SURGICAL PATHOLOGY CORRELATION

1. CARCINOMA BREAST
CLINICAL PATHOLOGY
DR MUHAMMMED MUNEER M
MS GENERAL SURGERY
SGMC & RF
TRIVANDRUM KERALA

2. • 63 yr old female
• Lump in the Left breast x 1 yr duration
O/e :
Lump palpable in the lower inner quadrant measuring
12x18mm
Tenderness ++
No h/o trauma
No discharge
Skin appeared normal
Multiple enlarged lymph nodes
Mammogram : BIRADS III - IV

3. C-5479/16

6. IMPRESSION
• Papillary lesion of breast with atypia
• Possibilities of Ductal carcinoma insitu /
Invasive papillary carcinoma may be ruled
out by excision biopsy
• Suggest intraoperative frozen section
examination for confirmation

7. FROZEN SECTION

15. IMPRESSION
Lumpectomy Specimen – Left breast
- Invasive cribriform carcinoma
(size 3x2.5x2.4cm)
- Modified Bloom Richardsons Grade II
- Lateral and deep resected margin are very
close 0.1cm away from the neoplasm but
inked margin is free of neoplasm
- Other margins medial,superior & inferior
margins are free of neoplasm

16. MRM

20. ESTROGEN RECEPTOR

21. PROGESTERONE RECEPTOR

22. Her 2 /neu receptor

23. IMPRESSION
Modified Radical Mastectomy – Left breast (post
lumpectomy)
- No residual carcinomatous focus
- Adjacent breast tissue shows a focus of DCIS
with cribriform pattern
- Rest of the breast tissue show fibroadenomatoid
change
Central Lymphnode
6/6 lymphnodes show reactive change only

24. HORMONE RECEPTOR STATUS
Estrogen Receptor
Proportion score = 2/3 = 4
Intensity score = 3 ( strong)
Total score = 4+3 = 7 ( POSITIVE)
Progesterone Receptor
Proportion score = 2/3 = 4
Intensity score = 3 = strong
Total score = 4+3 = 7 (POSITIVE)

25. HER 2/ Neu receptor
2 + equivocal – weak to moderate membrane
staining is observed in more than 10% of
tumor cells

26. INVASIVE CRIBRIFORM BREAST
CARCINOMA

27. WHO CLASSIFICATION
• Epithelial Tumors
• Invasive breast carcinoma
• Epithelial-Myoepithelial tumors
• Precursor Lesions
• Intraductal proliferative lesions
• Papillary Lesions
• Benign epithelial proliferations
• Mesenchymal tumors

28. • Fibroepithelial tumors
• Tumors of the nipple
• Malignant Lymphoma
• Metastatic Tumors
• Tumors of the male breast
• Clinical patterns

29. INVASIVE BREAST CARCINOMA
 Invasive carcinoma of no special type (NST)
 Invasive lobular carcinoma
 Tubular carcinoma
 Cribriform carcinoma
 Mucinous carcinoma
 Carcinoma with medullary features
 Carcinoma with apocrine differentiation
 Carcinoma with signet ring differentiation

30.  Invasive micropapillary carcinoma
 Metaplastic carcinoma of NST
 Rare types

31. INTRODUCTION
• Rare form of breast malignancy with an
excellent prognosis
• Grows in a pattern similar to that seen in
intraductal cribriform carcinoma
• 50% component of tubular carcinoma may be
admixed

32. EPIDEMIOLOGY
• 0.3 – 0.8% of breast carcinomas
• A frequency of upto 4% has been reported in
some countries
• Mean pt. age is 53-58yrs

33. CLINICAL FEATURES
• Tumor may present as a mass, which may be
radiologically occult
On mammography:
- Typically form a spiculate mass
- Frequently containing microcalcifications
- Multifocality is observed in 10-20% of cases
• Positive for ER in all cases & positive for PR in
69% of the cases

34. GROSS
• No specific gross pathologic features have
been noted
• Mean tumor size is 3.1cm

35. MICROSCOPY
• Pure ICC consists of an invasive cribriform
pattern in >90% of the lesion
• Tumor cells is arranged as invasive,often
angulated, islands in which well- defined
cribriform spaces are formed by arches of
cells (sieve-like pattern)
• Mucin-positive secretion bearing
microcalcifications can be present within
lumina

36. • Tumor cells – small to moderate in size with a
mild or moderate degree of pleomorphism
• Mitosis – rare
• DCIS generally of cribriform architecture is
frequent – 80% of cases
• Axillary LN metastases occur in 14.3% of
cases – retention of the cribriform pattern

39. • Invasive carcinoma with a cribriform
arrangement but associated with a
component (<50%) of tubular carcinoma is
also included in this category
• Cases with a 10-49% component of another
morphological type ( other than TC) are
regarded as mixed type

40. DIFFERENTIAL DIAGNOSIS
Well - differentiated neuroendocrine tumor :
Presence of intracytoplasmic argyrophilic
granules
Adenoid cystic carcinoma:
Have second population of cells as well as
intracystic secretory & basement membrane
material

41. Cribriform DCIS
Lack of a myoepithelial cell layer around its
invasive islands, haphazard distribution &
irregular configuration
» Carcinomas rich in osteoclast- like giant cells are
mostly seen in ICC, but such giant cells may be
seen in other types of invasive mammary
carcinoma & are not diagnostic of ICC

42. STAGING

45. HORMONE RECEPTORS
A crucial development in the treatment of
breast carcinoma has been the realization that
the presence of hormone receptors in the
tumor tissue correlates well with response to
hormone therapy & chemotherapy

46. • Estrogen receptor status – the most powerful
predictive marker in breast cancer
management
• Estrogen & progesterone receptors are
codependent variables
• Progesterone receptor being a weaker
predictor of response to endocrine therapy
than estrogen receptor

47. The two parameters evaluated in
immunohistochemical preparations of
hormone receptors are :
1. The number of tumor cell nuclei stained –
expressed as a percentage of the entire
tumor cell nuclei population
2. The intensity of the reaction

48. The two parameters are sometimes combined
into a scoring system :
1. Allred Scoring System
2. H
3. Quick scores

49. ALLRED SCORING SYSTEM
A clinical instrument based on the percentage of
cells that stain by immunohistochemistry for
- ER (on a scale of 0-5)
- Intensity of the staining (on a scale of 0-3,for a
possible total score of 8)
Stratifies a breast cancer patients ER status into
cancers that are likely to respond to hormone
therapy with tamoxifen

50. Proportion Score :
0 – No cells are ER+ve
1 - < 1% of cells are ER+ve
2 - 1-10% of cells are ER+ve
3 - 11-33% of cells are ER+ve
4 - 34-66% of cells are ER+ve
5 - 67-100% of cells are ER+ve

51. Intensity score :
0 – Negative
1 –Weak
2 – Intermediate
3 – Strong
0-1 No effect
2-3 Small (20%)chance of benefit
4-6 Moderate (50%)
7-8 Good

52. HER 2/neu
• Is an oncogene that encodes a transmembrane
glycoprotein with tyrosine kinase activity
known as p185 which belongs to the family of
epidermal growth factor receptors
• Its overexpression can be measured by
immunohistochemistry or FISH

55. MOLECULAR CLASSIFICATION
CRIBRIFORM CARCINOMA - LUMINAL A
BASAL LIKE SUBTYPE IS ASSOCIATED WITH THE WORST PROGNOSIS

56. PROGNOSIS & PREDICTIVE FACTORS
• The outcome for patients with ICC is
favourable 10 yr overall survival is between
90% & 100%
• The outcome for patients with mixed ICC is
less favourable than for patients with the
pure form, but better than for invasive
carcinoma NST