Patólogo Dr. Eduardo Amezcua / patología de mama

19/10/2021

Radial Scar
Wire-guided biopsy for an architectural distortion in the left breast ( BI-RADS 4b) in a 45yo woman.
The histology shows a  3 mm lesion with dense fibroelastotic core, radiating ducts with proliferative changes without atypia of the type usual ductal hyperplasia and columnar cell change, and cysts.
This entity can harbor proliferative changes with or without atypia, and the breast cancer risk seems to be related to the worst lesion found in the radial scar.

24/09/2021

Wire guided biopsy of a cluster of microcalcifications in the upper inner quadrant of the left breast in a 42yo woman, BI-RADS 4b. The histology showed dilated ducts with hyperplastic epithelium with arcades, ridgid bridges and micropapillae, the cells display a monomorphic atypia of low grade, microcalcifications were present in the lumen of ducts. 

Atypical ductal hyperplasia is a high risk lesion (relative risk 4-5) and confers a cumulative lifetime risk of breast cancer of 30% at 25 years of follow-up, surgical excision is recommended based on the image and clinical data due to upgrading to a higher risk lesion. Chemoprevention mainly with tamoxifen is used to reduce the risk of invasive and non-invasive breast cancer.

18/08/2021

Core needle biopsy of the left breast in a fifty decade woman with a rapid growing tumor of 4.2 cm with skin oedema, BI-RADS 4c by mammogram. The histological finding shows a metaplastic breast cancer with mixed components: no special type (NST) invasive carcinoma, spindle cells and matrix producing carcinoma with cartilaginous differentiation, grade 3, with extensive necrotic areas, in-situ ductal carcinoma was present. Also a fine needle aspiration biopsy of a suspicious lymph node was made with evidence of metastatic cells in the cytology specimen. The immunohistochemistry showed a triple negative profile (RE/RE, HER2 negative) and a high proliferative index (~90%),  

Metaplastic breast cancer is characterized by differentiation of the neoplastic epithelium towards squamous cells or mesenchymal-looking elements. They are most often triple negative by immunohistochemistry and grouped in the Basal-like 2 and Mesenchymal  in the molecular subtypes. Basal-like 2 subtype is enriched in growth factor signaling and myoepithelial markers, while Mesenchymal tumors had elevated expression of genes involved in epithelial-mesenchymal-transition and growth factor pathways. The patients with MBC used to present with more advanced locoregional disease, the tumours poorly respond to neoadjuvant chemotherapy (~11%) compared to triple negative breast cancer (~30-50%) and the use of adjuvant radiotherapy seems important to reduce the locoregional recurrence. 

09/02/2021

Invasive breast carcinoma of no special type (NST), Nottingham grade 3.

Luminal B, HER 2 positive subtype by immunohistochemistry (estrogen receptor positive, progesterone negative, HER2 positive 3+ and a high proliferative index).

This subtype is associated with resistance to endocrine therapy, early relapse with more frequent locoregional recurrence compared to the HER2-enriched subtype.

06/10/2020

Cystic neutrophilic granulomatous mastitis in a 36 yo woman with a palpable mass in the left breast, BI-RADS 4c by ultrasound and mammogram.

This is a rare type of mastitis, usually presented as a palpable mass, is characterized by lobulocentric granulomatous inflammation and cystic spaces surrounded by neutrophils, in this cysts sometimes gram positive bacillus are found, wich usually correspond to Corynebacterium species. This entity requires prolonged antibiotic therapy, steroid and on some cases surgery.

12/09/2020

Ductal adenoma is an uncommon lesion believed to be a highly sclerotic intraductal papilloma, could look worrisome because of the deformed entrapped gland but the citology, the presence of myoepithelial cells and the low power architecture help to classify this lesion.

27/08/2020

El carcinoma lobulillar in situ florido (CLIS) es un subtipo que se caracteriza por una marcada distensión de las unidades tubulares ductales y lobulillares con poco estroma interpuesto o un punto de corte de tamaño en el que un acino expandido o conducto llena un área equivalente a ~ 40-50 células de diámetro, esto aunado a características citológicas del CLIS clásico. Puede presentar necrosis y calcificaciones. Como todas las neoplasias lobulillares, la pérdida de la proteína e-cadherina causada por la mutación del gen CDH1 es el hallazgo característico. El CLIS es un precursor no obligado del carcinoma de mama invasivo con un riesgo aumentado de 8 a 10 veces en comparación con la población general. Sin embargo, en los subtipos florido y pleomórfico el hallazgo concurrente de un carcinoma invasivo es tan alto como 87%, siendo la mayoría carcinomas invasores lobulillares, por lo que se necesita un examen cuidadoso en la periferia de la lesión. Cuando se reporta CLIS florido en una biopsia se recomienda la escisión quirúrgica, con tumorectomía sola o tumorectomía más radiación asociadas con una mejor supervivencia general (OS). Las guías de la NCCN recomiendan la quimioprevención endocrina, con una reducción del riesgo del 56% para cáncer de mama invasivo en el ensayo NSABP-STAR P-2.

Florid lobular carcinoma in situ (LCIS) is a subtype characterized by a markedly distention of the tubular ductal and lobular units, with little intervening stroma or a size cut-off point at which an expanded acinus or duct fills an area equivalent to ~40-50 cells in diameter, this along with cytological features of classic LCIS. Could have necrosis and calcifications. Like all lobular neoplasms the loss of the protein e-cadherin caused by mutation of the CDH1 gene is the hallmark finding. LCIS is a non-obligated precursor of invasive breast carcinoma with an increased 8-10 times risk compared to the general population. However in the florid and pleomorphic subtypes the concurrent finding of an invasive carcinoma is as high as 87%, being the majority lobular invasive carcinomas, so careful examination in the peripheral tissue is needed. When florid LCIS is reported in a biopsy surgical excision is recommended, with lumpectomy and lumpectomy plus radiation associated with better overall survival. The NCCN guidelines recommend endocrine chemoprevention, with a reported risk reduction of 56% for invasive breast cancer in the NSABP-STAR P-2 trial.

@ Guadalajara, Jalisco

14/08/2020

Carcinoma ductal in situ quístico hipersecretor con grado nuclear alto y carcinoma invasor asociado.

Este tipo de carcinoma in situ es una variante rara caracterizada por ductos con dilatación quística con epitelio frecuentemente de crecimiento micropapilar con grado nuclear intermedio a alto, el espacio quístico está ocupado por líquido esoinofilo.

La hemorragia en las imágenes es secundaria a biopsia con aguja de corte previa.

@ Guadalajara, Jalisco

31/07/2020

Forty-six yo woman with a group of calcifications detected by mammogram in the left breast, a vacuum-assisted core biopsy was made and a metallic clip was placed, the control mammogram showed some residual calcifications, the histopathological study showed ductal carcinoma in situ (DCIS); a wire-guided excisional biopsy was done for the residual calcifications finding a residual DCIS of at least 8 mm, with solid and comedo pattern, intermediate nuclear grade, associated calcification and distant resections limits (>2mm). The estrogen receptor immunohistochemistry was positive in the neoplastic cells.

Newly diagnosed ductal carcinoma in situ in the absence of invasive carcinoma should be tested for estrogen receptor (ER) by immunohistochemistry. The NSABP B-24 and other trials had showed a benefit in adding tamoxifen, with reduction of subsequent breast cancer in patients treated with lumpectomy and radiotherapy in RE positive DCIS.

There's no supporting evidence that progesterone receptor (PR) testing adds predictive or prognostic information. In a study by Chaudhary et. al., the ER+/PR- subtype was not a significant predictor of recurrence in DCIS patients. So de PR testing is optional as referred in the ASCO/CAP guidelines.

@ Guadalajara, Jalisco

28/07/2020

22/07/2020

El receptor de estrógeno por inmunohistoquímica desde las recomendaciones ASCO / CAP 2010 para receptores hormonales en cáncer de mama invasivo se considera positivo cuando al menos el 1% de las células invasivas neoplásicas tienen tinción nuclear. Esto significa que el paciente es elegible para la terapia endocrina, sin embargo, cuanto menor es la expresión, menor es el beneficio, esto fue un reconocimiento en varios estudios y en este año la ASCO / CAP recomendó que el reporte de casos con un 1-10% de expresión del receptor de estrógenos como "Positivo bajo", ya que estos casos suelen comportarse como cáncer de mama triple negativo y el beneficio de la terapia endocrina es bajo.

@ Guadalajara, Jalisco

16/07/2020

Wire-guided excision biopsy lumpectomy.
Review material from a woman in the seven decade of life with a 9 mm nodule in the right breast R8. The nodule result to be an intrammamary lymph node with a 5 mm macrometastasis of a invasive breast carcinoma with low positive estrogen receptor by immunohistochemistry. No evidence of invasive carcinoma in the rest of the tissue, clinica, ultrasound and mammogram (Magnetic resonance pending).

@ Guadalajara, Jalisco