Series Editor David E. Elder, MB, ChB Consultant Pathology R E A S T A T H O L O G Y Melinda E. Sanders Jean F. Sitnpson Consultant Pathology breast pathology Sanders_87680_PTR_00_i-xvi_FM_02-13-14.indd 1 13/02/14 6:08 PM Consultant Pathology Series David E. Elder, MB, ChB Series Editor Tumorigenic Melanocytic Proliferations David E. Elder Brain Tumors Richard Prayson, Bette Kleinschmidt-DeMasters, and Mark L. Cohen Head and Neck Pathology Leon Barnes, Raja Seethala, and Simion Chiosea Liver Pathology Linda Ferrell and Sanjay Kakar Intraoperative Frozen Sections Pedram Argani and Ashley Cimino-Mathews Breast Pathology Melinda E. Sanders and Jean F. Simpson Forthcoming Volume in the Series Superficial Melanocytic Pathology David E. Elder Sanders_87680_PTR_00_i-xvi_FM_02-13-14.indd 2 13/02/14 6:08 PM Consultant Pathology Vo l u m e 6 breast pathology Melinda E. Sanders, MD Associate Professor of Pathology Vanderbilt University Medical Center Nashville, TN Jean F. Simpson, MD President Breast Pathology Consultants, Inc. Nashville, TN Adjunct Professor of Pathology University of South Alabama Mobile, AL New York Sanders_87680_PTR_00_i-xvi_FM_02-13-14.indd 3 13/02/14 6:08 PM Visit our website at www.demosmedical.com ISBN: 9781936287680 e-book ISBN: 9781617051173 Acquisitions Editor: Rich Winters Compositor: diacriTech © 2014 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Medicine is an ever-changing science. Research and clinical experience are continually expanding our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the contents of the publication. Every reader should examine care- fully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Library of Congress Cataloging-in-Publication Data Sanders, Melinda E., author. Breast pathology / Melinda E. Sanders, Jean F. Simpson. p. ; cm. — (Consultant pathology series ; v. 6) Includes bibliographical references and index. ISBN 978-1-936287-68-0 — ISBN 978-1-61705-117-3 (e-book) I. Simpson, Jean F., author. II. Title. III. Series: Consultant pathology series ; 6. [DNLM: 1. Breast Neoplasms—physiopathology. 2. Breast Diseases—physiopathology. WP 870] RG493 618.1’907—dc23 2013047924 Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. For details, please contact: Special Sales Department Demos Medical Publishing, LLC 11 West 42nd Street, 15th Floor New York, NY 10036 Phone: 800-532-8663 or 212-683-0072 Fax: 212-941-7842 E-mail: [email protected] Printed in the United States of America by Bradford & Bigelow. 14 15 16 17 / 5 4 3 2 1 Sanders_87680_PTR_00_i-xvi_FM_02-13-14.indd 4 13/02/14 6:08 PM To David Lee Page, mentor and friend Sanders_87680_PTR_00_i-xvi_FM_02-13-14.indd 5 13/02/14 6:08 PM Sanders_87680_PTR_00_i-xvi_FM_02-13-14.indd 6 13/02/14 6:08 PM C o n t e n t s Series Foreword xi Foreword xiii Preface xv 1. Alterations of Enlarged Lobular Units 1 1.1 Enlarged Lobular Unit With Apocrine Change 4 1.2 Columnar Cell Lesions Without Atypia 6 1.3 Columnar Cell Lesions With Atypia 9 1.4 Secretory Change 11 2. Epithelial Proliferative Lesions 13 2.1 Hyperplasia Without Atypia, Usual and Florid Patterns 18 2.2 Usual Hyperplasia Without Atypia, “Gynecomastoid Pattern” 20 2.3 Usual Hyperplasia Without Atypia, Compact Pattern 23 2.4 Papillary Apocrine Change 25 2.5 Usual Hyperplasia With Prominent Myoepithelial Cells 28 2.6 Usual Hyperplasia With Clear Cells 30 2.7 Atypical Ductal Hyperplasia, Cribriform Pattern 32 2.8 Collagenous Spherulosis 35 2.9 Atypical Ductal Hyperplasia, Solid Pattern 39 2.10 Atypical Ductal Hyperplasia, Micropapillary Pattern 41 2.11 Atypical Ductal Hyperplasia With Apocrine Cytology 43 2.12 Hypersecretory Hyperplasia 45 2.13 Atypical Ductal Hyperplasia in a Background of Hypersecretory Hyperplasia 47 2.14 Florid Hyperplasia Involving a Papilloma 49 2.15 Cells of Atypical Lobular Hyperplasia Admixed With Florid Hyperplasia, Involving an Intraductal Papilloma 51 2.16 Collagenous Spherulosis Involving Micropapillomas 53 2.17 Papilloma Involved by Atypical Ductal Hyperplasia 55 2.18 Nipple Adenoma 57 2.19 Mucocele-Like Lesion 59 2.20 Mucocele-Like Lesion With Atypical Ductal Hyperplasia 61 vii Sanders_87680_PTR_00_i-xvi_FM_02-13-14.indd 7 13/02/14 6:08 PM viii CoN T E N T S 3. Ductal Carcinoma In Situ, Special Considerations 63 3.1 Ductal Carcinoma In Situ, Low Grade, Minimal Example 70 3.2 Ductal Carcinoma In Situ, Solid Pattern Mimicking LCIS 72 3.3 Ductal Carcinoma In Situ, With Lobular Cytology 74 3.4 Spindle Cell Pattern Ductal Carcinoma 77 3.5 Ductal Carcinoma In Situ With Florid-Like Pattern 79 3.6 Ductal Carcinoma In Situ With Biphasic Pattern 81 3.7 Apocrine Ductal Carcinoma In Situ 83 3.8 Micropapillary Ductal Carcinoma In Situ 88 3.9 Ductal Carcinoma In Situ Arising in a Background of Hypersecretory Hyperplasia 90 3.10 Ductal Carcinoma In Situ Involving Sclerosing Adenosis 92 3.11 Displaced Epithelial Elements After Biopsy of Ductal Carcinoma In Situ 96 3.12 Invasive Carcinoma Associated With Ductal Carcinoma In Situ 99 3.13 Encysted Noninvasive Papillary Carcinoma 101 3.14 Ductal Carcinoma In Situ Involving a Papilloma With Areas of Pseudoinvasion 103 3.15 Paget’s Disease of the Nipple 106 3.16 Toker Cells 108 3.17 Ductal Carcinoma In Situ With Tall Cell Pattern, Involving Papillomas 109 3.18 Secretory Ductal Carcinoma In Situ 111 3.19 Pagetoid Pattern Ductal Carcinoma In Situ 113 3.20 Radiation Change Mimicking Ductal Carcinoma In Situ 115 4. Lobular Neoplasia 117 4.1 Atypical Lobular Hyperplasia With Involvement of Ducts 121 4.2 Classic Lobular Carcinoma In Situ 124 4.3 Lobular Carcinoma In Situ Involving a Fibroadenoma and an Adjacent Lobular Unit 126 5. Sclerosing and Adenotic Lesions 129 5.1 Nodular Apocrine Sclerosing Adenosis 133 5.2 Sclerosed Adenotic Intraductal Papilloma 135 5.3 Adenomyoepithelioma 139 5.4 Radial Scar 142 5.5 Atypical Lobular Hyperplasia Involving Sclerosing Adenosis Associated With a Radial Scar 144 5.6 Microglandular Adenosis 147 5.7 Atypical Microglandular Adenosis 149 6. Fibroepithelial Lesions 151 6.1 Cellular Fibroadenoma 155 6.2 Atypical Ductal Hyperplasia Involving a Fibroadenoma 157 6.3 Atypical Lobular Hyperplasia Involving a Fibroadenoma 159 Sanders_87680_PTR_00_i-xvi_FM_02-13-14.indd 8 13/02/14 6:08 PM ix CoN T E N T S 6.4 Benign Phyllodes Tumor 161 6.5 Borderline Phyllodes Tumor 164 6.6 Malignant Phyllodes Tumor 167 6.7 Hamartoma 173 7. Reactive and Benign Stromal Lesions 175 7.1 Pseudoangiomatous Stromal Hyperplasia 179 7.2 Reactive Spindle Cell Nodule 181 7.3 Nodular Fasciitis 184 7.4 Cellular Myofibroblastoma 187 7.5 Epithelioid Myofibroblastoma 189 7.6 Fibromatosis 192 7.7 Sclerosing Lymphocytic Lobulitis 195 8. Special Type Carcinomas 197 8.1 Tubular Carcinoma 204 8.2 Invasive Cribriform Carcinoma 208 8.3 Mucinous Carcinoma 212 8.4 Invasive Lobular Carcinoma 215 8.5 Secretory Carcinoma 222 8.6 Adenoid Cystic Carcinoma 224 8.7 Low Grade Fibromatosis-Like Metaplastic Carcinoma 229 8.8 Low Grade Adenosquamous Carcinoma 233 9. Invasive Carcinomas, Special Considerations 235 9.1 Invasive Micropapillary Features 239 9.2 Retraction Artifact 241 9.3 Invasive Carcinoma With Apocrine Differentiation 243 9.4 Invasive Carcinoma With Medullary Features 245 9.5 Invasive Carcinoma With Neuroendocrine Differentiation 247 9.6 Solid Pattern Invasive Carcinoma Mimicking Ductal Carcinoma In Situ 251 9.7 Lymphovascular Invasion Mimicking Ductal Carcinoma In Situ 253 9.8 Invasive Mammary Carcinoma in a Background of Microglandular Adenosis 255 9.9 Entrapped Squamous Morules Within a Previous Biopsy Site Reaction 257 10. Sentinel Lymph Nodes 259 10.1 Benign Transport 263 10.2 Isolated Tumor Cell Clusters 265 10.3 Micrometastasis 267 Sanders_87680_PTR_00_i-xvi_FM_02-13-14.indd 9 13/02/14 6:08 PM