Breast – Cyto-Histo Correlations of Fibroepithelial Lesions
Charles D. Sturgis, M.D.Associate Professor of Pathology
Mammary Fibroepithelial LesionsLecture Outline
Review of normal
Lesions:- Hamartoma- Fibroadenoma- Tubular adenoma- Lactating adenoma- Phyllodes Tumor
TDLU
Microanatomy of the Fibroglandular Component of the Female Breast
Benign mammary ductHistology 48F
Benign Ductal EpitheliumFocus on Epithelium
Benign Ductal EpitheliumFocus on Myoepithelium
“Benign Signet Ring ME Cell”
Breast Lobule inHistology and
Cytology
Image from scrape preparation ofnon-neoplasticbreast tissue
Benign mammary lobuleFNA Papanicolaou stain
60X
Hamartoma
Disorganized but benign appearing masses composed of cells indigenous to the particular site.
Focal malformations that resemble a neoplasm, grossly and even microscopically, but result from faulty development in an organ.
Comprised of abnormal mixtures of tissue elements or an abnormalproportion of elements normally present at that site.
Well circumscribed mass lesions developing at various body sites comprised of overgrown and sometimes disorganized mixtures of
mature tissue types native to the particular organ / anatomic location.
Mammary Hamartoma
4.8% of benign breast tumors (WHO, 2012, Chapter 11).
Term first applied by Arrigoni et al to breast lesions in 1971.Surg Gynecol Obstet 1971;133(4):577-582
Called “adenolipoma” & “lipofibroadenoma” by some.
Well circumscribed and sometimes encapsulated lobulatedlesions with ducts / lobules / fibrous tissue / adipose tissue
in varying amounts.
May contain areas of PASH and smooth muscle / myoid stroma.
Associated with Cowden syndrome (germline PTEN mutations).
RUOQ
41F10 yr history of painless lump
Gradually increasing in size over timeNo history of
trauma/surgery/radiationNo nipple discharge
12 x 10 cmNo skin fixation
Well circumscribed by imaging
WHO states: Differentiation of hamartomas from fibroadenomas may be difficult on needle biopsy and is often impossible on fine needle aspiration.
Tel-Aviv, Israel
Fibroadenoma
Benign fibroepithelial neoplasm arising from TDLUHyperplastic lesion of the specialized (intralobular) stroma
Usually seen in patients 20 to 35 years of ageTypically single, 20% multipleMay enlarge during pregnancy
Usually stabilize in size between 2 and 3 cmFirm, well circumscribed, sharply demarcated, freely mobile
“Marble” in the breast of a young woman
Malignant transformation reported in less than 0.1% of cases
Fibroadenoma
Ultrasound
Gross Cut Surface
Growth PatternsIn Adult Type Fibroadenomas
Intracanalicular PatternPericanalicular Pattern
Pericanalicular: Expanded stoma with ducts retaining rounded profiles.Intracanalicular: Elongated duct-like structures with slit-like lumens
Patterns descriptive; may coexist; have no clinical significance.
Histology of Fibroadenoma
Fibroadenoma
Cytomorphologic Features
Cellularity variable, possibly as high or higher than carcinomasCohesive groupings arranged in branching or antler-like patternMyoepithelial cells detectable in cohesive epithelial fragments
Apocrine change possible
Naked oval / bipolar nuclei in background / adjacent to epithelium(Myoepithelial and/or stromal in origin)
Well demarcated stromal fragments with spindle cells
Cytology of Fibroadenoma
Cytology of Fibroadenoma
Normocellular stroma for contrast Fibroadenoma stroma
20F 3 cm Breast Mass
Benign Ductal EpitheliumFocus on Epithelium
Benign Ductal EpitheliumFocus on Myoepithelium
Cytology of Fibroadenoma
Histologic “Types” of Fibroadenoma
AdultMyxoid
ComplexJuvenileApocrine
Myxoid
Apocrine
Cytologic “Types” of Fibroadenoma
AdultMyxoid
ComplexJuvenileApocrine
Apocrine
Myxoid
Fibroadenoma with hyalinized stroma and dystrophic calcifications - 62F
Fibroadenoma with intrinsic invasive carcinoma / UDH / ADH - 46F
Invasive ductal carcinoma - 53F
Tubular Adenoma
Considered by most to be a variant of pericanalicular fibroadenomaProminent / florid adenosis-like epithelial appearance
Clinical / imaging features indistinguishable from fibroadenoma
“Softer” than FA on palpation and tan rather than “white” surface
Well circumscribed
House small round tubules lined by uniform epithelial cells with surrounding myoepithelium throughout
Tubular lumina generally empty
2015
Histology of Tubular Adenoma
Histology of Tubular Adenoma
H&E p63
Cytology of Tubular Adenoma
Lactating Adenoma
Rounded mobile mass arising in setting of pregnancy / lactation
Have been reported in non-pregnant patients on high doseexogenous steroid hormones, antipsychotic and
antihypertensive medications
May be hyperplastic or neoplastic in etiology
Histologically localized collections of lobules showinglactational changes – can include hemorrhage and infarction
Benign lesions that are biopsied to exclude malignancy
Lactating Adenoma
36F7 weeks post partum
Cytomorphologic Features
Highly cellularIntact lobules possibly identified
Areas of dyscohesion
Large hyperchromatic granular nucleiProminent nucleoli
Fragile bubbly cytoplasmNaked nuclei
Background with vacuoles, granular debris and even necrosis
Lactating Adenoma
Cytology of Lactating Adenoma
Cytology of Lactating Adenoma
Phyllodes Tumor
Primary stromal neoplasms of the breastMedian age at diagnosis 45, (older than fibroadenomas),
although can occur in adolescentsSeparated from FA by morphology and not size
Less than 1% of all breast neoplasms
Classical clinical settingLarge, irregularly lobulated, rapidly growing, painless mass
in an older woman
Lesions may be labeled as benign vs indeterminate vs malignant
Phyllodes Tumor
Histomorphologic Features
Benign PTsWell circumscribed
Stromal hypercellularity and integral benign glandular elementsLeaf-like or club-like epithelial-lined expanses of mesenchyme
Enhanced intracanalicular growth patternHemorrhage and necrosis possible
Few to no mitoses
Borderline PTSStroma typical of low grade fibrosarcoma
Intermediate numbers of mitoses
Malignant PTsInfiltrative growth, frankly sarcomatous
More than 10 mitoses per 10 HPFHeterologous elements not uncommon
WH0 2012 Lakhani et al…
p. 145
Definition of Stromal OvergrowthAbsence of epithelial elements in one low-power
microscopic field (containing only stroma).Based on 10X objective and 4X ocular (40X).
Definition of Stromal ExpansionAbsence of epithelial elements in one intermediate-power microscopic field (containing only stroma).
Based on 10 x objective and 10X ocular (100X).
Histology of Phyllodes Tumor
Benign PTs
Malignant Phyllodes Tumor8 cm RUOQ
58 F
R-XCCL
Histology of Phyllodes Tumor
Malignant Phyllodes Tumors
______________________________
HeterologousElements
Osteosarcomatous area, 52F Chondrosarcomatous area, 52F
Liposarcomatous area, 51F
Phyllodes Tumor
Cytomorphologic Features
Dimorphic population of epithelial and stromal cells
Helping to differentiate from FAHigh stromal cellularity
Single intact mesenchymal cellsStromal atypia
Mesenchymal cells longer and more wavy with plump nuclei
Capillaries may traverse stroma
Cytology of Phyllodes Tumor
Normocellular stroma for contrast
Cytology of Phyllodes Tumor
Cytology of Phyllodes Tumor
Vol 42, Issue
5, pages 405-
415 May
2014
24 of 932 breast FNAs with erroneous or
inconclusive diagnoses over a 7 year
period.
Emphasize search for and recognition of
cellular stromal fragments in
fibroepithelial lesions.
Authors from:American University of Beirut, Lebanon
&Cleveland Clinic Lerner College of Medicine, U.S.A.
Differentiation Between Phyllodes Tumors and Fibroadenomas Based on Mammographic Sonographic and MRI FeaturesDuman L., Gezer N.S., Balcı P., Altay C., Başara I., Durak M.G., Sevinç A.İ.
Dokuz Eylul University, Izmir, Turkey
Background: This study was performed to compare the mammographic, sonographic, and magnetic resonance imaging (MRI) characteristics of phyllodes tumors and fibroadenomas, which may resemble each other. Methods: Preoperative mammograms, B-mode and Doppler sonograms, and dynamic breast MRIs of 72 patients with pathologically proven fibroadenomas and 70 patients with pathologically proven phyllodes tumor were evaluated in this retrospective study. Statistical significance was evaluated using chi-square and Fisher's exact tests. Correlations in lesion size among radiological methods were examined by Pearson's correlation analysis. Results: The features that differed on mammogram were size, shape, and margin of the mass. Sonograms showed significant differences in size, shape, margin, echo pattern, and vascularization of the mass. Pearson's correlation analysis showed strong agreement among radiological methods in terms of assessment of size. Tumor size ≥ 3 cm, irregular shape, microlobulated margins, complex internal echo pattern, and hypervascularity were significant findings of phyllodes tumors. Internal cystic areas on MRI were frequently associated with phyllodes tumors.Conclusion: Mammographic, sonographic, and MRI findings of fibroadenomas and phyllodes tumors could help radiologists to ascertain imaging-histological concordance and guide clinicians in their decision making regarding adequate follow-up or the necessity of biopsy.
Breast Care 2016;11:123-127
MRI of 41F: T2-weighted turbospin echo sequence with fatsuppression showed hyperintensecystic areas. Histopathologyindicated a borderline phyllodestumor.
Nuanced differentiations
may not always be
mandatory.
2016
FA with phyllodal features Benign PT Borderline PT
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