breast









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  • Normal

    • glands
    • stroma
    • intramammary lymph node
    • signout
      • Benign breast tissue
      • No atypia, in situ or invasive carcinoma identified
  • Specimen types

    • partial mastectomy = segmental mastectomy = lumpectomy = lump of breast fat
    • total mastectomy = simple mastectomy = breast with skin and nipple
      • skin sparing mastectomy: breast with nipple and areola, spares skin
      • nipple sparing mastectomy = total skin sparing mastectomy: spares all of skin, nipple and areola
    • radical mastectomy: includes axillary nodes and muscle
      • modified radical mastectomy: includes fascia, +/- axillary node sampling
  • Clinical

    • Early stage
      • criteria: tumor <= 5 cm and <= 3 nodes
      • stages: I, IIA, T2N1
      • tx: surgery, sentinel lymph node
      • caveats: dissection if 3+ positive SLNs or positive palpable node
    • Locally advanced
      • T3N0, stage IIIA-C = either tumor > 5 cm or > 3 node mets
      • tx: neoadjuvant chemo, surgery, node dissection
    • Metastatic = stage IV = contralateral node
      • liver, pulmonary mets = even worse prognosis
    • Hormones
      • ER/PR status: dual positive > single positivity > all negative
      • Her2 positive > negative due to Herceptin tx option
    • Worse clinical factors: wt loss, poor performance status, LDH elevation, fast relapse
    • Tumor burden markers: CA15-3, CA27.29, circulating tumor cells
  • Approach

    • epithelial lesions
      • ductal
      • lobular
      • other lesions: papillary, columnar cell, adenosis
      • other carcinomas, metastasis
    • stromal lesions
      • infiltrate: heme, soft tissue
      • fibroepithelial
      • PASH
    • clinical correlation
      • calcifications
      • does lesion explain mass
  • Ddx by categories

  • Other neoplasms

    • tubular carcinoma
    • cribriform carcinoma
    • medullary carcinoma
      • atypical medullary carcinoma
      • invasive carcinoma NST with medullary features
    • apocrine carcinoma
    • mucinous carcinoma
    • signet ring carcinoma
    • papillary carcinoma
    • micropapillary carcinoma
    • metaplastic carcinoma
      • adenosquamous carcinoma
      • squamous cell carcinoma
      • spindle cell carcinoma
      • myoepithelial carcinoma
      • metaplastic carcinoma with mesenchymal differentiation
      • mixed
    • myoepithelial lesions
      • myoepithelial hyperplasia
      • collagenous spherulosis
      • myoepithelial carcinoma
    • epithelial myoepithelial lesions
      • pleomorphic adenoma
      • adenomyoepithelioma
      • adenomyoepithelioma with carcinoma
      • adenoid cystic carcinoma
    • salivary gland tumor
      • pleomorphic adenoma
      • mucoepidermoid carcinoma
      • adenoid cystic carcinoma
      • acinic cell carcinoma
    • skin adnexal tumor
      • cylindroma
      • clear cell hidradenoma
      • sebaceous carcinoma
    • other
      • polymorphous carcinoma
      • neuroendocrine (pure vs with neuroendocrine differentiation)
      • secretory carcinoma
      • oncocytic carcinoma
      • lipid rich carcinoma
      • glycogen rich clear cell carcinoma
    • mesenchymal
      • PASH
      • granular cell tumor
      • fibrous
      • vascular
        • hemangioma
        • angiomatosis
        • atypical vascular lesions
        • angiosarcoma
      • peripheral nerve sheath
        • neurofibroma
        • schwannoma
      • fat
        • lipoma
        • angiolipoma
      • rhabdomyosarcoma
      • osteosarcoma
      • smooth muscle
        • leiomyoma
        • leiomyosarcoma
    • hematolymphoid
    • metastasis
    • clinically diagnosed
  • Grading (Nottingham score)

    • glandular score (wholistic)
      • 1: >75% glandular
      • 2: 10-75% glandular
      • 3: <10% glandular (lobular always get a 3)
    • nuclear score (wholistic)
      • 1: normal-ish
      • 2: cancer-ish
      • 3: ugly
    • mitotic score (worst area)
      • 1: <= 3
      • 2: 4-7
      • 3: >= 8
      • use 40x
    • overall grade
      • 1: score 3-5
      • 2: score 6-7
      • 3: score 8-9
  • Hormone status

    • ER and PR (nuclear stains, Allred system)
      • intensity: 0-3
        • 0: none
        • 1: weak
        • 2: moderatek
        • 3: strong
      • proportion: 0-5
        • 0: none
        • 1: <1%
        • 2: 1-10%
        • 3: 11-33%
        • 4: 34-66%
        • 5: >66%
      • status: positive if total score 3+
    • Her2 (membrane stain)
      • negative (scores 0 and 1+): faint incomplete or < 10%
        • 0: < 10% membrane staining of any intensity
        • 1+: faint incomplete membrane staining
      • equivocal (2+, send for FISH): complete membrane staining but is either weak/moderate or < 30%
      • positive (3+): strong complete membrane staining > 30%
    • Her2 (FISH)
      • negative: ratio < 1.8 or copy number < 4
      • borderline (retest): ratio 1.8-2.2 or copy number 4-6
        • borderline negative: ratio < 2
        • borderline positive: ratio 2+
      • positive: ratio > 2.2 or copy number > 6
  • TNM (useful for grossing)

    • Tis: in situ
    • T1: <= 20mm
      • T1mi: <= 1mm (microinvasion)
      • T1a: <= 5mm
      • T1b: <= 10mm
      • T1c: <= 20mm
    • T2: <= 50mm
    • T3: > 50mm
    • T4: involvement of skin or chest wall
      • T4a: chest wall (other than pectoralis muscle)
      • T4b: skin ulceration, nodules, or edema (peau d'orange)
      • T4c: both a and b
      • T4d: inflammatory carcinoma
    • N0: histologically negative, and...
      • N0 (i-): IHC negative
      • N0 (i+): IHC positive for isolated tumor clusters (<= 0.2mm and <= 200 cells)
      • N0 (mol-): molecular negative
      • N0 (mol+): molecular positive
    • N1mi: micrometastases (tumor 0.2-2 mm or > 200 cells)
    • N1a: macrometastases (tumor > 2mm)
    • N2a: > 3 nodes, at least one macrometastasis
    • N3a: >= 10 nodes, at least one macrometastasis
  • Staging

    • 0: Tis
    • IA: T1 or T1mi
    • IB: T0-1, N1mi
    • IIA
      • T0-1, N1
      • T2
    • IIIA
      • T0-2, N2
      • T3, N1-2
    • IIIB: T4, N0-2
    • IIIC: N3
    • IV: M1
  • CPT codes

    • 88309: mastectomy with node dissection
    • 88307: mastectomy, malignant lumpectomy, positive margin, sentinel lymph node (each), node dissection (lumped together)
    • 88305: biopsy, benign lumpectomy, negative margin
    • 88360: ER, PR, Her2
    • 88342: stains