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Quinn C, Maguire A, Rakha E. Pitfalls in breast pathology. Histopathology 2023; 82:140-161. [PMID: 36482276 PMCID: PMC10107929 DOI: 10.1111/his.14799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 12/13/2022]
Abstract
Accurate pathological diagnosis is the cornerstone of optimal clinical management for patients with breast disease. As non-operative diagnosis has now become the standard of care, histopathologists encounter the daily challenge of making definitive diagnoses on limited breast core needle biopsy (CNB) material. CNB samples are carefully evaluated using microscopic examination of haematoxylin and eosin (H&E)-stained slides and supportive immunohistochemistry (IHC), providing the necessary information to inform the next steps in the patient care pathway. Some entities may be difficult to distinguish on small tissue samples, and if there is uncertainty a diagnostic excision biopsy should be recommended. This review discusses (1) benign breast lesions that may mimic malignancy, (2) malignant conditions that may be misinterpreted as benign, (3) malignant conditions that may be incorrectly diagnosed as primary breast carcinoma, and (4) some IHC pitfalls. The aim of the review is to raise awareness of potential pitfalls in the interpretation of breast lesions that may lead to underdiagnosis, overdiagnosis, or incorrect classification of malignancy with potential adverse outcomes for individual patients.
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Affiliation(s)
- Cecily Quinn
- Irish National Breast Screening Programme and Department of Histopathology, St. Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Aoife Maguire
- Irish National Breast Screening Programme and Department of Histopathology, St. Vincent's University Hospital, Dublin, Ireland
| | - Emad Rakha
- Department of Histopathology, The University of Nottingham, Nottingham City Hospital, Nottingham, UK
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Maeda I, Tajima S, Kanemaki Y, Tsugawa K, Takagi M. Use of immunohistochemical analysis of CK5/6, CK14, and CK34betaE12 in the differential diagnosis of solid papillary carcinoma in situ from intraductal papilloma with usual ductal hyperplasia of the breast. SAGE Open Med 2018; 6:2050312118811542. [PMID: 30455948 PMCID: PMC6236862 DOI: 10.1177/2050312118811542] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 10/15/2018] [Indexed: 11/16/2022] Open
Abstract
Objectives: The aim of this study was to use immunohistochemistry to differentiate solid
papillary carcinoma in situ from intraductal papilloma with usual ductal
hyperplasia (IPUDH). Three types of high-molecular-weight cytokeratins (CKs)
– CK5/6, CK14, and CK34betaE12 – were targeted. Methods: We studied 17 patients with solid papillary carcinoma in situ and 18 patients
with IPUDH diagnosed by at least two pathologists. Immunohistochemical
analyses used antibodies to CK5/6, CK14, and CK34betaE12 to make the
differential diagnosis of solid papillary carcinoma in situ versus IPUDH.
Immunohistochemical staining was scored as 0–5 using Allred score. Results: Immunohistochemistry with CK5/6 and CK14 antibodies produced scores of 0–3 in
all patients with solid papillary carcinoma in situ and 2–5 in all patients
with IPUDH. Immunohistochemical staining with CK34betaE12 antibody produced
scores of 1–3 in all patients with solid papillary carcinoma and 3–5 in all
patients with IPUDH. In tissues from patients with IPUDH, significantly more
cells were stained with CK34betaE12 than CK5/6
(p < 0.05) or CK14 (p < 0.05). Conclusion: The immunoreactivity of CK5/6, CK14, and CK34betaE12 antibodies was useful to
differentiate solid papillary carcinoma in situ from IPUDH. CK34betaE12 is
especially useful for distinguishing solid papillary carcinoma from
IPUDH.
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Affiliation(s)
- Ichiro Maeda
- Department of Pathology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shinya Tajima
- Department of Pathology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshihide Kanemaki
- Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Koichiro Tsugawa
- Department of Breast and Endocrine Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masayuki Takagi
- Department of Pathology, St. Marianna University School of Medicine, Kawasaki, Japan
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Ueno N, Kuroda H, Kozuka Y, Harada O, Kato H, Kubota K, Imai Y. Dimorphic variant of ductal carcinoma in situ of the breast. HUMAN PATHOLOGY: CASE REPORTS 2017. [DOI: 10.1016/j.ehpc.2017.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Chong Y, Lee YS, Kim TJ, Park WC, Kang CS, Lee EJ. Fine needle aspiration of spindle cell ductal carcinoma in situ of the breast: A case report and the use of ancillary tests for the differential diagnosis of metaplastic carcinoma. Cytojournal 2017; 14:23. [PMID: 29021812 PMCID: PMC5634337 DOI: 10.4103/cytojournal.cytojournal_3_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 03/14/2017] [Indexed: 11/13/2022] Open
Abstract
Spindle cell ductal carcinoma in situ (DCIS) is a recently recognized subtype of DCIS, which is associated with a very rare and unique morphology. Although the histologic features have been relatively well described in a few reports, the cytologic features have not. Even though the distinction of this lesion from usual DCIS is not crucial clinically, it should be noted that this lesion might simulate the features of metaplastic carcinoma on fine needle aspiration cytology. Here, we report a case of spindle cell DCIS in a 45-year-old female, with the detailed cytologic features, both on conventional and liquid-based preparations, along with some useful immunohistochemical staining markers for the differential diagnosis.
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Affiliation(s)
- Yosep Chong
- Address: Department of Hospital Pathology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Sub Lee
- Address: Department of Hospital Pathology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae-Jung Kim
- Address: Department of Hospital Pathology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woo-Chan Park
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chang Suk Kang
- Address: Department of Hospital Pathology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Jung Lee
- Address: Department of Hospital Pathology, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Şenel F, Karaman H, Eroğlu M, Tuna Ö. Invasive papillary breast carcinoma, solid variant with neuroendocrine differentiation. Turk J Surg 2015; 33:302-304. [PMID: 29260140 DOI: 10.5152/ucd.2015.3074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/21/2015] [Indexed: 11/22/2022]
Abstract
Invasive papillary carcinoma, solid variant is a rarely observed breast tumor. It is encountered in patients of advanced ages and has a good prognosis. After the physical examination, mammography, and ultrasonography examinations, modified radical mastectomy were applied to the 72-year-old patient, who came to our hospital complaining of a mass in the left breast. During the macroscopic analysis, a well-limited, necrotic, and bleeding tumor with a diameter of 7 cm was found in the left breast, covering almost the whole area. The case was diagnosed as invasive papillary carcinoma, solid variant with neuroendocrine differentiation, which has been reported in the literature as a result of the histopathological and immunohistochemical analysis.
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Affiliation(s)
- Fatma Şenel
- Clinic of Pathology, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Hatice Karaman
- Clinic of Pathology, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Mehtap Eroğlu
- Clinic of Pathology, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Ömer Tuna
- Clinic of General Surgery, Kayseri Training and Research Hospital, Kayseri, Turkey
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Resetkova E. A Pictorial Journey Through Variants of Ductal Carcinoma in Situ (DCIS) and DCIS Mimickers. Clin Breast Cancer 2012; 12:347-63. [DOI: 10.1016/j.clbc.2012.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 06/06/2012] [Accepted: 07/09/2012] [Indexed: 11/16/2022]
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Abstract
The purpose of this review is to discuss the less common variants and mimics of ductal carcinoma in situ (DCIS). DCIS lesions are heterogeneous in clinical presentation and behavior, morphology, biomarker profile, and identified genetic aberrations. DCIS is most easily recognized when presenting with classical features. The diagnosis is more challenging when a lesion displays less common cytologic features and has architectural patterns that overlap with other benign or malignant entities.
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Affiliation(s)
- Nicole B Johnson
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - Laura C Collins
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
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9
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Tse GM, Tan PH, Moriya T. The role of immunohistochemistry in the differential diagnosis of papillary lesions of the breast. J Clin Pathol 2009; 62:407-13. [DOI: 10.1136/jcp.2008.063016] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Papillary lesions of the breast represent a heterogeneous group with differing biological behaviour. Correct diagnosis is crucial but may be difficult, as many benign and malignant papillary lesions have similar appearances. Immunohistochemistry plays a useful role in their differentiation. Myoepithelial markers can help in differentiating papilloma from papillary carcinoma, as the former usually shows a continuous layer of myoepithelial cells. In intracystic papillary carcinoma, there is controversy as to the presence of a complete myoepithelial cell layer around these lesions. p63 is the marker of choice as the staining is nuclear, cross-reactivity is minimal, and sensitivity is high. Papilloma may frequently be complicated by superimposed different types of epithelial hyperplasia, which range from usual to atypical or even ductal carcinoma in situ, and they many be morphologically similar. Basal cytokeratins (CKs) are useful to differentiate these entities; as usual hyperplasia is positive for basal CKs with a mosaic staining pattern. CK5/6 is probably the best marker. Neuroendocrine markers (chromogranin A and synaptophysin) may be positive in papillary carcinoma, particularly in the solid type, and there may be some overlap with the ductal carcinoma in situ with spindle cells or endocrine ductal carcinoma in situ. A panel of CK5/6, p63 and neuroendocrine markers can be useful in the diagnostic investigation of problematic papillary lesions of the breast. As the experience with these markers remains rather limited, it is too early to recommend basing treatment choices on these marker studies alone. Complete removal of lesion is probably still the treatment of choice.
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Kawasaki T, Nakamura S, Sakamoto G, Murata S, Tsunoda-shimizu H, Suzuki K, Takahashi O, Nakazawa T, Kondo T, Katoh R. Neuroendocrine ductal carcinomain situ(NE-DCIS) of the breast - comparative clinicopathological study of 20 NE-DCIS cases and 274 non-NE-DCIS cases. Histopathology 2008; 53:288-98. [DOI: 10.1111/j.1365-2559.2008.03093.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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11
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Elderly woman with an unusual breast lump Part 2. Pathology 2005. [DOI: 10.1097/01268031-200537010-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tan PH, Lui GG, Chiang G, Yap WM, Poh WT, Bay BH. Ductal carcinoma in situ with spindle cells: a potential diagnostic pitfall in the evaluation of breast lesions. Histopathology 2004; 45:343-51. [PMID: 15469472 DOI: 10.1111/j.1365-2559.2004.01947.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS To evaluate the morphological features of 11 cases of breast ductal carcinoma in situ (DCIS) with spindle cells and to propose an approach to distinguish it from benign mimics. The association with neuroendocrine differentiation was also investigated. METHODS Cases of breast DCIS with a spindle cell component diagnosed in the Department of Pathology, Singapore General Hospital, between June 1996 and January 2003, were included in the study. The histological characteristics were documented, and immunohistochemistry for neuroendocrine markers, hormone receptors, cerbB2, smooth muscle actin (SMA) and high-molecular-weight (HMW) cytokeratins, was carried out. Electron microscopy was carried out on reprocessed paraffin-embedded material in three cases. RESULTS Of 11 women diagnosed with DCIS with spindle cells, four presented with nipple discharge, six with a breast lump, while one was discovered to have a screen detected density. The tumour size ranged from 3 to 41 mm. The proportion of spindle cells varied from 10% to 80% of the in-situ tumour cell population. Nuclear grade was low in seven cases and intermediate in four. Necrosis was observed in two cases. Architectural pattern was papillary in six cases, and mixed in the rest. Microinvasion was present in two cases, with possible microinvasion in another two. Immunohistochemistry for neuroendocrine markers synaptophysin and chromogranin showed positive reactivity for at least one marker in all but three cases; one of these latter cases demonstrated ultrastructural neurosecretory granules. Oestrogen and progesterone receptors were expressed in 10 and nine cases, respectively, while cerbB2 was positive in only one case. HMW cytokeratin immunoprofile revealed a general lack of immunostaining within the abnormal cell population; likewise, no positivity for SMA of the cellular proliferation was detected. CONCLUSIONS Almost all DCIS lesions with spindle cells disclose neuroendocrine differentiation. Although the distinction from benign florid usual hyperplasia may pose a diagnostic histological problem, the presence of diffuse neuroendocrine expression, in conjunction with the pattern of HMW keratin profile on immunohistochemistry, supports an in-situ neoplastic process. The absence of SMA immunostaining, in conjunction with negative reactivity for cytokeratins 5/6 and 14, makes the possibility of a myoepithelial proliferation unlikely.
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Affiliation(s)
- P H Tan
- Department of Pathology, Singapore General Hospital, Singapore.
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