrane to the cytoplasm [304,1144, 1262) ‘Analysis of expression of E-cadherin and 1p120 may help to differentiate between lobular and low-grade invasive carcinoma NST that are dificult to classify on the get ng ela intacloplsmic urine (argetad sereton), Fig. 202 In sit and invasive lobule carcinoma, The larger cals onthe left an lower part ofthe eta are vase turour cals basis of morphological criteria: however, ‘about 15% of ILCs do express E-cadherin and so positive staining should not be Usad to re-classify a lobular lesion as in- vasive carcinoma NST {14, 903, 1144), Genetics Using flow cytometry, ILCs were found to be near diploid in about 50% of casos, 1451]. ILCs have fewer and different pat- terns of genomic alterations than invasive carcinoma NST (451,827, 1004, 1320}. The most frequently identified alterations in DNA copy number are loss of chromoso- mal arm 16q and gain of material on 14 and 169 |389, 617,827, 1004,1173). Other alterations are more heterogeneous, al- though recurrent gains (8q), amplifica- tions (1982, 8912-p11.2, 11413) and losses (8p23-p21, 11914.1-a25, 139) are identified PLCs exhibit similar alterations but in ad dition contain ampiications at loci such as 8924, 17912 and 20q13, which are characteristic of high-grade invasive carcinoma NST (129) arcarcinoma atFig. 305 A Cassicinvasv ot carcinoma wih unflon, singe-cl ls compared win}. B vase ploomepic oul noma win cared pleomophis, eal rid, Inactivation of E-cadherin is the most ‘commonly identified genetic alteration in ILC and occurs as an early event in onco- {genesis (1528), Somatic, truncating mut- ations within the E-cadherin gana (CDH, mapping to 16q22.1), together with loss of heterazygosity and promoter methyla- tion contribute to this loss af expression 1128,354,678, 1528) Gene-expression profiing studies have demonstrated that ILCs are most fre- ‘quently classified as luminal A type mol ecular tumours, but they can alsa be Classified as luminal B, HER2, normal-liko fr basalike |1569). In support of ge- nomic data, geno-expression data indi- cate that ILCs differ trom grade- and ER-matched invasive carcinoma NST and tubular carcinomas in the expression of genes associatad with call adhesion, coll- to-cell signalling and actin cytoskeletal signaling (717, 1469, 1568, 1625), Prognosis and predictive factors Despite the favourable prognostic foa- tures of ILC (low grade, ER-positive, HER2-nogative, low proliferative index), 42 Special sul there remains controversy as to whether the outcome differs for patients with ILC or invasive carcinoma NST. Several stud- jes have reported a more favourable out- come for ILC than invasive carcinoma NST (945,355,376, 19261444}, whereas thers founc no significant differences (73,716,940, 10841 138, 1814,1526] or @ worse prognosis for ILC {75,1094, 1138}. In large series, ILCs were more likely to be of larger size (>5cm), more ad- vanced tumour stage (stage Ill) and, with more Iymph-node positivity than in- vasive carcinoma NST (73,795), An im- Portant observation made in two series ‘shows that patients with ILC have a better oF similar outcome than pationts with in- vvasive carcinoma NST in the frst 10 years after diagnosis; however, the long-term ‘outcome associated with ILC is worse than tor invasive carcinoma NST |1094, 1138} The higher incidences of distant metas- tases, recurrences and mortality in ILC are long-term events following diagnosis, ‘When the histological subtypes of ILC were analysed separately, a more favourable ‘outcome was teported forthe classic type than for the variants, namely pleomorphic and solid 1203,241,345,955,396, 1043, 1865). However, tubulo-lobular carcinoma and alveolar ILC have been considered to be low-grade tumours (519, 1316} Alower frequency of axllary nodal motas- tasis in ILC than in invasive carcinoma NST has been roported in some series, the difference ranging from 3% to 10% {636, 757.1264, 1926, 1444] The metastatic pattern of ILC ditfers trom that of invasive carcinoma NST. A higher frequency of tumour extension to bone, gastrointestinal tract, uterus, meninges, Ovary and ciffuse serosal involvement is observed in ILC, while extension to the lung is more frequent in invasive carci (oma NST {73, 170,433,554, 636,757,128, 1926,1444) Immunohistochemistry using antibodies to GCDFP-15, keratin 7, ER, PR and E cacherin may help to establish an intra abdominal tumour as a metastatic ILC,ubular carcinoma and cribriform carcinoma war carcinoma of breast carcinoma with a favourable prognosis, tubular TC) is composed of well udular structures with open bya single layer of cells a2 ints for approximately 2% breast cancersin most series. equencies are found among ancers of stage T1 and in ;creoning programmes 144 fic clinical feature that es TC from the more common rcinomas of no special type pes, When compared invasive carcinoma NST, 2 likely to be smaller, less fre- ws lympho-vascuiar invasion al involwement and a better pa- sme is typical (340,428,672, 780, 41), Approximately 10-20% of been reported fo be multifocal phically, 22-57% of TCs do not lasion, but others are fre jculaled and calcifications are present (526, 1907, 1621]. On ultra ypoechoic mass with illdefined margins and posterior acoustic shadowing ‘are seen (526, 1302, 1307, 1621) Macroscopy TC oten presents as anil-defined grey to white, firm or hard mass measuring be. ‘ween 0.2 om and 2 em in diameter; most are 1.5 em or less {340,428,1021,1141 Histopathology The characteristic feature of TC isthe pre- dominance of open tubules composed of a single layer of epithelial cells enclosing a clear lumen. These should compose > 90% of the tumour, The tubules are generally an admixture of oval or rounded and angu: lated shapes and are arranged neohe: araly, The cells are small to moderato in size, regular with litte nuclear pleomor- phism, inconspicuous nucteali and scanty mitotic figures. Muitlayering of nuclei marked nuclear pleomorphism or high mi: totic activity are contraindications for a di= agnosis of TC. Apical snouts ara seen in up to a third of cases, but are not pathog romonic. Myoepithelial cells are absent around the tubules, but some may have fn incomplete surrounding layer of base: ment membrane. ‘A secondary, but important feature is the cellular desmoplastic strorna, commonly accompanying the tubular structures, TC occurs in association with flat epithelia! atypia, low-grade ductal carcinoma in situ (OCIS) and, less commonly, labular neo- plasia {435, 606,1141}. These epithelial proliferations typically share nuciear grade, ‘Tubular cardrama A Thee is aheghazaré dtrbuton of unde and angiatod ules wit opon kin, iy 8 sng lay of pn as separated ty abundant react, Srblestcstera. B Te nopas cols + esrchopshaned ubules ck sigan aja, E Rakha Fig. 306 Tubular carcnom, Specimen Xray immunophenotype and genotypical fea- tures {7,79,1141). An association with ra: dial scar has also besn proposed {1340}, There is a lack of consensus concerning the proportion of tubular structures nec essary for a diagnos's of TC, with the re quirement being set at between 75% and 100% [227,428 672,780,698, 1096, 1383, 1621] but pragmatically, 90% purity offers a practical solution and is recommenced [1141, 1413}, Tumours exhiatting between 50% and 90% tubules admixed with an- other morphology should be regarded! as, being of mixad type. TC is nearly always positive for estrogen and progesterone receptors, has a low gromih fraction, and is typically negative for HER2, EGFR, P-cadhern, p53 and high- molecular-weight keratins (1071,1141 Differential diagnosis Sclerosing adenos's can be distinguished from TC by its lobular architecture and the ‘compression and distortion of glandular structures. Myoepithelial cells are always present in sclerosing adenosis and bbe highlighted with immunostaining. Sim ilarly, a fully retained basement mem: borane can be shown ay immunostaining for collagen IV and laminin in sclerosing adenosis. Complex sclerosing lesionsira- dial scars have central fibrosis and elast- sis containing a few small, often distorted, tubular structures around which myo thelial calls are present. In a minority of cases of racial scar, attenuated or focally absent staining of myoepithelial cells is seen, particularly in areas of marked sclo- rosis, The peripheral glandular structures 28in a radial scar show varying degrees of dilatation and ductal epithelial hyperpla- sia. Microglandular adenosis can be more difficult to differentiate, because of the rather haphazard, ciffuse, inftrative pat- tern ofthe tubules and lack of myoepithe- lial cells around the tubules, in contrast to the localized growth found in TC. Impor tantly the tubules of microglandular adeno- sis are more rounded and regular and often contain colloid-ike secretory mate- rial compared to the often angulated tubules of TC. TC should be distinguished from tow- grade invasive carcinomas NST and {ubuloobular carcinomas, The presence Of single-layered angulated tubules in > 90% of the lesion, along with an ab- sence of marked pleomorphism and mi oses distinguishes TC from the former. The tubular structures in tubuloJobular carcinoma are different from those in TC, being small and round rather than angu- lated in shape, and are admixed with a ‘classic lobular component. Genetics TCs of the breast have a low frequency af genetic alterations. Using loss-of-netero- zygosity (LOH) and comparative genomic hybridization (CGH) techniques, alte ations are seen most frequenly at chro- mosomes 16q (loss) (78-86%), flowed by 19 (gain) (50-62%), and they usually ‘occur concomitantly. Other alterations in- clude 16p gain and loss of 6p, 3p (FHIT eer Fig. 3.08 invauve erbsierm aera, To haghaza cass wih the rounded coniguraton ofthe dts wih rire ductal carcinoma insu on he eta sid, 44 Speci gene locus) and 11q (ATM gene locus) [79,865,1186,1540). Although these chro- ‘mosornal alterations are common among other low-grade breast cancers, 1. low ‘grade invasive carcinoma NST, and lobu- lar carcinomas, small yet important aifferences at the transcriptome level have been demonstrated (831,1186}. Chromo- somal alterations found commonly in inva- sive carcinoma NST, such as 17p loss, are infrequent in TC. Profiling studies of global gene expression have demonstrated that TC belongs to the "luminal A” molecular class of breast cancer [1889 Prognosis and predictive factors Women with TC have an excellent long- term outcome |227, 645,808, 1021, 1096, 1525}, which in some series is similar to that of age-maiched women without breast cancer (340,428,1147, 1983]. Re- currence after complete excision is rare. Following breast conservation, whilst tak- ing into account mulifocaity and assoc aied in situ disease, the risk of local recurrence is £0 low that some contres ‘consider that adjuvant radiotherapy is un- necessary, Ter-year disease-free survival and overall survival rates after mastec- tomy or partial resection have been re- ported to be 93,1-99.1% and 99-100%, respectively (645,820,1141], Axilary-node metastases occur infrequently (average, 10%; range, 0-22%) and rarely involve mote than one axilary iymoh nods. Even when patients have axillary metastases from TC, the prognosis is very good and the use of systemic adjuvant therapy and axillary-node dissection are considered unnecessary by some groups [340,428,, 672,780,1071} Cribriform carcinoma Definition ‘An invasive carcinoma with an excellent ‘prognosis that grows in a pattem similar {o that seen in intraductal eribriform car- ‘cinoma; a 50% component of tubular car- ‘cinoma may be admixed. ICD-0 code 8201/3 Epidemiology Invasive eribriform carcinoma (ICC) ac- Counts for 0.3-0.8% of breast carcinomas {795,832 889.1136); however, a frequency Cf upto 4% has been reported in some se- ries 1053, 1508). Mean patient age is 53 158 years {1053, 1317, 1508} Clinical features The tumour may present as a mass which may be radiologically occult, How- ‘ever, on marrmography, ICC typically form a spiculate mass, frequently containing ‘mierocalettications {1003,1317, 1379) Multifocality is observed in 10-20% of ‘cases [889, 1053) ICC is positive for estrogen receptor in al cages and positive for progesterone re: ceptor in 69% of cases (1508), Macroscopy There is no specific mactoscopic feature that distinguishes cribriform carcinoma from invasive carcinoma NST of mixec types. Mean tumour size is 3.1 em (1053) Histopathology Pure ICC consists of an invasive crib form pattern in > 90% of the lesion. The tumour is arranged es invasive, often en. guiated, islands, in which well-defines crtibriform spaces are formed by arches of cells (sieve-lke pattern). Apical snouts ‘are common. Mucin-positive secretion bearing microcaleifications can be pres- ‘ont within lumina (1083,1317,1574}. The tumour cells are small to moderats in size, with a mild or moderate degree of pleo- morphism. Mitoses are rare. A prominent fibroblastic stroma is common; in occa sional cases, osteoclast-tke giant cells of histiocytic origin are found (588.286,1S, gonerally of cribriform ar- is Trequent (80% of cases) lary Iymoh-node metastases 1% of cases |1053}, typically = enten ofthe eroritorm pattern, © carcinoma with a cribrform but associated with a.com. 6) of TC is eso included in ory oF ICC | 1053). Cases with a omponent of another morpho- © (cher than TC) are regarded => of mixed type (1053, 1608} al diagnosis 2 diferentiated from well-cif- ‘euraendoerine tumour and = cystic carcinoma, The former has soplasmic argyrophilic granules, ‘= has a second population of cells 2s well as intracystic secretory and basement membrane-like (e.g, laminin: positive) material (1574}. ICC is distin Quished from cribrform DCIS by the lack of a myoepithelial-cell layer around its in- vasive islands, its haphazard cistribution, and irregular configuration. Carcinomas rich in osteoclast-like giant cells are mostly seen in ICC, but such giant cells, may be seen in other tynes of invasive mammary carcinoma and are not diag- rrostic for ICC. Genetics Both ICC and TC have similar genomic and transcriptomic features (both belong to molecular class “luminal A) and im- Munophenotype (e.g. consistent expres- sion of hormone receptors and lack of HER2 overexpression) and are assoc!- tated with the same family of low-grade precursor lesions (1569), Prognosis and predictive factors As for TC, the outcome for patients with ICC is favourable [376,1083,1508). 10-year overall survival is between 90% (376} and 100% (832, 1053}. The outcome for patients with mixed ICC is less favourable than for patients with the pure form, but better than for invasive carci noma NST {1063}. The biological behav- iour of ICC Is similar to thal of TC (376 however, many tumours have no tubular ‘component and the definition of ICC as a distinct clinico-pathological entity ap- pears to be justified ribriform carcinoma 45,Carcinomas with medullary features Definition Carcinomes with medullary features in- Clude medullary carcinomas (MC), atypical MC, and a subset of invasive carcinomas ‘of no special type (NST). These tumours demonstrate all or some of the following features: a circumscribed or pushing bor der, a syncytial growth patier, cells with high-grade nuclei, and prominent lymph- ‘id infitration, ICD-0 code Medullary carcinoma 510/93 ‘Atypical medullary carcinoma 8513/3 Invasive carcinoma NST with medullary features 50013 Epidemiology Classic MC is rare, representing < 1% of all breast carcinornas, although higher rates have been reported, depending on the stringency of the diagnostic criteria sed. Studies with higher prevalence likely include examples of alypical MC andifor in- vasive carcinomas NST with medullary ‘features. The average age at diagnosis re- ported for patients with these tumours ranges trom 45 to 52 years, but 26% ere Giagnosed at < 35 years {48,299,884,1534) Clinical features ‘These tumours are often well-defined clin- ‘cally and on imaging studios, Macroscopy Tumours in this group ere often wel-c= ccumsenibod, sf to moderately frm. Foci of ‘pecrosis or haemorhage are tequent, lead- ing in some cases to cystic degeneration. Median diameter varies tram 2 to 2.9 om, Histopathology Classically, the following criteria wore Used to define MC | 1082, 1164): syncytial architecture in > 75% a the tunour mass, histological circumscription or pushing margins, lack of tubular differentiation, prominent and aituse lymphoplasmacyric stoma infiltrate, and round tumour cells with abundant cytoplasm and pleomor phic high-grade vesicular nuciel contain- ing one or several nucieal. Mitoses are J. Jaequerier JS. Rais Filho S.R. Lakhani E Rakha Fig, 309 Medular carcinoma A Typicalmedulary carcinoma, > 75% wel-droumscrted, B Typical madullary ‘carénona wit > 75% syoytom. Note heros area ard he proinert eho ates, ‘numerous and atypical giant calls may be ‘observed. The terms “atypical medullary carcinorra’ and “carcinoma with medullary ‘eatures" have been proposed for tumours ‘hat do not fulfil all these criteria. These di- agnostic criteria are diffult to apply, e- sulting in poor interobserver repro. ducibilty. Therefore, we recommend that classic MC, atypical MC and invasive car- cinoma NST with medullary features be grouped within the category of carcino- mas with medullary features, Fig. 340 Nesily crcnara. A Tiica meso excrora Immunoprofie Tumours in this group are most often neg ative for estrogen and progesterone re ceptors (ER and PA) and HER2 (“rigle- negative") and variably express keratins ‘(6 and 14, smooth-muscle actin, EGFR, P-cadherin, p53, and caveotn-1 Immunophenotyping suggests that the lymphoid inflates show a predominance of CD3+ Tlymphocytes and increased levels of CDB+ cytotoxic Tlymphooytes (30,794,1081}, ose comer irae mainartureur cls ad anes Iynptorasnacyc ites. BHstlogral neces C Sync tumur nests accrparie by aburdat rpc ane ama als. Grae Simache carchara ino spec ye itm stoma shows snl hehade nour calserersal diagnosis: Eostein-Barr virus (EBV|-ass0- ‘onoepithelial-tke carcinomas in 2s: share some morphological fea- tumours in this group, only @ e been found ta be associ: in contast to the 31-51% posttvity found among com- 251e carcinoma NST {166}, = proportion of tumours in this « recognized as basal-ike. ‘ability is a common feature 's (126). Most tumours in 9 germline mutations in medullary feaiures {368, However, only about 13% of n carcinomas. harbouring features were confirmed to jermline mutations in a key ‘udy {746}. Somatic muta- {CAT promoter hypermethy- been observed in these zagesting a possible role for development of these tu- 4). The most frequent somatic ‘ed Is mutation of TP53 ogress and prediotive factors sionally considered to be as- relatively favourable prog- sd with grade-matched ‘oma NST. In a cohort of carcinomas, 46 cases of MC “in a double-reading ox- 34); the distant relapse-tree 10 years was significantly C than for the control group of joma NST (94.9% versus 028). However, the low level olty ofa diagnosis of MC has increase in the use of the meduliary-lie features the practice of treating MC, riple-negative carcinomas, ve therapy, invasive carcinomas NST of 1 was demonstrated that the prominent lymoho-piasma- 's associated wih good prog- 35,1147). Independent gene- orotling studies have demon- he expression leve's of im ‘Bain 16. CEGFR. DP-cadhern, on ‘ | Fig. 3.11 Madu careroma, Makers of he basl-tke features nay peal medulary carcinoma. A Kran. Table 3.01 Comparative inmutchisachemia profes of as exessing the given marke) Nien Basa pote (EReneatveHERZnegeve Not evade tis ‘and karat 88-postne gate andlor EGFR poive) ERegaie was PRnogaie Br HeRecenaive 77% Kerain56-poste 548% Pcadnesinpostive 50% petpostve wm iT > 50% 55% Opin oa P-cadhatinpolvaKi > 50% aa HERD-negatvep50-postive 29% 18% 43% 285% 70% 3% 0% TE 2% a0 179% 0% 19% sr 318% 912% 2% 85.2% 2% 20% % mune response genes, in particular a B- Calipiasma-cell metagene, are independent predictors of outcome in ER-negative and ER-positive highly prolilerative breast cancers {1 195). Consistent with these ob- servations, a MC signature was shown to Identity prognostic subgroups of triple- nogativejbasal-ike carcinomas (1247) These results suggest that the relatively good outcome of carcinomas with med- Ulery features may De related to the prom= ‘rent lymphoplasmacytic infitrate.Metaplastic carcinoma Definition Metaplastic carcinoma encompasses a ‘group of neoplasms characterized by dif- ferentiation of the neoplastic epithelium into squamous cells anc/ or mesenchyrral4ook- ing elements (616A, 1851A-D, 1852}, includ- ing but not restictad to spindle, chondkeid, osseous, and rhabdomyoid cells. These neoplasms may be ener ently composed ‘of metaplastic elements, or a complex act midure of carcinoma and metaplastic areas. ICD-0 codes Motaplastic carcinoma 8575/3 Low-grade adenosquamous carcinoma 8570/3 Fibromatosis-1ke metaplastic carcinoma. 8572/3 ‘Squamous cell carcinoma 8070/3 ‘Spindle cell carcinoma 8032/3 Carcinoma with mesenchymal differentiation Chondicid differentiation @571/ ‘Osseous differentiation 857113, (Other types of mesenchymal differentiation 8875/3 Myoepithelial carcinoma 3982/3 ‘Synonyms: Given the multiple histological appear- ances exhibited by metaplastic breast ‘cancers, a plethora of terms have been coined to refer to subgroups of metapias~ tic breast cancers, including carcinosar- coma (837A), sarcomatoid carcinoma 469A}, carcinoma with pseudosarcoma- tous metaplasia {8798}, carcinoma with pseudosarcomatous stroma [659A], spin- die call carcinoma [485A, 18514, spindle ccell metaplastic tumour {485A 499}, ma- ‘producing carcinoma or max produc- ing breast cancer {353818518}, adeno- squamous carcinoma (15944), ow-orade adenosquamous carcinoma (1215A}, squa- mous cell carcinoma {18510}, and fibro- matasislike metaplastic carcinoma or tumour [49,1 119A,1171A,1347), Epidemiology Metaplastic breast carcinomas account for 0.2-5% of al invasive breast cancers |448,679A, 19634, 1569C). The prevalence 4a varies to euch an extent, given the differ- ent definitions adopted by different au- thors, It should be noted that if only tumours with mesenchymal metaplasia are considered, metaplastic breast can- ‘bers account for approximately 19% of in- vasive breast cancers. Clinical features Metaplastic carcinomas present similar clinical features and age distribution to ther estragen-receptor (ER)-negative in- vvasive carcinomas of no special type (NST) (283,616A,679A, 10194, 1552,1569C| Macroscopy The gross appearance of metaplastic car- cinomas is not distinctive, and these tu- mours can elther be well-crcumscribed or show an indistinct or regular border. Cystic degenerative changes are not in- frequent, particularly in metaplastic squa- ‘maus cell carcinoma. In general, meta- plastic carcinomas tend to be relatively large tumours, compared ia invasive car- cinomas NST, with a mean size of 3.9m (range, 1.2 to > 10cm) [105A,283,2624, 100A, 1851A-D, 1852 DS peak ee . US, Reis-Filho SR. Lakhani H. Gobbi N. Sneige: Histopathology Motaplastic carcinomas comprise aheterc- geneous group of tumours. The conser sus of the Working Group was that descriptive classification system shoulo bbe adopted, Low-grade adenosquamous carcinoma Low-grade adenosquemous carcinom show well-developed glandular and tub larformation intimately admixed with sol nests of squamous calls in a spindle-c ‘background, The carcinomatous comp: rent is characterized by small glanduls structures, with rounded rather than a” gulated contours, and solid cords of ep thelial colls, which may contain squamous cells, squamous pearls or squamous cy formation. The invasive neoplastic come: rent typically shows long, slender 0» sions at the periphery and infra between normal breast siructures (35 125A 14034), Clusters of ymphooyte ‘often observed atthe periphery, sometin= ina*cannon bal!” pattern. The associet = between these tumours and adenomyo= thalioma (459A and sclerosing proifere!= lesions {331.4994} has been reportes ae =vatosis-ike metaplastic carcinoma stosis-ike mataplastic tumours ot st are characterized by bland is with a pale eosinophilic cyto and slender nuclei with tapered and finely distributed chromatin =aded in stroma with varying de: llagenization. Nuclear atypiais 2osent. The spindle cells are often in wavy, interlacing fascicles, or fascicles with finger-like exten: rating the adjacent breast cryma, Cords and clusters of plump ‘and more epithelioid cells are ind: not uncommonly, these cells ed in a pattern reminiscent of a s2Uar distribution [317A,499, 499A, 347], Focal squamous cifferenti- ay be found. A gradual transition mp cells to the spindle cell com. requently observed. These tu- almost invariably p63-positive +88, 1171A\; keratins ae invariably din these lesions, occasionally 2nd nat uncommonly restricted ta spindle and epithelioid cells 2770us cell carcinoma 1s cell carcinomas usually pres- cystic lesion, where the cavity is juamous cells with varying de- nuclear atypia and pleomor- he neoplastic cells infiltrate the stroma in the form af sheets, i¢ nests, which elicit a conspiou- mal reaction. Inflammatory infil- ly prominent. The infitrating us elements may vary in degrees crous differentiation, with spindle monly observed at the invasive ne tumour (659A, 15510}. The ylic variant of squamous cell car- characterized by the formation ot 2: spaces lined by alypical squa. 's leading to a pseudoglandular \doangiosarcomatous appear- id be considered as a potential =ntal diagnosis with angiosarcoma *) Metaplastic squamous cell carct y be pure or mixed with coexist- 've carcinoma NST (448,659A, Should be noted thal squamous I can also be found in carci in medullary-lke features (see ¥y carcinoma). For a diagnosis of squamous cell carcinoma af the 0 be rendered, a primary squa:

90% of these cancers are negative for ER, progesterone receptor (PR) and HERZ ‘and express keratins 5/6 and 14, and EGFR. (354A, 568A, 56BC, 11694, 1170A, 1347 114644). The identification of epithelia at- ferentiation in metaplastic breast carcino- mas requires the use of more than one2 —————E—eEaEws hemical marker. Usual mark- molecular-weight keratins, in seta 12, keratins 5/6 and 14, */AE3; low-molecular-weight ker- mmonly negative [184,366]. It noted that the expression of ften variable, and not uncom 63, which is expressed in etaplastic breast carcinomas, 27 :0 be a useful marker for the ation of these tumours and for entiation with other spindle anc ymal malignancies (233,707, ). Markers useful for difler- plastic broast cancers from tumours with sarcomatous include keratins, p63, CD34 keraling and p63 are negative 35 tumours and positive in © breast cancers, and CD34 2 show the opposite distribution le cell lesion, unequivocal ©» of high-molecular-weight ker- or P63in any proportion of calls, a diagnosis of metaplastic Adequate sampling of the le- ongly advised. 2y-based geno-expression profl- ‘onstrated that metaplastic mours are preferentially classi- of basallike subtype (1569, rdependent studies, however, ogested that a subgroup of these particular those with spindle aolasia, display transcriptomic ‘onsistent with those of cells un- plthelia-to-mesenchymal tran- down-regulation of genes ound in epithelial calls and overex- genes usually found in fibro ANtaplasc canna wih mesenchymal ferentiation (ratiacrodu blasts) (5688 806A, 1122, 15698}, and can be classified into a recently described molecular sublype named claucin-low, Claudin-low tumours are reported to be enriched in cells with epitholial-to-mes- ‘enchymal features and in the so-called canoer stem cells {1122} Genetic analysis of metaplastic breast cancers has been performed in a limited number of samples and only in pat sub- stratified according to histological type. These tumours, as a group, have complex genomes, characterized by complex pat tems of gene copy-number gains and losses, similar to those found in other types of riple-negative and basal-like breast cancers {4858, 485C, 5688, 11704), Mutations of the tumour suppressor gene P53 are found in the vast majority of these cancers [808B}. Loss of COKNZA (p16) and PTEN are found in subgroups of the cisease {S68B,951A}. Recurrent ‘mutations of PIKSCA |S68B, 951A) and of genes pertaining to the Wnt pathway {559A} have been reported in metaplas: tic breast cancers, Importantly, the high prevalence of CTNNBY mutations rep: crted in one study (.0. 26% of cases) Fig. 249 Nelapetc spina cl earonams. A Two aggagte of eacnama are sepa by reoplase pnl cals B immunestaring shows absonn of eat wh 2 pan keratin enody cocks ha mesenchymal meer, wile ‘hoopla cls are pesve. Bom (858A) was not validated in subsequent independent analyses {5688,738). Amoi. fication and high polysomy of the EGFR gene have been reported in 10-25% of metaplastic breast cancers (489A, 168A, 111704), and are more prevalent in tumours with squamous and/ or spindle cell ele ‘ments (11694) Genomic characterization of the different elements from metaplastic breast cancers performed to date has revealed that the histologically distinct components are clonally related in the vast majority of cases [485C, 14964]; however, specific, genetic aberrations may be restricted to specific components within a cancer, Prognosis and predictive factors Lymph-node metastases are significantly less frequent found in metaplastic breast cancers than in invasive carcinomas NST Of similar size and grade {233.3174 409A, B6BA,616A, 10194, 111 1A, 1581A-D, 1552, In @ way akin to other triple-negative breast cancers, distant metastases can be found in the absence of lymph-node metastases, and preferentially affect brain, andlungs. A present there areno validated areniaton Typically, these carcramas have a weldenated pushing marin. Ares of essecus andlor hana dlerenito are variably scared nan cherwse 2s canara tro special ype (NST). The aderecarinma admixed, pat wi chodrid mat cating lacuna paons ane rare choy. Metaplastic carcinoma 1prognostic markers for metaplastic carci. romas. Although specific subtypes have bean associated with a better or worse prognos's, the retrospective design of the studies, the consultation nature of the samples included, and differences in def- intions of the lesions studied do not lead todefinitive conclusions with regard to the prognostic information that can be derived from the presence of specific metaplastic ‘elemenis. Importantly, there is evidence to suggest that, 2s @ group, metaplastic breast cancers have lower response rates to conventional adjuvant chemotherapy and a worse clinical outcome than those of other forms of triplo-negative breast car cers [588A-C,870A, 836A\. It should ba noted, however, that there is evidence trom independent studies to suggest that low- grade fibromatosis-Ike tumoursicarcino- mas end low-grade adenosquamous carcinomas may have a better clinical out- ‘come than other types of motaplastic breast cancer 499,11 134, 12154, 14934. The prognostic value of histological grad- ing of metaplastic breast carcinomas is uncertain. 52 Special subtypes Fe.s2t = oP ‘Mod metals caronoma wth spiel, mesunchynal (honda squamous ferent.s\ve carcinoma in which the cells fological features of apocrine O code mmours are coded according to ry invasive type. cology ecocrine differentiation is a com- - ur9 in invasive carcinomas of no 2¢ (NST) as well as some spo- However, extensive apocrine nis seen in approximately 4% east carcinomas (396, 124 ‘features ‘as with apocrine differentiation a nguishable clinically and radio- < om those without apocrine fea- PY NST and in special-type car- cluding tubular, lobular, micro- nd medullary) (3,396,398), + cifferentiation is also seen in shows cals wih abundant cary cplasm type 8 cl) Carcinomas with apocrine differentiation lobular carcinoma in situ and ductal car cinoma in situ {258,292,390,768). The constituent cels have enlarged nuclei with prominent nucleoli anc ether abun: dant granular, eosinophiic cytoplasm that shows diastase-resisiant_periodic-acid— Schiff (PAS) posivy('yoe A cals), or abun- dant foamy cytoplasm (type B cells), ora combination of both. intracytoplasmic lipid has also been demonstrated in tu- mours with apocrine differentiation (388, 947} Immunoprofite Areas ofthe tumour wih apoctine difer entation are typically BCL2-negative and GCOFP-15-posive although GCDFP-15 expression may be lost in advanced- stage tumours (519A). Staining for esto gen and progesterone receptors (ER and FR) is usually negative, but a novel isoform of ER (ER-alphasé) has recently been shown to be frequently overexpressed {1822}. Tumours that show androgen re- ccoptor positivity, in combination with ER and PR negativity and HER2 positivity overwhelminaly demonstrate apocrine features histologically (132,998, 1387). It 's likely that this immunophenotype iden- tes tumours that have tne distinct “apoc- rine molecular signature,” as discussed below. F O'Malley . Eusebi SR. Lakhani Differential dlagnosis ‘Tumours composed entirely of type A calls may be confused with a granular cell tumour and those in which type B cells predominate may resemble an inflarnma- {ory reaction or a histiocytic proliferation {395}; antibooies to keratin can aid ciag- rosie in such cases ( 1416}, Genetics ‘Comparative genomic hybridization (CGH) has revealed copy-number changes in carcinomas with apocrine differentiation, with chromosomal gains of 1p, 1q and 2g and losses of 1p, 124, 16q, 17a and 22g |657A|. These are common regions Of allerations for breast carcinamas in general. An “apocrine molecular signa- ture," identified by gone-expression array analysis, is characterized by in. creased androgen signalling and signit- leant overlap with the "HER2 group,” as detined by microarray studies (422, 1090, 1356, 1957]. should be noted that the molecular apocrine subtype as de- fined by gene-expression array analysis, is nat equivalent to apocrine differentia- tion in breast cancer. Approximatoly halt of carcinomas with apocrine differentiation show this molecular signature, including ‘most pleomorphic lobular carcinomas with apocrine features (396). However, overall, ‘carcinomas with apocrine differentiationdo nat form a distinct cluster and are composed of "apocrine" and “luminal” molecular subtypes {1569}. Hence the deia suggest that apocrine differentia. ‘ion is a common feature of many sub- types of breast cancer, and that apocrine carcinomas” do not represent a distinct entity 54 Special subtypes Prognosis and predictive factors Some studies have shown that carcino- mas with apocrine ifferentiation have the same cinical outcome as invasive carci rnomas NST, when matched for grace and stage (3,301), although one preliminary study suggests belle prognosis (642). An in slico analysis using microarray-derived readings of two sets of prognostic genes, showed that carcinomas with apocrine dif: ferentiation clustering with the “molecular apocrine signature" had a high 21-gene Feourrence score and @ poor 70-gene prognosis signature, suggesting worse ‘prognosis {1869}. The androgen signaling associated with these tumours may lead) to the development of new therapeutic ‘modalities for these tumours in the future,Salivary gland/skin adnexal type tumours Detention ‘oma and clear cell hidradenoma ©) of the breast show features similar '20us hormonymous neoplasms of 8200/0 840210 = also known as nodular hidrade- or eccrine acrospiroma, SSceriology + breast cylindroma (26,502, 1547] CHs are extremely rare (351,438, Bath occur in adult to elderly cal features cyindromas may be associated ular and invasive carcinoma NST 9 gccasionally occur in patients with Brooke-Spiegler syndrome (1011, 1547). CCHs are circumscribec tumours often found in the suiareolar area, with- ‘out connection to the overiying skin Macroscopy Cylindromas are well-circumscribed, non encapsulated tumours (usually < 2 cm), CCHs are sharply demarcated from the surrounding areas and show an indistinct lobulated architecture protruding into cys- tic spaces filed by clear mucous substance ‘without haemorthage (35 1,438,681, 1025), Histopathology Gylindromas are composed of multiple variously shaped and sized epithelial ob- ules arranged in a jigsaw puzzle simulat- ing a pseudainfitrative pattern. Occas- ional sebaceous-cell differentiation may be found (26). Homogeneous eosinophilic hyaline periodic-acic-Schiff (PAS) positive extracellular matrix surrounds most of the lobules and round masses of similar mein maious (adsnosquamous) carcinor (1200), which suggests @ close relation ship between these combined epithe! ‘and myoepithelial tumours, A third type of cells that have sebaceous diferentiation can be rarely identi: {11418}, but hese elements can oocasio ally be numerous (1416). ACC is generally negaiive for estro and progesterone receptors (ER and PF and HER? (82,293, 1261, 1569). Recent {novel 36 kDa isoform of the fullleng: ER (ER-alpha36) has been detected ‘ACC {1583}. Overexpression of EGFR nes bean shown in 65% of cases (1531), Ditierentia diagnosis ‘ACC must be distinguished from collage ‘nous spherulosis (273) and from invasive cibriform carcinoma (892) that shows.a¢es lined by a single cell type positive [1416]. A solic variant of » asaloid features is distinguished cel carcinama, solid papilary 2 oF metaplastic carcinoma on ne presence of intercalated ducts rohistochemistry [1310}. gland ACCs, breast ACCS ne recurrent chremasomal translo- \(q22-23)023-24), which gen- on transcripts involving the sem YE and NFIB [1082} in > 90% of == Somatic mutations of PIK3CA and ‘been shown in one primary its renal metastasis (1530), Seapess and predictive factors === = 2 ov-grade malignant tumour that red by simple mastectomy. 10} performed tumour grad- - ng to the eriteria accepted for ACC and suggested that ied as grade 3 (solid growth y have a higher rate of metas- urrence. This result has not mad by othar studies (700, © is analogue in the salivary ACC rarely spreads via the Rey Beige a lymphatic system and rarely involves re- gional lymph nodes and most cases are associated with excellent survival (486) ‘The solid variant of ACC with basaloid features may have a greater propensity tor axillary metastasis than conventional ACC {1310} lactin isiccarenama, A The unos composed of2 cl pes, domirant asad and ew eosinaphi cal, Theres nest in tis tutu whchisan uncom 2. Bin hiscase, her is a predominant uo achitcte. Local recurrences related to incomplete excision, but pationts have been reported to survive 16 years after the excision of the recurrent tumour {1095}. The reported S-year and 10-year survival rates for pa- tients with breast ACC are > 95% and 90%, respectively (877). E oD ha ‘arcinoma BTMucoepidermoid carcinoma Definition ‘A primary breast carcinoma that is histo~ logically similar to its counterpart in the salivary gland, and that concomitantly shows basalcid, intermediate, epidermoid and mucinous cells. ICD-0 code Epidemiology Mucoepidermoid carcinomas (MEC) are very rare tumours of the breast. The esti- mated incidence is approximately 0.3% of all breast cancers [448 e4g0'3 Clinical features Cinically, MECs are similar to invesive ‘carcinomas of no special ype (NST). Nip- pple discharge can be the first syinpiom of MEC located in the retro-areolar region (338) Macroscopy Tumour size ranges from 0.5 to 15¢m, Low-grade MECs are well-circumseribed, sontetimes containing mucoid cysts, Histopathology MECs of the breast are comparable to ‘those of the salivary gland. Central nests Cf “epidermoid or mucus-secreting” cells and cysts that are positive for keratin 7 and 16 are lined by "basaloid” cells that ate positive for keratin 14 and “intermedi ate" cells that are positive for keratin 5/6 and p63 (398, 1104}. Intermediate celis may express EGFR {998}. Most MECs in the breast are of low grade with a preva lence of mucus calls (218). High-grade MECs are rere, generally sold, and contain Dimmunstaining for kertin 1 indicates besa cals predominantly intermediate and squamous cells (549,559,719,783}, An intraductal ‘component may be present {218,332). Hormone-receptor status was negative in the three cases studied (559,598) Dierential. MEC must be differentiated from invasive carcinoma NST with squamous-cell dif- ferentiation. True Keratinization with tor- mation of squamous peerls should exclude MEC and favour the olagnosis of metaplastic carcinoma with squamous difforentiation (459), Fig 328 Mucous cra HED). Law pa WEC. BCs ln-gade HEC. C Wah gode MEC A. Sapino N. Sneige V. Euseb Genetics In one case of breast MEC, partial dele tion of 11421 (MAML2) has been de soribed {216} Prognosis and predictive factors: ‘Accurate grading is important for prog- nosis {338). All reported patients with low- grade MEC have been disease-free in the follow-up period, whereas high-grade ‘MECs show usually aggressive behaviou: with metastasis to axilary nodes and dis tant organs (338)Polymorphous carcinoma Cation fs » histological features similar red to as “palymorphous areinoma” in salivary glands 8525/9 idence of polymorphous car net known as ithas been rec- ery recently and studies on aie lacking, Only tree cases reported to date |76) ‘Dinca features = 16 ranges from 37 to 74 years ecroscopy “erphous carcinoma in the breast nodules ranging in size from exoathology gy to polymorphous carcinoma of vary glands {1104}, polymor- Sees carcinoma of the breast displays 2st, surrounded at the periphery © scolar, cribrform and trabecular a8 ale-fle patterns, which simulate = ©-28ve lobuler carcinoma, In contrast oid cystic carcinomas, polymor- carcinoma is constituted by a sin- 128, which shows round to ovoid and numerous rritoses. The neo- lis stain strongly for BCL2 ant == =ntly immunoreactive for keratin 7 ‘A, Sapino, N. Sneige V. Eusebi Fig, 229 Paymrphous cocoa wir veda and sngle-cal pan and E-cadherin. Staining for epithelial ‘membrane antigen, estrogen receptor, progesterone receptor, keratin 14, actin, HER? and CD117 is consistently negative (758), Genetics ‘There are no available data on the genetic, features of these lesions, Prognosis and predictive factors (One case out of the three described in the literature showed aggressive behaviour, with the patient dying of widespread dis ease 3 years after diagnosis. All cases were of grade 2 and large size at the mo- ‘ment of diagnosis. It thus seems that the biological behaviour and morphological features of polymorphous carcinoma are those of a high-grade carcinoma and the form “low grade” as used for polymor- hous carcinoma of salivary glands does ol seem to be appropriate to tumours seen in the breast. Six cases of polyrnor phous carcinoma ofthe skin with aggres- sive behaviour were reported |1385) as “polymorahous sweat gland carcinoma’, a name that was adopied for polymor phous carcinoma af the breast for the same reason |76},Mucinous carcinoma and carcinomas with signet-ring-cell differentiation Mucinous carcinoma Definition ‘Mucinous carcinoma is characterized by clusters of generally small and uniform cells floating in large amounts of extra- cellular mucin. ICD-0 code 2480/8 ‘Synonyms Colloid carcinoma; mucoid carcinoma; gol- salinous carcinoma; mucinous adenocarc- roma, Epidemiology Pure mucinous carcinoma accounts for about 2% of all roast carcinomas [337, 1187, 1290). It often oceurs in patients aged > 55 years (104), Clinical features Mammography of mucinous carcinoma, simulates a benign process; magnetic resonance imaging (MA) shows a typical dyramic enhancement pattern {1603} Sonographicaly, airost all tumours are hypoechoic [821}, Macroscopy {Gross examination shows @ glistening gel- atinous lesion with pushing margins and a soft consistency that is readily recog- rizable. The tumours range in size from < 1.0m to > 20 om (104) Ba Fig. 331 Mucnouscarnoma, A Hypecallar vata with lage dusters of dersely packed malgnant cals, ‘th pure mucous carcinoma ino longer exceed wn it adixed wth og evasive crcroma NST. Histopathology Mucinous carcinoma is characterized oy nests of cells floating in lakes of mucin parlitioned by delicate fibrous septae Containing capillary blood vessels. The cell clusters ere variable in size and shape; sometimes with a tubular arrange- ment. Nuclear atypia is generally low in Classic mucinous carcinoma, but in rare cases atypia and mitoses may prevail (1407). A micropapilary or eribniform in traepithelial component is rarely seen [1407]. Mucinous carcinoma presenting B Hypocllrvaian. Late of mucus are spared by feu Sopae Afow sates or cst of arcom calls re oaing in the mca kes. 60 jal su G. Bussolal 5 A Sapino ; > a os = = = > - = = = with large cell oustrs,eperted by Cape {219} as ryperceluiar or ype B mucinc.= carcinoma, shows frequent neuroenc= Me ctine difierertiation, 2s demonstrated > ‘expression of chromogranin and sy! tophysin (1187,1259}. Type A mucino. ‘carcinoma with larger quantilies of e3°"= cellular mucin represents the “class on-endocrine variety. Pure and) mix= variants have beon described (712,147 1443). The most common admixture = with invasive carcinoma of no sp type (NST). A pure tumour must be posed of > 90% mucinous carcine (1407 Differential diagnosis ‘The main challenge on core biopsy is differential diagnosis of mucinous ca" noma with mucocosle-like-lesion (ML. with extravasated mucin {113}. The o fence of ducts distended by mucin material and of myoepithelial cells adr ing to the strips of cells floating in lakes of mucin serve as important ol to differentiate benign MLL (1407 mucinous carcinoma. However, se’ studies have described MLL assoo\2'=cluctal hyperplasia or ductal 9 stu (OCIS) 1689, 1564), sug- 2: MLL and mucinous carci represent two ends of the al spectrum of mucinous lo- = breast (113) ;cinous carcinoma is positive nd progesterone receptors ) (104), while androgen ro- expressed at a low level HER@ is not amplified (738) mixed mucinous carcinomas to express WT! (349). mic studies have demon- 3t mucinous tumours are of lu: olaoular subtype {1569}, and cvonaly distinet from grade- and sublype-matched invasive car {1567}. The transcriptomic mucinous A ate distint from ucinous B tumours, the latter sattern of gene expression that ‘at of neuroendocrine carci 67). The Lacrols-Tiki group (own that pure mucinous car- arbour alow level of genetic in- rare recurrent amplifications, © genomic profiles of the dif- our componionts of mixed mu- ‘ours are remarkably similar to mucinous eaneers. CP. tas fons wih srling el fereniaton Th nese cas assur or gromh Sat and dertineefopasne mh, eforing a serengceltoesrnce ne cas Prognosis and predictive factors Pure mucinous carcinomas are generally associated with low rates of local and! dis- tant recurrence and excellent 6-year dis. ease-free survival rales (104,337,340, 1832). The 10-year overall survival ranges from 80% (712) to 100% |431). Mixed mu- cinous carcinomas have a far worse prog- osis and higher incidence of lymph. node metastasos than do pure mucinous carcinomas {7 12,1012}. Late distant metas- tases may occur in pure mucinous carc noma {1157,1443), Carcinomas with signet-ring-cell differentiation Definition Carcinomas with signet-ring-cell differ- ‘entiation are characterized by abundant intracellular mucin that pushes the nu ‘claus to one side, creating the charac- teristic signet-ring-cell marpholagy, 10D-0 code These tumours are codled according to the primary invasive type. Epidemiology Primary breast carcinomas compased Predominantly or exclusively of signet ‘ing cells are rare; focal signet-ring-cell differentiation is seen mare commonly. Clinical features No specttic clinical features have been described, Macroscopy There are no specific macroscopic fea: tures. Histopathology Prominent signet-ring-cell differentiation is most common in invasive lobular car- ccinomas but may also be seen in inva- sive carcinoma NST and other special- type cancers. As such, carcinomas with signet-ring-cell dferentation do not rep- resent a distinct entity, Two cytological types of carcinomas with signet-ring-call cifferentiation have been described in the breast. One type is characterized by large intracytoplasmic vacuoles, with & target” appearance owing to the pres- ence of large intracytoplasmic lumina ‘containing a periodie acid-Schit (PASWA\- clan blue and HMFG2-positive central globule {679,915}. This cytological pat- tern is observed in lobular neoplasia (412, 1258), in classic invasive lobular car cinoma and it has also beon associated with the pleomorphic variant of lobular carcinoma (258). The other cytological ‘ype is similar to the cells of diffuse gastric Carcinoma, and is characterized by acidic ‘muco-substances that ifusely fl tre cyto: plasm and disladge the nucleus to one ole of the cell. This tyne of signet-ring cell may populate DCIS. Primary carcinomas of the breast with signet-ring-cell differentiation have to be distinguished from metastases to the breast of signet ring cell carcinomas from other organs, particularly from the stom- ach. Hormone receptors (ER and PR) and, GCDFP-15 are frequently expressed in breast carcinomas with signet-ring-cell aiflerentition; lack of staining for all three. favours a primary gastric carcinoma 11014) Genetics There are no available data on the genetic features of these tumours, Prognosis and precictive factors The prognostic significance of tumours with prominent signet-ring-cellciferentia~ tion is uncertain,Carcinomas with neuroendocrine features Datinition Carcinomas with neuroendocrine diferen- tiation exhibit morphological features sim- liar to those of neuroendocrine tumours of the gastrointestinal tract and of the lung, ‘Alltumours express neuroendocrine mark- fers to a greater or a lesser degree. Other invasive breast carcinomas of no special type (NST), and some special variants, may show neuroendocrine diferentiation. ICD-0 code Neuroendocrine tumour, wel-ciferentiated Neuroendocrine carcinoma, poorly diferentiatedismall cel carcinoma. 8044/3 8286/3 Invasive breast carcinoma with neuroendocrine diferentiation 8574/3 ‘Synonyms Endocrine carcinoma; carcinoid tumour of the breast Epidemiology Carcinomas with neuroendocrine differ- entiation represent < 1% of breast carck nomas. Most patients are in the sixth or seventh decades of ife (1259). However, since neuroendocrine markers are not rou tinely used on lreast tumours with solid alveolar and nested patterns of growth, the true incidence is dificult to assess, Fig. 3.3 Newoendocina unour of thbreast. ATunour peste for tramograni, 62 Special Neutaendocrine differentiation as deter- mined by histochemical and immunobisio- ‘chemical analysis occurs more frequently (up 100%) ininvasive carcinoma NST and ther special types, particularly mucinous carcinomas. Clinical features There are no notable or specific differ- ‘ences in presentation from other tumour ‘types. Clinical syndromes related to hor- mone production are extremely rare. Serological tests may detect circulating neuroendocrine markers such as chro- mogranin A. Macroscopy Neuroendocrine breast carcinomas can {grow as infiltrating or expansite tumours, The consistency of tumours with mucin production is soft and gelatinous. Histopathology ‘Neuroendocrine tumour, welkiferentiated ‘These tumours consist of densely cellular, solid nests end trabeculae of cells that vary from spindle to plasmacytoid and large clear cells 1260} separated by del- icate fibrovascular stroma. Tho classic features of carcinoid tumours of the gas- trointestinal tract or lung, i.e. ribbons, cords and rosettes, are not features of ca ina some cls show eosaghe anus (caceld tka patie). B lrmunosi G. Bussolati S.Bauve Neuroendocrine carcinomas of the brea’ ‘The majority are of low or intermediat= grade [1259], Neuroendocrine carcinoma, poorly aif entiated/small cell carcinoma ‘This carcinoma is morphologically ind's tinguishable from its counterpart in lung on the basis of histological and in- munohistochemical features (1308). T tumours are composed of dense packed hyperchromatic cells with cytoplasm and display an infirati= growth pattern. Large numbers of mi figures and focal areas of necrosis present {1250}, An in situ component the same cytological features may be c= tected. Lymphatic tumour emboli are * quently encountered. Invasive breast carcinoma with neuroe~ doerine differentiation Neuroendocrine differentiation as det rmined by histochemical and immuncn Jochemical analysis occurs more freque™ (up to 30%) in invasive carcinoma Nv and other special lypes, particulary > cinous carcinomas. Mucinous care mas, hyperceliular variant, repr approximately one quarter of mamm ‘aarcinamas with neuroendocrine difier= tiation (1259), are almost invariably of ox (grade [1004). Solid papillary carcinam= om ie'er7) frequently show neuroen- entiation in both in situ and components. “Dien! diagnosis = mary mammary carcinoma with ing fealures is rare, metasta- ‘entiated neuroendocrine tu- noid) and poory differentiated ing carcinoma/small cell hould be excluded before 2 dstinite diagnosis (391). The of ductal carcinoma in situ » similar cytological features is origin in the breast. SD fle # chromogranin proteins and) vysin is the characteristic fea- nomas with neuroendocrine 9. About 80% of law- or inter- de neuroendocrine tumours jegranin and only 16% ex: ‘ophysin [1259). A monaclonal 0 neurone-specitic enolase also been used and is ex- 20% of poorly differentiated ‘nomas of the breast | 1308), ‘omogranin A and synapto- coreesed in about 50% of 5 progesterone receptors (ER ‘expressed in the majority of no woll-cifferentiated tumours. of poorly differentiated cnomas. metre of dense core granules, -retory nature is confirmed Fig. 324 Neu ‘danse colageneus soma, by ultrastructural immunolocalization of ‘chromogranin A have been identified by ‘electron microscopy in carcinomas with neuroendocrine differentiation (220). The presonce of clear vesicles of presynaptic. type is correlated with the expression of synaptophysin, Both dense core granules land mucin vacuoles are present in neu- roendocrine mucinous carcinomas (61 1]. Genetics The only relevant gene-exoression stud- ies have used genome-wide oligonucieo- tide microanalysis and demonstrated that solid papillary and mucinous carcinomas exhibiting neuroendocrine differentiation a aage of the breast fall within the luminal A sub- group. No transcriptomic differences were detecled between the subtypes of these tumours {1867) Prognosis and prodictive factors Histological grading and staging are im- portant prognostic parameters. However no specific guidelines exist for grading carcinomas with neuroendocrine differen tiation and grading is probably not clini- cally significant. ndoctine features 69Invasive papillary carcinoma Definition An invasive papillary carcinoma Is an in- vvasive adenocarcinoma which has a pro- dominantly papillary morphology (> 90%) in the invasive component, Invasive non- papillary carcinoma associated with en- capsulatec papillary carcinoma and solid Papillary carcinoma should not be classi- ‘ed as invasive papillary carcinoma, but categorized according to the individual invasive component. AS a consequence, true invasive papillary carcinomas aro rar9, Papillary metastases from other pri- mary sites should therefore be consid- ered in the differential diagnosis, ICD-0 code 8503/3 Epidemiology AS this rare group of tumours has not ‘been well-defined in the past, there are currently no specific epidemiological data available, Clinical features True invasive papilary carcinomas have no spectic or known clinical characteristics, Macroscopy ‘There ere no spectic macroscopic features, Histopathology {As these lesions are extremely rare, his- ‘ological characteristics are not well-doc- umented. Invasive elements harbour a papillary architecture with papiliae formed ‘by malignant epithelial cells intimately re- lated to fine fibrovascular cores. These tu- ours have a permeative front, Gonetios ‘There are no available data on the genetic features of these tumours, Ditierentia dlagnosis ‘The main differential diagnosis is a papil lary metastasis originating fram another organ site, particularly ovary or lung. ‘These tumours should be distinguished from invasive carcinoma arising in con- 64 —_Spevitl subtypes Bar Gee T Moriya Nu é Fig. 3235 Invasive papa carcroma showing cows pally stucues Ines by maigran els, Tho nwasie junction with encapsulated and sold pap- ‘ary carcinoma (see Chapter 7). Prognosis and predictive factors Survival data are scanty. Prognosis is = lated to grade and stage of the tumour WAAGHY JARTACEVAO TENE FO On duke eee COP ha2 composed of small, hollow worse clusters of cancer cells, clear stromal spaces. The ‘ characteristically display arity, also known as an “in- 2rowth pattern, whereby the api- Is faces the stroma and 2! surface. 50713 carcinoma llary carcinomas are rare, 2 for approximately 0.9-2% of t cancers {527,1076,1835), {areas with & micropapll- und in Up t0 7.4% oF all in cancers (529, 1544, 1622), 298 at presentation of patients ‘mixed micronapillary carc sistent with that of patients “receptor positive (ER-posi- carcinoma of no special type 37, 1935, 1544). Single case vasive micropapillary carcino- are on recard 18, 384} Doce! features Ss: majority of micropepillary carci- sent as a palpable mass. Mam- usually reveals a dense, =-= mass with indistinct margins and ications, By ultrasound analy- apillary carcinomas are prefer ==) *ypoechoic but occasionally homogeneously hypoechoic, microlabulated masses with or === posterior acoustic shadowing (18, 5) ecescopy = micropapilary carcinomas ap- ‘have any specitic features on analysts “sxxoathology cillary carcinomas are character- ne presence of hollow or morula sive micropapillary carcinoma JS Reis-Filho LO. Elis Fig.237 lavas mzcpailayctcnoma. Tumour cel cists wih ireuat cel spaces oleae wn empty storal spaces. Some cisters have versa polar wth an “ideo morpoog, like aggregates of cuboidal-to-colurnar neoplastic cells devoid of fibrovascular cores, surrounded by empty stromal spaces, which at fist glance confer an ap- pearance reminiscent of that of lympho- vascular invasion. The empty stromal spaces, although resembling dilated Iym- phate channels, have been shown not to be nod by endothelial cells, and may po- tentially constitute a fixation artefact. Cyto- logically, the cytoplasm eosinophilic, and either dense or finaly granular; in some ‘cases, overt apocrine features can be identified. Nuclear pleomorphism is vari able, but rarely pronounced. Mitotic ac- tivity ranges. from low to moderate Necrosis and brisk Iymphocytc infiltrate are rare findings Characteristcally the neoplestc cells of mictopapillary carcinomas cisplay a re- verse polarity (Le. “inside-out” pattern), ‘whereby tho apical pole of neoplastic calls faces the emoly stromal spaces, rather than the hollowed central aspects Of the tumour cell aggregates, Tnis pal- tem can be easly appreciated by immuno histochemical analysis with MUC1 enti- bodies, end is useful for disingushing bo- ween invasive micropapillay carcinornas ‘and artefactval stromal retraction in an inva sive carcinoma NST. Up to 75% of invasive rmicropapillary carcinomas are of Notting- ham histological grades 2 or 3 (529,819, £837,875,876,923, 1076,1009,1335,1453, 1644), ‘The vast majority of micropapillary carci- nomas are ER-positive (61-100%) and progesterone receptor-positive (PR-posi- tive) (46-83%) {793,897,898,875,876, 1076,1453,1844, 1603}; however, in other series a lower prevalence of hormone-re- ceptor expression has been described (25-22% for ER, and 13-20% for PR) {923,1099}. Conflicting results on HER2 expression in micropapilary carcinomas have also been reported; while in some studies, up to 100% of micropapilary car cinomas displayed HER? “overexpres- sion” {923,1099,1499}, more recent studies adopting current criteria for HER2 over- expression documented HER? positivity in < 10% to 35% of cases (733,838,875, 876,1603}. In addition, HERZ mRNA over- expression and HEA2 gene amplification appear to be less frequent (10-30% of ‘cases) 875,876, 1569}. pilary carcinoma 65:ay SS a eee Bey Fi 338 eco ize carama AN te pnb eszrio an asin icra witn te cent ses, Byepode nls, Pos sarin forepiilal membrane aniga on he pephera cel membranes i suggestive ofa “inside-out marplogy. Genetics Consistent with the high prevalence of ER, exoression, microarray gene-expression profiling of invasive micropapillary carci- homas has revealed that these tumours are classified as of luminal A or B subtype [1569], Expression of "basal" markers is, vanishingly rare (693,875,876, 1569). Micro- artay-based comparative genornic hybrid- ization analyses have demonstrated that these tumours display recurrent gains of cchramasome 80, 179 and 20q and dele- tions of chromosomes 6q and 13q 66 Special subtypes {875,1438); Infact, pure and mixed inva~ sive’ micropepilary carcinomas have ‘econ shown to be characterized by a repertoire of gene copy-number aberra- tions distinct from that of grade- and ER- ‘matched invasive carcinomas NST (808, '875,876}. Interesting, inrmixed micro-pap- lary carcinomas, the non-mieropapilary component displays genetic aberrations re- ‘marketbly siilar to those found inthe micro- papillary areas (875,876). In a small series, of invasive micro-napillary carcinomas, re- current amplifications of MYC, CCND1 and FGFRt were found in 33%, 8% ar 17% of the tumours, respectively (876) Prognosis and predictive factors Micropapillary carcinomas significen’y ‘more frequently present with iympho-vss- ‘cular invasion and lymph-node metastes= at diagnosis than do invasive carcinor: NST (693,€02,967, 1614}. H remains to be determined whether micropapillary phenotype is an. in: pendent prognostic factor.carcinoma is a rare but very ‘orm of breast carcinoma with = | andjor pathological erite- clinical inflammatory symp- the presence of numerous emboli, that alone define ammatory breast carcinoma 8530/3, ands increasing, There are ‘cial disparities since inci- S= 5 highest in African-American 3 awest in Asians and Paoitic. Sarees (545.1192). The reported fre: “flammatory breast carcinama 4% and 10%, according to = Se3ostec criteria used to define this m= (375,545]. Inflammatory breast 2 shows a prominent geographic common in north Attica, in- aypt and Tunisia) (177,245, calnsopnenotpal ears of lana cara, AP = C Absence ofestogen-ecoptor exyessenin tour cel, secels|FStong and csp memtraros sling fr HERZ. ‘nflammatory carcinoma 1949), At present, there are few estab- lished risk factors for inflammatory broast carcinoma, but a high body-mass index, ‘anda younger age at disease onset have been suggested in Airican-Americans (1192) Clinical features The clinical inflammatory symptoms are rapid breast enlargement and changes in the overtying skin (redness, oedema, “or ‘ange-peel” skin) often without a discrete palpable mass {1192 Diffuse firmness of the breast is common. They involve more than one third ofthe breast. Palpable, firm ipsilateral, axillary nodes are common findings. Inflammatory carcinoma is rec- ognized as Tad carcinoma of the breast for staging purposes. Macroscopy Usually there is no clinically discrete ‘mass; biopsies of the tumour are facli- tated by ciagnostic imaging. When a gen- eralized increase in breast density is the only imaging finding, random needle egnoori drm patent. B Stang mentxanous staining for cadherin he intamphate gh peat index nro nu (57 sang). lense nd fuse MUC' string jonas E, CharafeJautfrot H Teuda E. Rutgers biopsies are otten diagnostic. Nipple in- volvement is not a diagnostically defining Glinical feature, but flattening, retraction and crusting may be frequent, Histopathology The pathognomonic feature is the pres ence of numerous dermal lymphatic em- boli in the skin overiying the breast. Tho ‘emboli may not always be found in small punch biopsies, 80 the absence of der mal lymphatic invasion doas not exclude the diagnosis. The emboli cause dermal lymphatic obstruction and subsequent ‘oedema, but are not associated with any significant degree of inflammatory cell in- filtration. The underlying invasive carci- noma is often of no sneciel type (NST), and grade 3. inflammatory breast carci: tomas are highly angiogenic, iymph- angiogenic and vasculogeni (27,896, 1912) Immunoprotite The immunoprofie reflects the aggressive nature of these tumours: inflammatorybreast carcinoma often lacks hormone re- ceptors (up to 50% of cases), overex: presses HER2 (about 40%) and, less frequently, EGFR {523.1487} and highly ‘expresses 83 and sialomucin MUC1 (44,1487). E-cadherin overexpression is a hallmark of inflammatory breast care noma and sustains the cohesion of tu- moral clumps forming emboli {37,701} Differential agnosis Clinical features can be confused with in- fection (mastitis or abscess), other tu- mours with skin changes, and locally ‘advanced breast cancers, which can all be excluded on the basis of morphology cal and immunchistochemical findings (246,523, 1494) Genetics There is no genetic hallmark of inflamma- tory breast carcinoma, but HERZ amplif- cation and TP63 mutations are common [823,1472,1494), Molecular subtyping often classifies this carcinoma within the HERZ or basal subtype (1494. Most genetic studies have described overexpression of RhoC GTPase (90%) ‘anda loss of Wht-inducible signalling pro- tain 3 (WISPS/CCN6) (703,1492,1493, 1494). Microarray technology has sug- gested a role for other specific pathways, such as NFkaopaB, IGF-1 signalling acti- vation or angiogenic pathways (702, 1494, 1489]. Recent studies have demonstrated high level ofthe translation initiation fac tor elF4Gi, which regulates p120-catenin, that anchors E-cadharin |1322), Very recent data have suggested that there is a highly specific and unknown al- {eration in activation of the anaplastic lym- phoma kinase (ALK) pathway related 10 ALK gene amplification at the 2p23 locus in inflammatory breast cancer. I ongoing studies confirm ALK amplification, pa- lients with inflammatory breast cancer might be eligible for specttic targeted thorapies (11928 Prognosis and predictive factors The use of neoadjuvant therapy has ir proved eurvval rates from 25% to 50% but survival outcomes for patients with ir flammatory breast carcinoma are st worse than those for patients with non flammatory locally advanced breast ca cers (294,295,318, 1266). Pathological complete response to chemotherapy is very strong prognostic factor for overs and disease-free survival (1266) Classic prognostic factors in breast ca" ccor do not have a real prognostic value inflammatory carcinoma, with the exct tion of expression of ER and BCL2 (242 1851}. The cancer stem-cell populat'o- contains the tumorigenic and metasta fraction (244,1351, 1602] and ALDH1. = marker for cancer stem cells, is an in= pendent prognostic indicator for ine ‘matory breast carcinoma {244},Bilateral breast carcinoma and non-synchronous breast carcinoma ‘oma is designated as bilat- 2 primary carcinoma develops red time intervals vary, bi- carcinoma (BBC) is gener ta be synchronaus when 8 CBC ‘cinoma (CBC) is months, and meta- is diagnosed more F Glagnosis of the first 55): however, 12 months would propria from an epiderio- (615) 9 the iagnosis of BBC, ancer in the contralateral luded, Patients with regional or distant 2 al a higher risk of having ase in the contralateral having a primary cancer. ne presence of carcinoma in histological type ‘and grade between the two tumours is evidence for BEC (248}. Several studies, using different molecular methods, have shown that BBCs are most likely to be genetically nor-identical Epidemiology BBC accounts for between 2% and 6% of all breast cancers (555), The incidence of BBC ranges from 3.8 (08.3 per 1000 per. sonyears in patients with a first primary breast cancer [257]. Women who already breast cancer have a two- to sixfold risk of developing CBC compared with the risk of developing a first primary breast cancer among other women, and the risk is inversely correlated with age at intial diagnosis (15,257 546,593). Median lime between diagnosis of the frst breast cancer and metachronous CBC varies from 3.9 t0 7.7 years |15 855,593}, In a Swedish nationwide population based study covering three dece Mo east carcinoma (B8C), A Magnet resnanveinayng of yncrennus BBC. The caresponding scons an HER2 immunchisbchensty ae shown B vase carciara ono spacal yoo, grade wih Jon oF HERZ. invasive lobule carom rade 2 an negative HERZ Inmunoistochmisty M Morrow BBC was reported in 5.9% of patients with primary breast carcinoma; of these, 1.5% were synchronous tumours and 3.8% were metachronous. Between 1970 and £2000, an increase in the incidence of syn- Chronous BBC was observed, consistent with the introduction of bilateral mam: mography, while a decrease of one third was observed in the incidence of meta- hronous BBC. owing to the introduction of systemi¢ adjuvant therapy [555] Women who have hormone receptor-pos- live primary breast cancers have a more than twofold risk of developing a con tralateral tumour, and women who have hormone receptor-negative breast can: cers have nearly a fourfold risk, com: pared with the general population, after adjusting for age, race, and year, Those with hormone recentor-negative first tu mours are much more likely 1o develop hormone receptornegative second tu: ours, especially when the first diagno. sis is made before age 50 years (732) Although exposure 0 radiotherapy does not affect risk of BBC in the general ulation, young patients («< 45 years) with breast cancer treated by postiumpectomy radiotherapy using tangential fields expe- rience an increased risk of CBC, espe. cially women with a family history of breast cancer (187,271 471,593, 1378) The risk is highest for cancers of the me- dial part of the contralateral breast that is exposed to the highest dose of radiation {693}. Women having undergone mantle radiation in their youth for the treatment of Hodgkin disease also have an increased risk (range. 9-29%4) of developing BBC. 110,134) It is recognized that adjuvant systemic hormone therapy reduces the incidence of CBC by 39-85%, depending on menopausal status and disease status [360); this benefit seems to last for up to BS years atter the first diagnosis (125), Ad juvant chemotherapy is also associated with a reduction (-20%) in the incidence of CBC in women aged <50 years, but not in women aged 50 years and older {360}. One study in women aged < 55 69years with primary breast cancer has found that chemotherapy was associ- ated with a lower risk of CBC (relative risk, 0.57; 95% Cl, 0.42-0,75) than no chemotherapy (125]. For patients aged ‘< 50 years, the duration of the protective effect of adjuvant chemotherapy varies from 6 to 10 years {125,693} and seems to be stronger among women who be. ‘come postmenopausal within 1 year after the diagnosis of primary cancer {125}, Clinical features ‘There are no specific clinical features. Macroscopy There are no specific macroscopic fea- tures Histopathology ‘Synchronous BBC tends to be more often Of lobular histological type, lower histo- logical grade and hormone-tecepior pos- itive than unilateral breast cancer (257, 623,1114, 1272). One large epidemioleg: ial study found that the estrogen-recep- tor (ER) status of two bilateral tumours was highly concordant (ods ratio, 7.64; 95% Cl, 7.00-8.35). The strength of the association in ER status between the two tumours appeared to decrease as the time between initial diagnoses of the two tumours increased, levelling off after 12 months, although it was sill highly signif- jant, even for twa tumours separated by 10 years (615). Similar but weaker trends were observed for progesterone-receptor (PR) status, tumour type and tumour rade, These results indicate that there is 10 biological cut-off point for synchronous breast cancer and that the biological closeness of two tumours is a function of time {615}. The similarities between the two bilateral tumours can be explained by the fact that they develop in he same go- netic background and in the same hor- monal and environmental milieux, However, despite the statistical similari- ties, substantial dferences may exist in hormone-receptor and HER2 status be- tween the tumours in BBC in individual cases, therefore separate assessment of these parameters is recommended in rou tine practice. Genetics Women with a first-degree relative with breast cancer experience a 50% higher relative risk of BBC than those without a ‘amily history (556) ‘Compared with non-carriers, women wit BRCAt and BRCA2 mutations have 4 = fold and 3.4-fold risks of BBC, respec tively (862). The relative risk of CBC f ceartiors of BRCAT mutations increases: ‘age at first ciagnosis decreases {862}. Tre Fisk also approximately doubles in carrie of rate low-penetrance inactivating ver ants of CHEK2, ATM, BRIP1, and PALE {555}. Conversely, carriers of comm: variants of the ATM gene have a radu: tion in risk of CBC (268), Prognosis and predictive factors ‘Assessment of prognosis in BBC is di cult as the outcome cannot be attribute> unequivocally to the fist or second ce: ‘cer Survival of patients with synchronc. BBC seems to be dependent an the # ‘our with the worst pathological featur (625), Women aged > 50 yoars with chronous BBC or who develop CSC within 5 years have respectively a tworo > and a fourfold risk of dying of canc= compared with women with unilater cancer. Women with BBC diagno: > 1 years ator the first cancer have prognosis similar to that women with lateral breast cancer (555),-grade, transiocation-associ- ive carcinoma with a solid, and tubular architecture com- cells that produce intracellular ‘lular secretory material =o code 8502/3 Srenyrs => = breast carcinoma (899) Scerivciogy arcinomas account for < 0.15% cancers (171). These tumours, reported in both sexes {66) ‘sn age of presentation is 25 years 87 years) {1019, 1213, 1416), Seca! features y carcinomas are well-circum- ‘mobile masses located near the cially in men and children. Mecescopy ee sours measure an average of 3 om 12cm). The cut surface om grey-white to yellow-tan in Smosthology Sees carcinomas show pushing bor ui areas of frank invasion are fre- Thee pattems are seen in various ns: microoystic, solid and tuou- rooyst¢ paltem is composed of mimicking thyroid folicies that into sold istends. The tubular WS lumina containing secretions, 8 contain all three patterns, ‘ssue in the centre of the lesion oserved. Cells are polygonal with sinophilic to foamy cytoplasm. -egular with inconspicuous nu- © activty is minimal ce of intracellular and extrace! sory material that is positive on wth periodic acid-Schiff (PAS) or |. consistent finding, Exceptionally rare types and variants Fig. 241 Seco carcinoma. A Th trou cs and extacellar seco matealis vet. In situ carcinoma, when present, displays. similar secretory features, occasionally with necrosis, or can be cf low-grade type (740), Immunoprofiie Epithelial membrane antigen (EMA), alpha lactoaloumin and $100 protein are tre- ‘quently expressed. Estrogen receptor (ER), progesterone receptor (PR), HER2 and p63. are negalive, while E-cadherin, keratine 8 and 18, CD117, and alpna-smooth-muscle actin can be expressed {672,740} Uttastructure ‘The variably sized intracytoplasmic lu- rmina contain secretory material. The cells V. Eusebi S. Ichihara, A Vincent-Saloran N. Sneige A Sapino: are attached to one another by desmo- somes and surround extracellular spaces filled with secretory material {1417}, Genetics ‘Tognon et al. [1442] have shown that se- cretory carcinoma is associated with a characteristic balanced translocation, 1(12;18), that creates a ETVE.NTAK3 geno fusion. Paradoxically, secretory carcinoma har- bours a translocation known to be onco- genic in two other tumour types (including megenchyrnal tumours), while also dernon- stating true epithelial differentiation with seoretory activity. Alteration of the ETV6 ai Sarai: RINE ORL) 4) )0onMed gown palon composed ofmienaste rds. -xceptionally rare types and variants agene is present in both the in situ and invasive components when analysed by fluorescence in sity hybridization (FISH) {740} The ditforantial ciagnosis with acinic car cinoma is based on the absence of the ETV6-NTRKG translocation in acinic car- cinomas (1170) Prognosis and predictive factors Secretory carcinoma has a low-grade clin- ieal course and is associated with 2 favourable prognosis {997}, especially in children and young adults aged <20 years (1416), However, in older patients, a more ‘aggressive course is manifested with late recurrences arising after up to 20 years (722,858, Axillary lymph-node metastases rarely in- volve mare than three lymph nodes. Dis- tant metastases are extremely rare (66 5721. Oncoeytic carcinoma Definition breast carcinoma composed of > 70% of cells showing oncooytic characteris- tics. Oncocyies are defined as cells with ‘eosinophilic eytaplasm due to high num- ‘bers of mitochondria, ICD-0 code 2903 Epidemiology ‘The mean age al presentation is 66 years. Cases occur rarely in men. Although generally regarded as a very rare form of breast carcinoma in its pure form, in one series. mitochondrion-rich features, defined as strong positive mito- ‘chondrial immunocytochemical staining of > 50% of the tumour calls, represented 19.7% out of 76 invasive carcinomas of the breast (1131), Clinical features Clinical features are not distinctive from those of invasive carcinoma of no special type (NST), Lymph-node metastases are present at diagnosis in 44% of patients, ‘The mean tumour size is 3.¢m, Histopathology Oncosyte (2 Greok-derived word) means “swollen cell’, which in this case is attrib- table fo an accumulation of mitachanctia, 72 x Fi. 243 Ono ana Nowe websvoneted resale eee The term ‘oncocyte” is used when dlf- ‘usely dispersed mitochondria occupy not less than 80% of the cytoplasm. Three cases ware originally reported by Damiani et al, (312) who, using immuno- histochemistry for mitochondria, found that 70-90% of cells were packed with immunoreactive granules, Ragazzi et al (1181) classified cases as oncocytic ‘carcinoma if at least 70% of the tumour cells showed strong immunopositivity (B+) for mitochondria, Oncocytic carcinoma shows a solid pat- tern of growth with pushing margins. The cells are characterized by abundant, granular, strongly eosinophilic cytoplasm and well-defined borders, while nuclei vary from monotonous to pleamarphic with prominent nucleoll Fig 344 Orcas crore. Cle th burn eesrphe nl cfoposn an rep no== Bimmunestching wih an antboy to ritochonne Hghlghts coarse cvcplasmic rans, Immunoprotte In addition to immunoreactivity for m chondria, EMA was present in ail ‘cases described in one series. Ker='~ was present in 27 (64%), GCDFP-15 » (84%), ER in 25 (78%), PR in 20 (62. of cases and HER? was strongly © pressed in 8 (25%) cases, respec! v= [1131] Oncocytic carcinomas can be dst! guished from apocrine and nei docrine carcinomas by their im phionotype. Ultrastructure Numerous mitochondria are scatte throughout the cytoplasm, without dence of polar condensation. No <=: relory granules are observed. Bhatia batjie carcinomas often display gains of 11q13.1-9132 and to oncocytic tumours ofthe 23 thyroid, respectively, Srapesss and predictive factors vival is similar to that for inva- 'a NST when matched for ” ‘oma with prominent seba- ton in no lees than 50% of ould be no evidence of origin us adnoxal sebaceous glands, B41093 ‘amples of this rare mammary been renorted (age range, 1582,894,956,1 124,1150,1414, case manifested in @ man, Sees tectures “ee -sually present with a palpable s sharply delineated margins <= bright yellow cut surface, ‘ed O-positive cytoplasm are 24 with smaller ovoid to spindle 1g eosinophilic cytoplasm with- cuslization. The nuclei of 6oth 2'9 globoid with up to two nucle- gues can be numerous. Squa- 8s may be present focally -ases examined ultrasiruc- cytoplasm ofall cells was filed "ous non-membrane-bound lipid 6.1414,1497), cells stain for kerating, and -gen receptor and HER2 can -20 (582,956, 1160, 1497} aeue WeHaes eer! diagnosis Serer with apocrine differentiation, “Se carcinoma and liposarcoma "= cifferential diagnosis (1416), “Sous morules are characteristic of Fig.248 Sebaxuscacera Cals dere rn tf esorhicoeurdart nixed otasn and varity compressv mci resembling pode ee adie, sebaceous carcinoma. Sebaceous differ. entiation is also seen in adenoid cystic carcinomas |1416). The extent of the se- ‘baceous differentiation varies in different ‘cases, and the term “sebaceous carci noma’ applies only where sebaceous dif- ferentiation is evident inno fewer than 50% of the neoplastic colls 894, 11241414), Genetics There are no available data on the genetic features of these tumours, Prognosis and predictive factors Not much is known about the behaviour ‘of these tumours, A tumour of 75. om in Giameter was treated by radical masteo- tomy, but none of the 20 axillary lymph odes was positive for metastases. Two cases were reported to be associated with metastases to axillary nodes (582. 956], and one patient had distant metas- tases 10 years after surgery {1497}. 345 Sobicoous acne, The turer sows attr Ca ebaceos cl preter» SO ho tal reepast prolferato 73(sisining shows abundant ineacyloplsic ids win almost vey cl Lipid-rich carcinoma Definition An invasive breast carcinoma in which no fewer than 90% of the cells contain abun- dant cytoplasmic neutral lipids. ICD-0 code astai3 ‘Synonyms Lipid-secreting carcinoma Epidemiology | morphological features and histochem- ical confirmation are used to identity lipid- rich carcinoma, the incidence is < 11.6% {8,1182, 486]. Age at presentation ranges from 33 to 81 years [1485, 1600}. An asso- ciation with neuroleptic drugs has been reported (1465} Clinical features One case presented as Paget disease (8), Ametastaticlipic-rich carcinoma pro- ducing pancreatic-ype iscamylase has been reported {1872}, Macroscopy Tumour size varies from 1.2 to 150m (1485,1600), At he Fi. 248 Lp cacona Lei pets rpc inte opesaon, 74 Spec Histopathology Two thirds to three quarters of breast carcinomas contain cytoplasmic lipid droplets to some extent {8,444}, Linie-rich carcinoma is characterized by cytoplas. ‘mic vacuoles containing lipids in no fener than 90% of the tumour cells: In mast cases, lipid-rich carcinoma is classified as histological grade 3 Apocrine histiocytoid carcinoma closely mimics lipid-rich cereinama, suggesting a kinship between the two entities (947, 1416). Chondroid metaplasia may be seen (1498). The associated DCIS may show cells with hobnail or lactational fea- tures (1465,1485}. Immungprofile Tumour calls stain positively for alphe-lac- toalbumin {21,1465,1972, 1600], lactoter- rin [1872,1600), CEA {1872), EMA (21. 234,1498) and adipophylin and are neg. ative for ER and PR (21,731,809,894, 1166,1465,1498, 1600}. HER2 and basal type keratin were both negative in one cage (1166) Utirastructure ‘Well-developed Golgi apparatus and lipid ropiets of different sizes are recognized in the cytoplasm |1152,1510), as well as intramitochondrial needle-like crystals (809, 1152) Ditferential diagnosis Lipid-rich carcinoma has to be distin- guished from glycogen-rich, histioeytcid Secretory, signetving, myoepithelial {228}, metastatic renal cell carcinomas (343) and breast carcinomas moxified by hor monal therapy and chemothorapy (22, 6683]. Fat necrosis and xenthogranuloma~ tous mastitis may simulate lipic-rich car- cinoma {714}. Genetics There are no available data on the genetic features of those tumours, Prognosis and predictive factors 0 87 female patients who underwent e ilary dissection, 19 (51.4%) showe> lymph-node metastases at presentato ([21,234,731,894,1152, 1166, 1465, 1485 1498, 1600}. Inpatients with follow-uo longer than 2 years, 12 out of 21 (67.1% developed distant metastases [234,76 £209, 1166,1510, 1600). In the largest s= ties published so far, a first-year mortal rate of 38.5% was reported {1182} Glycogen-rich clear cell carcinoma Definition ‘A carcinoma in which > 90% of the neo plastic cells have abundant clear ¢; plasm containing glycogen, ICD-0 cove aatss ‘Synonyms Clear cell carcinoma 8310) Glycogen-tich carcinoma astss Epidemiology The incidence is between 1% and 3% o breast carcinomas, with an age range © 41-78 years (median, 87 years). Clinical features ‘The features of these tumours at presen- tation are similar to those of invasive car ‘cinoma NST. Macroscopy ‘The tumour ranges fram 1 to 8 cmin si Histopathology ‘Astict definition for glyeogen-tich clear ce! carcinoma is necessary for two reasonscinomas that have a clearcell fe uncammon in the breast © 68 an artefact ofthe extraction of plasmic substances during tissue ==50g, The substances that are ex © oifer, a8 does their biological sig- 343). Secondly, intracytoplasmic o2° has been observed without a clear-coll appearance in 60% Differential diagnosis Glycogen-rich clear cell carcinoma must be ditferentiated irom lipidtich carcinoma, histiocytoid apocrine carcinoma, adeno- ‘myospithelioma, clear coll hidradenoma, metastatic renal cell carcinoma and tu- ‘mours comprised of perivascular epithe- lioid cells (PEComa) {1416} ns have the structural features of al and invasive carcinoma NST those of lobular, medullary or tu- 2s (1416). Glycogen-rich clear noma may have either circum= or infiltrative borders 51u component, either in the pure © association with most invasive 125 a. compact solid, comedo or There are no available data on the genetic features of these tumours Prognosis and predictive factors Although mast reports suggest that glycogen-rich clear cell carcinoma is more aggressive than invasive carcinoma NST, Hayes et al. (562) contend that prognosis is no different once giycogen- rich clear cell carcinoma and conven tional mammary carcinomas are matched by tumour size, grade, and lymph-node our ells tend to have sharply de- ets and polygonal contours. The ‘ely granular cytoplasm contains ve diastase-labile glycogen. The yperchromatic, with clumped and prominent nucteo! Acinic cell carcinoma ie in 50% of cases, while PR is 1218}. Cases that are positive and negative for ER and PR A breast carcinoma similar to the acinic cell carcinoma of the parotid gland that shows (serous) cifferentiation with zymo- ger-type cytoplasmic granules uscle actin, GCDFP-15 or CD10 Epidemiology Acinic cell carcinoma (ACCA) of the ‘oreast is @ rare tumour but its true inci- dence is not known as studies on large series are lacking. First reported in 1996 by Roncaroli et al (1198] as the counter- art of similar tumours of the salivary Gland, no more than 20 additional cases have been reported since (314,1276} Carcinomas showing serous secretion, and probably related to ACCA, have also bbeen described |621,705). ACCA affects women aged between 35 and 80 years (mean, 56 years) (314) Clinical features ACCA may present as a palpable nodule ranging from 1 to 5 om in size {1416} Macroscopy The tumour shows infiltrating growth, Histopathology ACCA varies from well-ditferentiated and easly recognizable to structurally solid (Gediferentiated) {1416}, Some show micro- cystic and microgiandular areas, of solid nests with comedo-lke necrosis and a rim Of microglandular structures at the pe- riphery |1198}. The cells have irregular round to ovoid nuclei, evident single nuc- leoli and abundant cytoplasm, which is Usually granular, amphophilic to eosino- philic. Granules can be large and coarse i tS nora wth miogenulsk nave pate and cals win bund cle ops conning eosnophic wanes Exceptbright ted in colour, reminiscent of those seen in Paneth colls and ultrastructurally similar to zymogen-lke granules {314, 1198, 1276). Cells with clear “hyper. nephroid’ oytoplasm are a feature and may predominate. Mitoses can number up to 15 per 10 high-power fields (314), In almost all tumours, calls express a high level of alpha-t-antichymotrypsin, salvary- Gland amylase, lysozyme, EMA and S100 protein (314). The mucoapocrine marker GCDFP-15 can be focally positive ACCAs are consistently negative for ER, PR, androgen receptors [1083] and HER2 (459) Kahan et al. (673) reported a case of ACCA that merged with microglandular adenosis and suggested a close relation- ship between the two lesions, One of the 76 ‘ypical features of ACCA is the presence a the edge or within the bulk ofthe tumour of small carcinomatous tubules [1798 1416}. These tubules have been inter: preted as the malignant transformation of ‘microglandiular adenosis {637,705,1177, 1371) and the term "micraglandular carci. noma” has been used to describe some cases. Nevertheless, some of the mor phologiesl,immunohistochemical and ul= trastructural features of these lesions are different (1416) such that at the moment a Fistogenetic link remains to be proven, Difierental ciagnosis ACCA has to be differentiated from secro- tory carcinoma {580}, which lacks hyper nephroid features and all the proteins of the salivary-gland counterpart of ACCA Genetics From a molecular point of view, ACC does not show the l(12:15)ETVE-NTRK= rearrangement typical of secretory care noma (1170, 1336) Prognosis and predictive factors None of the patients reported have dec = a consequence of this tumour, althou: follow-up is limited to a maximum of years (mean, 3.3 years) {1416}. Axi lymph-node metastases may be cbseryCHAPTER 4 Lobular neoplasiaLobular neoplasia Definition Lobular neoplasia (LN) refers to the entire spectrum of atypical epithelial lesions Criginating in the terminal-duct lobular unit (TDLU) and characterized by a prolifera. lion of generally small, non-cohesive calls, with or without pagetoid involve- ‘ment of terminal ducts. The designations atypical lobular hyperplasia (ALM) and lobular carcinoma in sity (CIS) are widely used to describe the variable extent of proliferation of the lesion. The distinction ‘between atypical lobular hyperplasia and classic lobular carcinoma in situis based Con the extent of involvement of individual lobular units (1055, 1056, 1058}, ICD-0 codes Lobular carcinoma in situ a520/2 Pleomarphic lobular carcinoma in situ esigi2 Epidemiology LLNis found in 0.5-4% of otherwise benign breast biopsies. LN has been diagnosed inwomon of all ages, but is predominantly found in premenopausal women with an average age of 49 years |190.464,533) Analysis of the Surveillance, Epiderial- ogy and End Results (SEER) database show that the age-adjusted incidence rates for LN increased between 1978 and 1998 (788,792) Clinical features There are no specific clinica features for LN, Macroscopy LNis not associated with any grossly rec ognizable features, Histopathology LN is. a proliferation within the TOLU 1873) and may have pagetoid involve ‘ment of the terminal ducts. The lesion is. ‘multicentric in as many as 88% of patients ‘and bilateral in 30-67% [130,532,034, 4221,1414). On low-power examination, while lobviar architecture is maintained, the acini are expanded to varying de- grees by a monomorphic proliferation of dyshesive cells, wth uniform round nucle, 73 indistinct nucleoli, uniform chromatin and scant cytoplasm, intracytoplasmic lumina are often present but are not specific to LN {45]. These lumina can be large enough to produce signet-ring celltypos. {in addition to the usual setting within a lobular unit, LN may also involve @ variety ‘of lesions, including selerasing adenosis radial scars, papillary lesions, fioroadeno- mas and may be associated with ool lagenous spherulosis. Classic LCIS is diagnosed when more than half of the acini of a lobular unit are distended and distorted by a dyshesive piolferation of cels win smal, uniform nu- clei Lesser involvement by te character- istic cels is diagnosed as atypical lobular hyperplasia, Pagetoid spread along the terminal ducts a common feature. Examples of LCIS with mild to moderate ogres of nuclear variabilty are best cat- egorized as classic LCIS. The two forms of LCIS have previously been termed types A and B, a distinction which is of no known significance (533) More recently, soveral variants of LCIS have been recognized with increasing frequency because of the presence of mmictocaletications detected on screening ‘mammography, These mammographical- detected lesions include: (1) lesions in which the LCIS cells show the cytological features of classic LCIS (type A or B) but in which there is marked distention of in- volved spaces with areas of comedo necrosis; and (2) lesions that show marked nuclear pleomorphism (equiva lent to that seen in high-grade ductal car cinoma in situ (DCIS), with or without apo- Crine features and comedo necrosis (pleomorphic LCIS). All lesions in these ‘groups typically lack E-cadherin expres- sion and display genomic alterations by array-based comparative genomic hyb- fidization (CGH) typical of obular lesions (169 losses and 1a gains) (258, 1346} While anecdotal data suggest that these variants may have a different clinical course than classical LCIS, the clinical significance and appropriate manage- ment of these LCIS variants is at this tme uncertain SR. Lakhani SJ. Schnitt F O'Malley MJ. van de Viiver PIT. Simpson aoe’ “ lg, 401 Atypical itu yperasia Ufo els == ‘sont witaut dering th inolied a Fig. 408 Peropiic blr carcrerainsu, Sold ofneonase als wih certal reco nd cae Immunaprofite The classical variety of LN has an = munoprofile similar to that of is invas ccounterpatt, invasive lobular carcino and to low-grade DCIS. Lesions are ‘= quently (up to 90%) positive for est gen receplor (ER) and progesters~ receptor (PR) and rarely overexp’ HER? or p53 protein [25,209,494, 10 1148, 1234}. Ploomorphic LCIS is mo likely 1o be negative for ER, particularine variant {258}, positive for ‘© p53 and to have a higher Ki67 ve index |116,258,922.1172, 1346). rphic LOIS, apacrine differenti. 88 been described, and the cells =xcress GCDFP-15 (gross cystic ais- J protein-1§). intracytoplasmic activity for casein has also been (97,1054), Some authors have hat positive staining of LN for eta 12 is useful in distinguish- Lt rom solid DCIS (which is typically = for keratin 34beta 12), but this has not been reproducible and ce related to methodolagicel details = immunostaining procedure |180, ‘0 the majority of ductal le- classic and pleomorphic types of a invasive lobular carcinoma are 6 for E-cadherin in about 80-30% 5 |489, 1062). Approximately 10 cases will exoress E-cadherin, al- ‘nis is usually aberrant and this should not be used to make a di- 5 of ductal carcinoma (303,114) ‘enin, alpha-catenin and’ p120- proteins found to complex with E- =, respond differently to functional E-cadherin. Whereas beta-catenin ‘a-calenin are also lost together herin, 120 Is aberrantly lo- the cytoplasm and, in some in- nthe nuclei of cells of LN (304, 8.1785, 1262} ial diagnosis on of LIN from a solid DCIS af low ==" grade can be difficult on marpho- ‘ounds alone, particularly when ins confined to the lobule with- ing it (so-called lobular cancer- The presence of secondary a rosette-lko arrangement of noicates a DCIS, Pleomorphic N also sometimes be difficult to differentiate from high-grade DCIS. The ‘absence of E-cacherin may be useful to help ifferentiate OCIS and LCIS or to Classify indeterminate lesions (304,633, 1382). Hovrever careful analysis of stain- ing and morphology should be used to make the diagnosis since LN can some- times be positive for E-cadherin (303, 1144. In some cases, apparent positivity for E-cadherin might be due to admixture Inthe same TDLU of E-cadherin-negative neoplastic cells with residual E-cadnerin- Positive normal epithelial cells. In addi- lion, some mutations in the E-cadherin gene might produce non-functional E- ‘cadherin protein that can be immunohisto- chemically detected with aberrant (oyto- plasmic) or normal membrane staining. If after careful assessment of morphological ‘and immunohistochemical features, & ‘case cannot be definitively classified as DCIS or LCIS, then a designation of ‘ear. cinoma in sity with mixed ductal and loo Ular features’ should be rendered, In addition, LN can atten be found 10 co ‘exist with lon-grade DCIS within the same ductal-lobular unit and so cases of mixed ductal and Jobular lesions or mixed E- cadherin staining should be recorded, When LN involves selerasing lesions, it ‘can be confused with an invasive carci- noma. The presence af a myoepithelial cell layer around the neoplastic cell clus- ters excludes the possibiliy of an invasive carcinoma; immunostaining for smooth- muscle actin, p63, keratin 14 or keratin 5/6 can reveal myoepithelial cells, thus ‘eciltating the distinction, The presence of isolated cells invading the stroma around a focus of LN can cause diag- Nostic problems. The absence of myospi- thelial cols around the incividual calls and their haphazard distribution accentuated by any of the epithelial markers (optimally with double immunostaining techniques) can help establish the presence of stromal ue nt ular carcnomain stu (LOIS). A Classic LCIS shows srl uniform nucle. B Ths tumour shows mid degrees of nua enlepemen, buts *y dagnesed as dass LCS. € Penmerpic bur carsam in stu:nudiearenargent vaabilty, or praniontrucet ar assecaod wih abundant egos, invasion by individual or small clusters of neoplastic cells. Poor tissue preser- vation may give a false impression of loosely cohesive cells leading to over- Giagnosis of LN. Genetics Molecular analysis has Cemonetrated that Lisa clonal neoplastic proliferation and € precursor for invasive cancer. Loss of heterozygosity (LOH) at loc! frequently ‘observed in invasive carcinoma, such 2s 11q18, 16q, 17p and 179, has been re- Ported {744,971}. Loss of chromosomal ‘material rom 16p, 16q, 17p and 22q and gain of material to 69 was also identified in equal frequency by CGH in 14 ALH and 31 LCIS lesions (835), and by array- based CGH (890) suggesting that both are “neoplastic” andi at a similer stage of genetic evolution. Aray-based CGH demonstrated thai LN and pleomorphic CIS share recurrent genomic alterations, ‘Such as frequent gains on chromosome ‘1g and losses of 16q and complex, high ‘eve! amplifications of 11413 encompass- ing the CCND1 locus. Pleomorphic LCIS. harbours greater genomic instability with increased copy-number alterations, in- cluding at 8p, 16p, 17q and amplitica- tions at loct including 8424 and 17412 (160,258,1172). These alterations are ‘more commen in high-grade ductal carci nomas and reflact the more aggressive ‘features of pleomorphic LCIS compared with LN. Analysis of synchronous LN and invasive lobular carcinoma and of synchronous pleomorphic LCIS and pleomorphic lobu- lar carcinoma demonstrated concordant genomic profies providing strong evidence for LN and pleomorphic LCIS being non- obligate precursor lesions for classic inva sive lobular carcinoma and pleomorphic lobular carcinoma respectively (617, 1172) InLN and pleomorphic LCIS, the deletion fo. Ne es SOO SPS Lot . 2Fig. 05 Pleomarphi lobular carcinoma in stu lacks ‘xpresson of E-cadherin con chromosomal 16q is accompanied by cother mutational events (e.g, gene muta- tion and promoter methylation) to inacti- vate the E-cadherin gene, CDH1. which is found at 16922.1 (127,128,354, 1630), In one study (129), 27 of 48 (56%) inva sive lobular carcinomas had a mutation in CDH}, while none of 50 breast cancers of other tyes showed any alteration. It was ‘subsequently demonstrated that truncat- ing mutations identified in invasive lobu- lar carcinoma were also present in the adjacent LN, supporting the concept that LN is a precursor lesion (1828), Prognosis and predictive factors While ALH and classic LCIS represent a morpholagical and biological continuum, the diagnostic separation is useful from an epidemiological and clinical point of view, because the risk of subsequent in- vvasive cancer development associated with ALH is half that of LCIS ‘The relative risk for subsequent develop- ‘ment of invasive carcinoma among pa- tionts with LN ranges from 4 to about 12 times that expected in women without LN (47,583). The variation in raported subse- ‘quent cancer incidence is related to dif- {ferences in lengths of follow-up, which LN lesions were included (ALH alone, LCIS aione or both) and lack of complete pathological review. Early studies sug- {gested that both breasts were at equal Tisk for later cancer development (534; however, recent carefully conducted co- hort studies show that approximately two thirds of subsequent carcinomas oceur in the ipsiiateral breast (881, 1058}. ‘There is controversy regarding the time- ‘course for developing invasive carcinoma aller diagnosis of LN. Some studies find 80 Lobularr continued risk, while others show a de- crease alter menopause. ‘The type of invasive cancer that may arise following LN can be either lobular or duc ‘al, Although all types of invasive carci noma have been observed after @ dia- ‘gnosis of LN, invasive lobular carcinoma or special-ype carcinomas are seen with higher frequency than in the general breast-cancer population (6,268,447, 1056} Features useful for identifying which pa tients diagnosed with LCIS will eventually develop an invasive carcinoma have not been elucidated through clinical or patho- logical features (1056,1219), ‘The current consensus is that LN consti- tutes both a risk factor and non-obligate precursor for subsequent development of invasive carcinoma in either bresst, of elt- hher ductal or lobular type, but only in a mi- nority of women after long-term follow-up. ‘As definad in large epidemiological fol- low-up studies, ALH and classic LCIS are generally incidental findings. For this rea son, when ALH or classic LCIS is ciag- nosed on needie-core biopsy, careful radiologyrpathology correlation should be performed to determine the need for sur- ical excision. Studies that have shown a substantial rate of upgrades generally show @ selection bias. The management of patients with ALH and classical LCIS when diagnosed on needle-core biopsy is controversial. Re- ported rates of upgrade to a worse lesion, on excision vary widely due fo variations in study design {1018}. There is consen- sus that excision should be performed if there is another lesion which by itself ‘would warrant excision ori there is patho- logical-mammographic discordance. In cases where ALH or LCIS on core biopsy is ‘completely incidental finding, radiological pathological correlations recommended for determining further management. In con- trast, excision should be performed for cases of classical LCIS with comedo necro- sis, bulky mass-iorming LIS lesions and ‘cases of pleomorphic LCIS identiied on needle-core biopsy, Information on the natural history of pleomorphic LCIS is extremely limited. ‘Although the nuclear pleomorphism ani necrosis suggest a more “aggressiv. lesion, it remains unproven that the le- sion is associated with a higher risk of subsequent breast cancor than that as- sociated with classic LCIS, Obtaining natural history data will be dificult be- cause these lesions are often treated as DCIS (complete excision with or withou reciation therapy). More than 180 cases originally diagnosed as DCIS in clinica trial NSABP-B-17 were later categorize as LOIS. These lesions probably repre sented pleomorphic LGIS based on the presentation and wore associated with ic siiateral recurrence in 14% of cases. the absence of better information on the natural history of pleomorphic LOIS, ca tion should be exercised in recommend more aggressive management strategies such a8 excision to negative margins mastectomy as a routine practice etter diagnostic surgical biopsy reveals pie~ morphic LCIS. Decisions regarding ‘= need for excision to negative mars should be considered alter 2 carotul r= view of the pathological criteria used the diagnosis of pleomorphic LCIS, extent of surgery required for comple'= excision, as well as the patients suite iy for, and acceptance of, non-sura = fisk-management strategies Histological features, including degree pleomorphism, bulk of disease, soc involvement and presence of com necrosis are belng used to cistnguisn teniielly more aggressive and estab forms of LCIS that would appear from limited existing evidence to merit cor eration for complete excision. The de tion of what constitutes bulky cise: florid” LCIS remains debatable would generally incorporate invoer== of several contiguous lobules by LC often with accompanying mass forme Importantly for cases of classic there is no indication that excision te ative margins is useful, and we doc = ommend reporting margin statu classic LOIS. Likewise, we do not & cate the need to report presence oF sic LCIS at margins when are pleomorphic LCISin the same case aeady boon completaly excised. C= LCIS with comedo necrosis at ma can be problematic, and will ecuire ful pathological review as stated 2c as well as close discussion withthe cal managing teem.