Breast pathology

Usual ductal hyperplasia

1) mild variation in size, shape and distribution,
2) lightly granular chromatin,
3) coffee bean-like grooves and
4) pseudoinclusions
Many nuclei show asymmetrical taperin
Lightly granular chromatin and small nucleoli.
 Cellular maturation

Cells get progressively smaller from the base Tightly swirled mature
to the center of the proliferation, becoming hyperplastic cells
nearly pyknotic in the middle.
Peripheral irregular slit-like spaces.
 Cytokeratin 5/6

Mosaic pattern of positivity, typically most robust in the central zone

of proliferation
 Estrogen receptor

Heterogeneous positivity
 Usual ductal hyperplasia

Essential features
• Component of fibrocystic changes
• Mild cytologic variability
• Streaming growth pattern with fenestrated spaces and lack of cellular polarity
• Immunoreactive for high molecular weight cytokeratins
• Associated with slight increase in subsequent breast cancer risk (1.5 - 2 times)
 Usual ducatal hyperplasia note:

• Formation of irregular slit like spaces at periphery.

• Indistinct cell borders.
• Myoepithelail layer intact.
• Nuclei parallel to the direction of epithelial bridge. ( and perpendicular in
DCIS)

DCIS:
Referred to as “cookie cutter” or “punched out” lesions
No streaming

DCIS
What is the risk for subsequent breast cancer associated with the illustrated lesion?
A. 1.5 - 2 times increased risk
B. 2 - 3 times decreased risk
C. 4 - 5 times increased risk
D. 8 - 11 times increased risk
E. No change in risk compared to control populations

A. 1.5 - 2 times increased risk

This is usual ductal hyperplasia. Usual ductal hyperplasia is associated with a

slight increase in risk (1.5 - 2 times) for subsequent breast cancer. Risk appears to
be slightly higher in those patients with a positive family history of breast cancer.
What is the typical high molecular weight cytokeratin / estrogen receptor
(HWMCK / ER) immunoprofile for usual ductal hyperplasia of the breast?

A. HMWCK negative / ER diffusely positive

B. HMWCK negative / ER negative
C. HMWCK mosaic positive / ER diffusely positive
D. HMWCK mosaic positive / ER heterogeneously positive
E. HMWCK mosaic positive / ER negative

D. HMWCK mosaic positive / ER heterogeneously positive

Usual ductal hyperplasia is positive for HMWCK in a mosaic to occasionally diffuse pattern
and demonstrates heterogeneous positivity for ER.
 Which of the following is a feature of usual ductal hyperplasia that aids in
distinguishing it from low grade ductal carcinoma in situ?
A. Cellular maturation
B. Monomorphic hyperchromatic nuclei
C. Palisading around fibrovascular cores
D. Polarization around secondary spaces
E. Red macronucleoli

A. Cellular maturation

Many examples of usual ductal hyperplasia demonstrate cellular maturation, where the
cells shrink as they progress from a basal location to the center of the proliferation,
becoming small and nearly pyknotic.

Cellular maturation is not a feature of low grade ductal carcinoma in situ or atypical
ductal hyperplasia.
What is the most useful immunohistochemical stain in the differential diagnosis of usual
ductal hyperplasia and atypical ductal hyperplasia?
A. Calponin
B. CK5/6
C. CK7
D. CK20
E. P63

B. CK5/6
Usual ductal hyperplasia and atypical ductal hyperplasia of the breast may sometimes be difficult to
distinguish morphologically.

Thus, use of CK5/6 immunohistochemical staining may be helpful in the differential diagnosis, as usual
ductal hyperplasia is positive (in a mosaic or patchwork pattern) and atypical ductal hyperplasia is
negative for CK5/6.

Both usual ductal hyperplasia and atypical ductal hyperplasia are typically positive for CK7 and
negative for CK20 (breast ductal epithelium immunophenotype).

Myoepithelial markers p63 and calponin show positive myoepithelial staining in both usual ductal
hyperplasia and atypical ductal hyperplasia
 Atypical ductal hyperplasia
• Intraductal clonal epithelial cell proliferation with similar histologic features to (but insufficient
involvement or volume for the diagnosis of) low grade ductal carcinoma in situ (DCIS)

Essential features
• Intraductal clonal epithelial cell proliferation with cytologic and morphologic features similar to low
grade ductal carcinoma in situ

• Differentiated from low grade ductal carcinoma in situ by size (≤ 2 mm) or space occupied by clonal
cells (≤ 2 spaces or only portion of involved space)

• Rigid bridges, polarization around lumen and estrogen receptor (ER) (diffuse, strong) positivity

Breast cancer risk

• 4-5x increased risk of breast cancer (60% in ipsilateral breast)
• Shows loss of 16q and 17p
 LCIS
ER+/ HER2 -ve

Almost always ER positive:

• Lobular carcinoma.
• Tubular carcinoma.
• Mucinous carcinoma
• Papillary carcinoma.
• Small monotonous cell with less atypia.
• may have intracytoplasmic mucin vacuoles.
• No inflammation or fibroplasia in the background.
• LCIS is no longer classified as Tis because it is considered a risk factor, not
a malignancy.
• Negative for E-cadherin and high molecular Wight CK
 gynecomastia
Definition / general
• Benign enlargement of the male breast, typically presenting as a palpable
subareolar mass

• Histologically identical gynecomastoid hyperplasia can be seen in female

breast.

• Most cases retroareolar and bilateral. ( typically unilateral (Q book)).

• Associated with a small increased risk of breast cancer.

• Due to imbalance between estrogen and androgen (liver cirrhosis.)

• Testicular neoplasm ( leydig and sertoli cells )
• Klinefelter syndrome
Dense collagenous connective tissue.
Epithelial hyperplasia of ducts.
Lobules formation never observed.
 3 layer epithelium

CK5 stain highlights luminal epithelial and myoepithelial layer of

hyperplastic ducts and is negative in intermediate epithelium
 Lymphocytic / diabetic mastitis
• Histologic triad of: (B-catanin-)
o keloidal type fibrosis,
o lymphocytic inflammation and
o epithelioid myofibroblasts

• Associated with type I (insulin dependent) diabetes or other autoimmune diseases

• Young to middle aged women presenting with breast mass(es)
Stromal myofibroblasts showing characteristic epithelioid features including enlarged
oval to polygonal nuclei with variably prominent nucleoli and abundant cytoplasm
Small, bland lymphocytes are present surrounding this duct structure
A CD20 immunostain shows the predominance of B lymphocytes in this focus of
periductal inflammation
A CD3 immunostain shows rare T lymphocytes in this focus of periductal inflammation
• Stromal cells stain for myofibroblastic markers (CD10, SMA,
desmin, CD34 and S100).
• Lymphocytes stain with B cell markers (CD20)

• Negative for Cytokeratins, p63 (useful in differential of

invasive carcinoma)

• Negative Nuclear beta catenin (useful in differential of

fibromatosis)
For the breast stroma shown, which of the following is true?
A. Lesion is associated with increased risk of developing lymphoma
B. Lymphocytes are predominantly T cells and are clonal
C. Patient may have insulin dependent diabetes or an autoimmune
disorder
D. Spindle cells in the stroma show beta catenin nuclear expression

answer : C. Patient may have insulin dependent diabetes or an autoimmune disorder

Which of the following is true regarding diabetic / lymphocytic
mastopathy?
A. All patients have a history of diabetes
B. Characteristic histologic triad includes dense keloid-like fibrosis,
epithelioid myofibroblasts and periductal, perilobular and
perivascular lymphocytic inflammation
C. If surgically excised, these lesions never recur
D. Typical mammographic finding is an infiltrative mass lesion

B. Characteristic histologic triad includes dense keloid-like fibrosis, epithelioid

myofibroblasts and periductal, perilobular and perivascular lymphocytic inflammation
 Pseudoangiomatous stromal hyperplasia
ER+/ CD34+/CD31-/Factor VII-/Pan-CK-/ B-Catanin-

Essential features
• Benign myofibroblastic proliferation simulating a vascular lesion
• Usually an incidental finding but may produce palpable or mammographic mass
• Complex interanastomosing spaces in dense collagenous, keloid-like stroma
• Some of these spaces have spindle shaped myofibroblasts at their margins that
simulate endothelial cells
• Spindle cells are positive for ER, PR and CD34 but negative for other vascular
markers, e.g. CD31

• Positive ER, PR, SMA, vimentin, CD34

• Negative CK, CD31, factorVIII

Complex interanastomosing spaces in dense

collagenous, keloid-like stroma
Slit-like spaces have spindle cells (myofibroblasts) at the margins that
simulate endothelial cells.
CD31 stain: myofibroblasts at the margins of the slit-like spaces
are negative, while highlighting the normal blood vessels in the
background
CD34 stain: all the stromal cells show strong and diffuse staining.
 Which of the following set of immunohistochemical stains would
be most suitable for the diagnosis of pseudoangiomatous
hyperplasia (PASH)?

A. CD34-, CD31-, ER-, nuclear beta-catenin+

B. CD34-, CD31-, nuclear beta catenin+, AE1 / AE3+
C. CD34+, CD31-, ER+, factor VIII-
D. CD34+, CD31+, ER-, factor VIII+

answer :
C. CD34+, CD31-, ER+, factor VIII-

The immunoprofile in option D is most consistent with angiosarcoma or other vascular lesions,
with positive vascular markers.

Option A is the immunoprofile for fibromatosis with positive nuclear beta catenin. It is important
to note that fibromatosis is negative for CD34 as it does not arise from myofibroblasts.

Option B is the classic staining pattern for a spindle cell carcinoma with positive AE1 / AE3.
 Angiosarcoma
ER-/ ERG1, CD34+, CD31+, factor VIII+
Essential features
• Rare overall tumor of the breast (0.05% of all primary breast malignancies)
but most common sarcoma of the breast
• Occurs most frequently secondary to prior radiation therapy for breast
carcinoma, typically in older patients
• May arise as primary (de novo) sarcoma of the breast, typically in younger
patients
• Worst prognosis of all breast sarcomas
• Postive for Vascular markers (ERG, CD31, CD34, Factor VIII)
• ER : Negative (-ve)
 Angiosarcoma
ER-/ ERG1, CD34+, CD31+, factor VIII+
 Micropapillary carcinoma
ER+/ HER-2+( cup shaped basolateral staining).

• Micropapillary carcinoma is characterized by pseudopapillary,

tubular and morular epithelial structures with inside out
growth pattern.

• Micropapillae are composed of cell clusters with inverted

polarity floating in empty spaces and often separated by
delicate strands of fibrous stroma.
Pseudopapillae with knobby outer surface floating in clear space
separated by thin fibrocollagenous stroma.
Micropapillae with inside out polarity of tumor cells
• The pictured lesion shows characteristic features of the micropapillary
subtype of invasive breast carcinoma, which is frequently ER positive,
with cup shaped basolateral HER2 immunostaining.

• Tumors often present at high stage with lymph node involvement. (Q)

• Tumor cells show reverse polarity, also known as inside out pattern with
apical surface placed towards the stroma.

• Inside out pattern can be demonstrated by EMA staining of the apical

surface
 IHC for EMA stains apical membrane abutting the stroma
confirming inside out epithelial polarity
Tumor cells show inside out pattern with EMA immunostaining.
 Tubular carcinoma
ER+/HER-2 (-)
• Special type of breast carcinoma with favorable prognosis.

• composed of distinct, well differentiated angular tubular structures (90%+

according to WHO) with open lumina, lined by a single layer of epithelial
cells
• ER+/PR+/HER-2 (-)

Almost always ER positive:

• Lobular carcinoma.
• Tubular carcinoma.
• Mucinous carcinoma
• Papillary carcinoma.
• Excellent prognosis is restricted to tumors with 70%+ tubules, pure grade
1 nuclei and no / rare mitoses.

• Mixture with ordinary ductal carcinoma has worse prognosis.

Differential diagnosis
• Benign sclerosing lesion:
– overall lobular architecture, compression of glandular structures,
– positive for myoepithelial markers p63 and CD10 or smooth muscle
actin
• 90%+ tubules with low grade features,
• irregular angulated contours of glands ("teardrop-like"),
• open lumina with apocrine-like snouts and basophilic secretions /
columnar cell lesions in almost all cases usually with flat epithelial atypia.
• No myoepithelial layer, no mitotic figures, no necrosis, no angiolymphatic
or perineural invasion and no basement membrane after PAS or type IV
collagen staining
 Microglandular adenosis
• Disordered proliferation of small open glands comprised of bland epithelial cells
• Retains basement membrane but lacks myoepithelium
• Infiltrates adipose and fibrous stroma without a stromal response
• S100+, ER-, PR-
• Potential precursor to triple negative invasive breast cancer
• No apocrine snouts, no nucleoli, no myoepithelial layer but thick basement
membrane

Round, open glands with bland epithelium and

intraluminal eosinophilic secretions
 Microglandular adenosis

diffuse, strong S100 positivity loss of myoepithlial staining via p63

(normal gland internal control staining
present in upper righthand corner)
 The pictured lesion shows 3 regions in a breast core biopsy. What is the
expected biomarker profile of the invasive carcinoma?

A. ER-, PR-, HER2-

B. ER+, PR-, HER2-
C. ER+, PR+, HER2-
D. ER+, PR+, HER2+

A. ER-, PR-, HER2-

The pictured lesion is

microglandular adenosis (MGA)
with associated invasive
carcinoma, which is supported
by S100 positivity in the MGA.

Both MGA and associated

carcinomas are most
frequently ER-, PR- and HER2-
(triple negative).
Secretory carcinoma

demonstrating well-differentiated but invasive glands

containing eosinophilic secretion
 Lactating adenoma

a well-demarcated proliferation of closely packed glands with delicate strands of intervening

stroma.

The closely packed glands are comprised of uniform cuboidal cells with small nucleoli and
cytoplasmic vacuolization. Eosinophilic secretions are seen within the lumen.
Histologically composed of closely packed glands lined by actively secreting cuboidal or hobnail
shaped cells
Lactating adenoma Secretory carcinoma
 Adenoid Cystic Carcinoma of Breast
• MYB-NFIB fusion gene (t(6;9)(q22-23;p23-24))

• Cribriform, solid, tubular or trabecular architectural patterns

• Dual population of cells

– Luminal / ductal epithelial cells with variable glandular / squamous / sebaceous
differentiation
– Myoepithelial / basaloid cells

• 2 types of lumens that are lined by 2 cell types:

– True glandular lumina lined by luminal / ductal epithelial cells (low molecular weight
cytokeratin+ (CAM5.2), CK7+)

– Pseudolumens containing eosinophilic "cylinders" comprised of basement membrane

material (laminin and collagen IV positive) lined by myoepithelial / basal type cells
(p63 / p40+, smooth muscle myosin+, calponin+, S100+)
 dual population of basaloid and p40 highlights myoepithelial / basal cells
epithelioid cells, pseudolumens contain surrounding psuedolumens.
basement membrane material.
 Adenoid Cystic Carcinoma of Breast

CD117 / KIT positive in the epithelial strong membrane positivity for

cell component CD117/c-kit. The location of this
tumor was nasopharyngeal
Almost always ER positive:

• Lobular carcinoma.
• Tubular carcinoma.
• Mucinous carcinoma
• Papillary carcinoma.
Almost always ER positive:
(Her-2 –ve)
• Lobular carcinoma.
• Tubular carcinoma.
• Mucinous carcinoma
• Papillary carcinoma.
• Mucinous carcinomas are ER+, PR+ and largely HER2-, making them a
luminal A lesion, which is associated with a favorable prognosis

• What percentage of a breast carcinoma must have a mucinous component

to be considered pure mucinous carcinoma? > 90%
– To be considered a pure mucinous carcinoma with a favorable prognosis, the mucinous
component must comprise > 90% of a breast carcinoma.
– If it comprises 50 - 90% of the tumor, it is termed mixed.
– If the mucinous component is < 50%, the tumor is termed invasive ductal carcinoma
with mucinous features.
– The latter two diagnoses do not have as favorable a diagnosis.

• Mucoepidermoid carcinoma s are triple negative tumor .

– Resembles salivary gland counterpart
– Mixture of neoplastic mucus secreting, squamous and intermediate cells
Almost always ER positive:
(Her-2 –ve)
• Lobular carcinoma.
• Tubular carcinoma.
• Mucinous carcinoma
• Papillary carcinoma.
 Mucocele-like lesion:

Ruptured cyst with detached strips of

bland epithelium lined by myoepithelial
cells floating within extravasated mucin
p63 (highlighting squamous differentiation).
 CK7 p63

Low grade adenosquamous

Lesional glands/nests demonstrate

CK7 show Core staining in glandular
varying luminal immunoreactivity for
component where luminal cells demonstrate
p63 (highlighting squamous
greater intensity of staining compared to basal
differentiation)
cells
 Low grade adenosquamous
Summary :
• Dense sclerotic lesion
• Triple negative

• Luminal cells show varying immunoreactivity for p63 (highlighting squamous differentiation)
• Glandular component often shows core staining, where luminal cells demonstrate greater
intensity of cytokeratin staining compared with the basal cells.
– CK AE1 / AE3 (57%)
– CK5/6 (58%)
– CK7 (50%)
 NOTE from article

• In case of absence of residual tumor by gross and microscopic evaluation, if tumor bed and
biopsy site changes are not identified, additional sections should be submitted to prove
the absence of invasive carcinoma by higher probability.

• In this case try to cover the pretreatment size of the tumor including one full face of the
cross section of the suspected area (pretreatment location of tumor) per 1 cm of pretreatment
size of the tumor for small tumors and 5 representative sections per full face per 1-2 cm of
the larger suspicious area to maximum of 25 blocks.

• The other approach that is recommended by FDA is to put one section per 1 cm of
pretreatment tumor size or at least 10 blocks in total (whichever is greater) to rule out the
presence of residual tumor.
Per AJCC 8th edition, measurement of the tumor size (ypT size for staging) :
is based on the largest focus of contiguous residual invasive carcinoma.

The treatment related fibrosis, adjacent to the invasive carcinoma is not

considered in the tumor size measurement in this content.
In general a post NAT breast cancer pathology report should include :

• the presence or absence of residual tumor,

• tumor histologic type, grade and size (ypT size based on AJCC),
• presence or absence of TIL,
• LVI,
• necrosis, calcification and any treatment effect,
• Presence or absence of DCIS with its nuclear grade and measurement,
• surgical margins status,
• post NAT tumor biomarkers,
• RCB score and RCB index.
• It is important to understand the differences between “tumor bed”, “residual tumor
bed” and the “tumor size (ypT)” to evaluate and report the response of the tumor.

• Tumor bed is a fibrotic area that is grossly or microscopically abnormal and it is

located at the location of the primary tumor.

• If there is any residual tumor identified after treatment, the largest cross section
of residual tumor, including the adjacent fibrotic area is the “residual tumor
bed”. It can be larger, smaller or the same size as tumor bed
 Pathologic Complete Response (pCR) is the absence of the residual invasive
tumor (ypT0) if it associated with the absence of metastatic carcinoma in lymph
nodes (ypN0) and lymphovascular invasion.
• Pathologic Complete Response (pCR) :
No residual invasive tumor (ypT0) + NO metastatic carcinoma in lymph nodes (ypN0) +
NO lymphovascular invasion.

For example:
1-NO residual tumor,
2-presence of isolated tumor cells in a lymph node (ypN0(þi))
preclude the diagnosis or categorization of the lesion as pCR.

The other example that does not correlate to a pCR is when there is
1- no invasive disease in breast (ypT0),
2- no lymph nodes involvement (ypN0),
3-but there are foci of LVI in the specimen.
Presence of LVI is associated with worse prognosis,
and does not categorize as pCR.

On the other hand presence of only DCIS (ypTis) in the tumor bed without an invasive
component does not change the diagnosis of pCR and is not a prognostic finding and the
survival rate is comparable to patients with no residual tumor (invasive and in situ)
NOTE:
-The surgical margins should be evaluated and reported.
-The presence of any residual tumor or DCIS is associated with a higher recurrence rate.
• In a normal breast, NAT can cause atrophy of the terminal duct lobule units (TDLU),
attenuation of the lobules’ epithelial cells, and subsequently prominent myoepithelial cells,
stromal sclerosis and cytological atypia including large vacuolated cytoplasm, large
hyperchromatic nuclei and presence of nucleoli.

• The residual tumor morphology in post NAT specimen, have to be reported especially if it is
different and especially has a higher grade in compare to the primary tumor obtained by core
needle biopsy.

• The best way to evaluate any changes in the size of the tumor after treatment is to compare the
post NAT tumor size with the imaging size of the primary tumor.

• It is very important to recognize the post treatment stromal changes at tumor bed especially
when there is no residual tumor . There are no normal ducts, lobules or TDLU in the tumor
bed.

• The stromal changes include an edematous fibrosis ,myxoid changes, remaining tumor
angiogenesis in the area that the tumor used to be, foreign body giant cells, cholesterol clefts,
chronic inflammatory cells and histiocytes, some with hemosiderin pigment. Sometimes the
histiocytes can mimic treated tumor cells and a cytokeratin immunostain is necessary to
differentiate them.
Her-2
• When the
ratio of HER2/CEP17 was ≥2.0 or
the average HER2 gene copy number/tumor cell was ≥6.0 with a
ratio of HER2/CEP17 <2.0, the HER2 status was classified as
positive.

When the ratio of HER2/CEP17 was <2.0 with an average HER2

signals/cell <4.0, the HER2 status was considered negative
Positive (Score 3+) Complete membrane staining that is intense and >10% of tumor
cells*
Almost always ER positive:

• Lobular carcinoma.
• Tubular carcinoma.
• Mucinous carcinoma
• Papillary carcinoma.
Silicon granuloma
• Features are not specific:
– Chronic inflammatory cells, foreign body giant cell reaction and fibrosis
– Fat necrosis → histiocytes containing clear, refractile, nonpolarizable material
within cytoplasmic vacuoles
– Extracellular silicone can also be seen as nonbirefringent crystals or particles
within empty spaces
ER+/ CD34+/CD31-/Factor VII-/Pan-
CK-/ B-Catanin-
ER+/ CD34+/CD31-/Factor VII-/Pan-
CK-/ B-Catanin-
p63 stain for myoepithelial cells is positive throughout the lesion,
including in the fibrovascular cores and at the periphery of the
involved duct
Circumscribed solid growth pattern with
interspersed delicate fibrovascular cores

Neuroendocrine differentiation is common