Ugur Ozerdem

Invasive Paget Disease of the Nipple A Brief Review of the Literature and Report of the First Case With Axillary Nodal Metastases

Although Paget disease of the nipple (PDN) is a well-established clinical and pathological neoplastic process, invasive PDN (IPDN) is a relatively newly described disease. The latter entity is characterized by invasive carcinoma that is localized to the nipple and is associated with PDN as well as with either intraductal and/or invasive carcinoma in the underlying breast. To our knowledge, only 17 cases of IPDN, all node negative, have been reported. Here, we report the case of a 68-year-old woman with invasive Paget disease of the left nipple. The patient had a history of intraductal carcinoma, treated by lumpectomy alone. She presented 6 years later with “eczematous” lesion of the ipsilateral nipple, a punch biopsy of which showed a superficially IPDN as well as conventional PDN. The subsequently performed wide excision of the nipple, areola, and underlying breast tissue showed the invasive carcinoma to span 0.6 cm. Then, 3 months later, the patient presented with ipsilateral palpable axillary lymphadenopathy. Axillary dissection revealed metastatic carcinoma in 7 of 19 lymph nodes. This case of IPDN not only represents the deepest extent of invasion reported thus far but also the only one known to be node positive.

Basal Cell Carcinoma of the Nipple

papillary proliferation is admixed with fibrocystic changes including cysts, apocrine metaplasia, usual ductal hyperplasia and other proliferative fibrocystic changes, which impart the classic “swiss cheese” appearance. These features were absent in this case, ruling out that diagnosis. Therefore, the diagnosis was most consistent with papillary duct hyperplasia, which lacks these additional features. Papillary duct hyperplasia involving multiple ducts, or papillomatosis, typically spreads along ducts linearly, often in the periphery of the breast. It does not usually form a discrete nodule as seen in this case, making this a very unusual presentation. The descriptive term “nodular papillomatosis” was used to convey this unusual benign diagnosis. There are little data on the rare diagnosis of papillomatosis of the juvenile breast, but within the sparse literature there is evidence to support increased risk for future breast cancer. Thus, conservative resection with clinical follow-up to assess for recurrence as well as future breast disease is generally recommended. For this patient, it was felt that the mass had been adequately excised and further plans included clinical follow-up only.

Swiss Cheese Disease of the Breast Macroscopic Appearance of Microscopic Slides Offers a Diagnostic Clue

Coxsackie viruses, which causes the worst kinds of sniffles (is named after) a town in upstate New York, and Junin virus, causing a hemorrhagic fever, is linked to a town near Buenos Aires. At a time when General Motors advertisements were calling for customers to get “Pontiac fever,” a bacterial infection spread in Pontiac, Michigan, and immediately became known as Pontiac fever. Lyme arthritis is named after the town in Connecticut where the flu-like symptoms were first observed. Lyme is nowhere near the Rocky Mountains, where spotted fever was supposedly confined; in fact, more cases of Rocky Mountain spotted fever occur in the East.

Endosalpingiosis of Axillary Sentinel Lymph Node: A Mimic of Metastatic Breast Carcinoma

A 46-year-old woman underwent left mastectomy for recurrence of an invasive poorly differentiated ductal carcinoma. Nine years previously, the patient had undergone breast conserving therapy with lumpectomy, sentinel lymph node biopsy, and radiation. A repeat ipsilateral sentinel lymph node biopsy, at the time of mastectomy, showed no metastatic carcinoma. The patient also underwent a concurrent prophylactic right mastectomy, which showed benign inactive breast tissue. The contralateral (right) axillary sentinel lymph node biopsy, showed no evidence of metastatic carcinoma; however, a 0.2 cm cyst (Fig. 1) was identified therein. The entirely intra-nodal cyst was mainly lined by cuboidal to columnar ciliated cells (Fig. 2). The presence of much fewer interspersed “peg” cells was notable. The latter cells were slightly larger and showed clearer cytoplasm than the dominant lining epithelia, and possessed rounded bland nuclei (Fig. 2, inset). Neither cytologic atypia nor mitotic activity was identified in the lining epithelia. Smooth muscle myosin heavy-chain showed absence of a subepithelial myoepithelial cell layer (Fig. 3a). The

Complexities and challenges in the pathologic assessment of size (T) of invasive breast carcinoma.

Size (the “T” in the TNM System) of invasive breast carcinoma is a proven independent prognostic factor; however, its accurate determination can be challenging. The purpose of this review is to discuss the complexities inherent in determining “T”—including those encountered in the clinical measurement (“cT”, ie, physical and radiologic assessment) as well as pathologic determination (pT) of invasive breast carcinomas. Pathologic estimation of tumor size, macroscopic, as well as microscopic, can be problematic due to the complexity of multiple situations, seeming confusion regarding staging guidelines, and interobserver variation in interpretation. Additional problematic scenarios in determination of “T” include those incurred in excisions performed after the performance of needle core biopsies, and in cases wherein there are multiple foci of invasive carcinoma, as well as in carcinomas status post-neoadjuvant chemotherapy. It can also be difficult to determine “T” in certain types of invasive carcinoma, particularly those of the lobular type. In this communication, some of the complexities and challenges in determing “T” are discussed, and modest suggestions are offered to assist in optimizing such assessments.

Mammary "Swiss Cheese Disease" in a 26-Year-Old Woman with Cowden Syndrome.

lymphomas, and mesenchymal neoplasms. An important differential is primary neuroendocrine neoplasia of the breast, which should demonstrate neuroendocrine marker positivity in ≥50% of cells but typically expresses CK7, ER, and PR and is found associated with ductal or lobular carcinoma. Management of MCC varies by stage. For individuals without clinical nodal disease, wide local excision, and sentinel lymph node biopsy are recommended. For regional lymph node or metastatic disease presentations, multi-disciplinary tumor-board consultation is recommended. Multi-modality treatment may consist of surgery, radiation, and chemotherapy. 5-year survival is approximately 40%, with better prognosis for individuals with early stage disease.

Intracytoplasmic inclusion bodies and myoid-type of differentiation in the stroma of a benign phyllodes tumor.

in the sensitive alteration of tissues: ionizing radiations are acting via a direct damage to DNA and cellular proteins, and indirectly through the induction of an oxidative stress. The histologic changes observed in the long term are numerous and include hyperplasia and atrophy of the skin, the increasing density of collagen fibers in the dermis, the absence of pilosebaceous follicles, changes in skin thickness and sclerosis of dermal vessels which leads to a microvascular occlusion and thermoregulation troubles. The hypoesthesia after breast reconstruction is a common sequela that can potentially lead to very serious consequences as in our case in which the burn that was not detected in time by the patient, led to the loss of reconstruction. The knowledge of the pathologic mechanisms that lead to these sensory abnormalities should be investigated to find ways to minimize them. In this regard, agreeing with Lagergren et al., a study that compares the degree of hypoesthesia in mastectomised patients before and after reconstruction would be interesting to understand what is the surgical time that mostly has a negative impact on the sensitivity of breast. This atypical case allows to remind once again the risks of thermal injuries on reconstructed breast. Patient’s education is therefore essential and several situations need to be identified such as contact with hot or cold objects, but also wearing black clothes associated with sun exposure that can cause the same type of burns. It seems essential making clear to patients the vulnerability of their reconstructed breast to thermal burns most of all in the first year after surgery, but unfortunately education on these parameters remains too rarely mentioned in current practice. Understandable and codified instructions manuals should be prepared and distributed to each patient.

Neighboring look-a-likes: distinguishing between breast and dermatologic lesions.

Due to the proximity of the skin, subcutis, and axilla to the breast, the possibility of a “breast mass” actually representing a dermatologic lesion should be considered, particularly if the proliferation does not look characteristically “mammary” in appearance. Even more underappreciated is the scenario of a dermatologic proliferation morphologically masquerading as a breast tumor. The pathologist can fall prey to this pitfall if he/she is led to believe that the location of the tumor is the breast proper. The aim of this review is to provide an overview of dermatologic mimickers of breast lesions and helpful ways to discern between them when possible.

Invasive Mammary Adenoid Cystic Carcinoma with an Intraductal Component.

A 47-year-old woman presented with a palpable mass in the left breast. Bilateral saline mammary implants had been placed in the remote past. A circumscribed 2.7 cm tan and firm neoplasm was excised. Microscopically, the tumor was composed of infiltrative glands populated by basaloid cells with intermediate-grade nuclei arranged in solid and cribriform architectural patterns (Fig. 1a). Mitotic activity was brisk (mean: 5/10 high-power fields). Glands with pseudolumens containing PAS-positive basement membrane-like material (Fig. 1b) and round “true” luminal spaces containing PAS-positive granular substance were present. These findings were characteristic of mammary adenoid cystic carcinoma (ACC) of the classical type, grade II (i.e. solid areas comprised less than 30%). Rare, otherwise unremarkable, ducts at the perimeter of the tumor mass showed intraductal ACC (Fig. 1c–e). The foci of intraductal ACC appeared to “bud” from the luminal epithelium and invaginate into the ducts with an abrupt transition from inactive epithelia to ACC. Whether the intraductal ACC represented a pre-invasive phase or intraglandular extension of invasive carcinoma is an unanswerable question. The invasive and intraductal components of the carcinoma were immunoreactive for CK5, EGFR, and CD117 (C-KIT), and were “triple-negative,” i.e. negative for ER, PR, and HER2. This reactivity pattern is characteristic of ACC. p63 immunostain showed a similar reactivity pattern in invasive and intraductal carcinoma (Fig. 1f). All margins were widely free of invasive and intraductal tumor. Six months after resection, the patient had neither clinical nor radiological (including PET/CT) evidence of residual or metastatic disease. (a) (b)

Hyaline globules in mammary myofibroblastoma: a case report.

A 52-year-old otherwise healthy woman presented with a solitary firm mass in the right breast. Histopathological evaluation of the 1.5-cm mass showed a mammary myofibroblastoma of the conventional spindle-cell type. High-power examination of hematoxylin–eosin-stained sections showed round, eosinophilic, intracytoplasmic, as well as extracellular, hyaline globules. These 5- to 20-µm globules appeared gray with a pinkish rim on Masson’s trichrome stain. Immunohistochemically, the hyaline globules were strongly reactive with smooth muscle myosin heavy chain, desmin, and caldesmon. Histologically similar inclusion bodies have been reported in phylloides tumors—including those with myoid differentiation. To our knowledge, this is the first description of hyaline globules, a peculiar histological curiosity with no known clinical significance, in mammary myofibroblastoma.