The prevalence of axillary lymph-node metastases in patients with pure tubular carcinoma of the breast and sentinel node biopsy

Omission of Surgical Axillary Lymph Node Staging in Patients with Tubular Breast Cancer

BACKGROUND

With more effective screening and treatment strategies, there is debate over whether surgical axillary staging should be deescalated for patients with small favorable breast cancers, such as tubular carcinoma (TC).

PATIENTS AND METHODS

We identified patients with TC [defined as > 90% tubular tubules (angulated, not multilayered)] and known surgical axillary staging from our institutional database (2000-2018). Using the National Cancer Database (NCDB) (2004-2015), we identified patients with TC, ductal carcinoma in situ (DCIS), and pT1 estrogen receptor (ER)-positive invasive ductal carcinoma (IDC). We determined the rates of lymph node (LN) metastases, and the 5- and 10-year overall survival (OS) for patients with LN-negative versus LN-positive disease using the Kaplan-Meier method and propensity match analysis.

RESULTS

In our institutional cohort, we identified 112 patients with T1 TC; only one (0.9%) patient had nodal involvement. In the NCDB cohort, we identified 6938 patients with T1 TC; 323 (4.7%) patients had axillary LN disease. The rate of axillary LN involvement for TC was comparable to that identified for patients with DCIS (4.2%), and much lower than that found for patients with grade I-III, T1, ER-positive IDC (20.5%), and patients with grade I, T1, ER-positive IDC (14.4%). There was no difference in 5-year (94.6% versus 95.4%, p = 0.67) and 10-year (83.9% versus 85.2%, p = 0.98) OS between TC patients with or without LN involvement. Kaplan-Meier survival curves even after propensity score matching suggest that tubular histology is independently associated with improved survival.

CONCLUSIONS

T1 TC is an excellent starting point for deescalation of surgical axillary staging.

Small Glandular Proliferations of the Breast With Absent or Attenuated Myoepithelial Reactivity by Immunohistochemistry: A Review Focusing on the Differential Diagnosis and Interpretative Pitfalls

CONTEXT

-Small glandular proliferations of the breast encompass a variety of benign, atypical, and malignant lesions that show some overlapping morphologic features. Myoepithelial stains are frequently used in the workup of these lesions in order to rule out or establish a diagnosis of invasive carcinoma. Some benign lesions show absent or diminished myoepithelial staining, and may represent an interpretative pitfall, particularly in small core biopsy samples.

OBJECTIVE

-To review small glandular proliferations of the breast that show absent or diminished staining with myoepithelial immunohistochemical markers.

DATA SOURCES

-The study comprised a review of published literature and clinical case material.

CONCLUSIONS

-The interpretation of myoepithelial stains in small glandular proliferations of the breast can, on some occasions, represent a challenge in diagnosing these lesions. Recognition of the key histopathologic features and immunohistochemical staining patterns of the entities in the differential diagnosis is crucial in their workup.

Tubular Carcinoma of the Breast: A Single Institution's Experience of a Favorable Prognosis

Tubular carcinoma is a subtype of invasive breast cancer that comprises 1 to 4 per cent of invasive breast cancers. Prior studies show nearly 100 per cent 15 year survival rate for tubular carcinoma compared to the 89.2 per cent five year survival of all breast cancers. These encouraging statistics beg the question should tubular cancers be treated as other invasive cancers, or can some patients be spared an invasive procedure or the side effects of adjuvant therapy? Fifty-seven cases of tubular carcinoma over 16 years were analyzed. All relevant aspects of the patient's history, treatment, and outcomes were documented. The aim was compare treatment outcomes of tubular breast cancer outcomes to that of all invasive breast cancers. Of the 57 patients, local recurrence was seen in two patients (3.5%) only one of which recurred as a tubular carcinoma (1.75%). There were no cancer-related mortalities. A look into our institution's data supported the notion that tubular carcinoma of the breast is a less aggressive histological type. Of our 57 cases, only two recurrences (3.5%) were noted and there were no cancer-related mortalities. Interestingly only one patient (1.75%) recurred as tubular carcinoma. Without controlling for adjuvant therapy, recommendations cannot be made for a less aggressive treatment plan at this point. Future randomized controlled trials may lead to a less aggressive treatment plan for this favorable subtype. On the basis of this study and others like it, physicians can give evidenced-based favorable prognosis with a diagnosis of tubular carcinoma of the breast.

Small Glandular Proliferations of the Breast

This article discusses the most common small glandular proliferations, namely sclerosing lesions (sclerosing adenosis and radial scar), tubular carcinoma, and epithelial displacement after needle core biopsy, as well as less common entities, such as low-grade adenosquamous carcinoma, microglandular adenosis, and syringomatous adenoma. Due to significant morphologic overlap, these entities are easily mistaken for one another. The similarities and differences among these lesions in their clinicopathologic features, radiologic findings, and immunohistochemical profiles are emphasizesd.

Breast carcinoma--rare types: review of the literature

Invasive breast cancer is a heterogeneous disease in its presentation, pathological classification and clinical course. However, there are more than a dozen variants which are less common but still very well defined by the World Health Organization (WHO) classification. The rarity of many of these neoplasms does not allow large or randomized studies to define the optimal treatment. Many of the descriptions of these cancers are from case reports and small series. Our review brings updated information on 16 epithelial subtypes as classified by the WHO system with a very concise histopathology description and parameters helpful in the clinic. The aim of our review is to provide a tool for breast cancer caregivers which will enable a better understanding of the disease and its optimal approach to therapy. This may also stand as a clinical framework for a future understanding of these rarer breast cancers when gene analysis work is reported.

The "Rosen Triad": tubular carcinoma, lobular carcinoma in situ, and columnar cell lesions

The histologic triad of tubular carcinoma (TC), columnar cell lesion (CCL), and lobular carcinoma in situ (LCIS) has been recognized, but has not yet been fully characterized. The "Rosen Triad"-named in tribute to its first categorical description by the eponymous pathologist-is a morphologic observation that may have important clinical and pathologic implications. To study these implications, the literature on the topic was reviewed. Our own institution's experience with this triad was also reviewed via a study of clinicopathologic material from all TCs diagnosed at excision during a 5-year period (2001 to 2006). The diagnosis of TC was confirmed in 86 of our cases, and relevant patient data were analyzed. TC was associated with some degree of CCL in all (100%, 86/86) cases and with LCIS in 53% (46/86) of cases. Although cases of TC that were associated with LCIS (vs. those not associated with LCIS) seemed to be slightly more likely to have multifocal TC, have another synchronous higher-grade invasive carcinoma and show nodal positivity, these differences were not found to be statistically significant (P<0.05). All 3 lesions (TC, CCL, and LCIS), whenever tested, were estrogen receptor positive, progesterone receptor-positive, and Her-2/neu negative. On the basis of our review of the literature and our own experience, until such time as the biologic explanation and clinical implication of this triad is further elucidated, we recommend that pathologists be aware of this triad and should proactively seek the other 2 lesions if any one of these elements of this triad is identified in any diagnostic breast tissue.