Surgical Pathology

3rd Shifting
CASE: BREAST
 41 year old female

8 cm right breast mass

 3

“The diagnosis of a breast mass

should be on the basis of triple
assessment, clinical (history and
examination), imaging (usually
mammography and/or ultrasound)
and cytopathological diagnosis
(cytology or histology).”

Jatoi, I., & Kaufmann, M. (2010). Management of Breast Diseases. NY: Springer Science+Business Media. p10
 Clinical breast examination
Diagnostic mammogram
Ultrasonography
UTZ-guided core-needle biopsy
 5

Normal Breast Histology Scanner (4x) and HPO (40x)

Scanner (4x)
Scanner (4x)
HPO (100x)
 9

SALIENT FEATURES OF THE CASE

▫ 41 years old, female
▫ 8 cm right breast mass
▫ Loose stroma with moderate cellularity
▫ No alveoli or lobules
▫ Myxoid stromal appearance
▫ Stromal borders lined by single layer of cuboidal epithelium
▫ Several broad projections from the borders
▫ Presence of few lymphocytes
▫ Presence of several dispersedly-arranged oval to round and spindle-
shaped cells with conspicuous nucleoli
▫ Presence of mitotic figures
 Epithelial Epithelial
Many
Fibroepithelial
Common benign
Lymphomas tumors
typesand
may tumours
malignant
include
arise from
in are breast
the a
haematological as
amesenchymal
heterogeneous
proliferation
malignancies,
primary tumoroflesions
group
or asofthat
epithelial
melanoma, maybiphasic
occur
parenchyma.
carcinomas
involve the
DCIS
elsewhere
neoplasms
of and
the lung,
breast in
LCIS
consisting
the body
ovary,
secondarily are two
and of
(WHO,have
alesions
proliferation
kidney been ofInthe
(WHO,
2012).
Mesenchymal breast
described
of both
2012).
adult classified
epithelial
in theprimary
patients, breast.
byand
WHOstromal
(Schnitt
under et al.,
lymphomas of
2019).
components
precursor
the are(WHO,
breast lesions.
nearly 2012).
They are of non-
always
proliferation
Hodgkin typeofandepithelial cells that are
are usually
Malignant found in the
composed ofductal-lobular
B cells, although
lymphoma architecture.
examples
on record.
of T-cell lymphoma are also

Metastatic

Fibroepithelial
 Fibroadenoma

Fibroepithelial Phyllodes tumor

Hamartoma
 12

DIFFERENTIAL
DIAGNOSIS
13
 BENIGN PHYLLODES TUMOR

LOW-GRADE
CASE SPECIMEN PHYLLODES TUMOR [1]
(4X) (4X)Heidelberg.
[1] Moinfar, F. (2007). Essentials of Diagnostic Breast Pathology: A Practical Approach. Springer-Verlag Berlin
 BENIGN PHYLLODES TUMOR
RULE IN RULE OUT

EPIDEMIOLOGY
● Middle-aged women (40-50 years of age)

CLINICAL
● 8 cm right breast mass

HISTOPATHOLOGY RULE IN
● Loose stroma with moderate cellularity
● Stromal borders lined by single layer of
cuboidal epithelium
● Several broad projections from the
borders
● Presence of mitotic figures (4 in one HPO
field)
 MALIGNANT PHYLLODES TUMOR

CASE SPECIMEN MALIGNANT PT

(40X) (40X)
Lakhani, S., Ellis, I., Schnitt, S., Tan, P.H., & Van de Vijver, M. Eds. (2012). WHO Classification of Tumours of the Breast. 4th Ed. International Agency for Research on Cancer, WHO
OMS.
 MALIGNANT PHYLLODES TUMOR
RULE IN RULE OUT

EPIDEMIOLOGY
● First appears on average on the 4th to 5th

CANNOT BE TOTALLY
decade of life

CLINICAL
● 8 cm right breast mass

RULED OUT
HISTOPATHOLOGY
● Loose stroma with moderate cellularity
● Presence of several dispersedly-arranged
oval to round and spindle-shaped cells
with conspicuous nucleoli
● Presence of mitotic figures (4 in one HPO
field)
 18

▫ *Table ng grading*
 FIBROADENOMA

Fibroadenoma[1] (4x)

Breast mass (4x) [1] Moinfar, F. (2007). Essentials of Diagnostic Breast Pathology: A Practical
Approach. Springer-Verlag Berlin Heidelberg.
 FIBROADENOMA
RULE IN RULE OUT

● F>M[1] ● Rarely occurs beyond 30 years of

age[1]
● 8 cm right breast mass (may grow
together synchronously or
metachronously up to 20 cm[2])

● Lesion well circumscribed from

RULE OUT ● Usually no mitotic figures, and if
normal parenchyma[2] present (<3 per 10 hpf) it is found in
● Presence of abundant loose myxoid the young or pregnant[2]
stroma and flattened ducts[3] ● No broad projections from borders[4]

[1] Stolnicu, S. & Alvarado-Cabrero, I. Eds. (2018). Practical Atlas of Breast Pathology. Springer International Publishing AG, Springer Nature.
[2] Lakhani, S., Ellis, I., Schnitt, S., Tan, P.H., & Van de Vijver, M. Eds. (2012). WHO Classification of Tumours of the Breast. 4th Ed. International Agency for Research on Cancer, WHO OMS.
[3] Goldblum, J.R., Lamps, L.W., McKenny, J.K., & Myers, J.L. (2018). Rosai and Ackerman’s Surgical Pathology (11th ed). Philadelphia, PA: Saunders, Elsevier Inc.
[4] Atkins, K. & Kong, C. (2013). Practical Breast Pathology - A Diagnostic Approach. Philadelphia, PA: Saunders, Elsevier Inc.
 HAMARTOMA

Breast hamartoma[1] (4x)

Breast mass (4x) [1] Goldblum, J.R., Lamps, L.W., McKenny, J.K., & Myers, J.L. (2018).
Rosai and Ackerman’s Surgical Pathology (11th ed). Philadelphia,
PA: Saunders, Elsevier Inc.
 HAMARTOMA
RULE IN RULE OUT

● Premenopausal (4th-5th decade of

life)[1]
● F>M[1]
● 8 cm mass (soft palpable mass
measuring up to 20 cm[2][3]) RULE OUT
● Lesion well circumscribed from ● No disorganized lobules or
normal parenchyma [4] alveoli[4]
● Presence of abundant loose stroma
and ducts[4]

[1] Atkins, K. & Kong, C. (2013). Practical Breast Pathology - A Diagnostic Approach. Philadelphia, PA: Saunders, Elsevier Inc.
[2] Stolnicu, S. & Alvarado-Cabrero, I. Eds. (2018). Practical Atlas of Breast Pathology. Springer International Publishing AG, Springer Nature.
[3] Lakhani, S., Ellis, I., Schnitt, S., Tan, P.H., & Van de Vijver, M. Eds. (2012). WHO Classification of Tumours of the Breast. 4th Ed. International Agency for Research on Cancer, WHO OMS.
[4] Goldblum, J.R., Lamps, L.W., McKenny, J.K., & Myers, J.L. (2018). Rosai and Ackerman’s Surgical Pathology (11th ed). Philadelphia, PA: Saunders, Elsevier Inc.
 23

A CASE OF
BENIGN PHYLLODES
TUMOR
TO RULE OUT
MALIGNANT PHYLLODES
 24

EPIDEMIOLOGY
▫ Phyllodes tumors occurs predominantly in middle-aged
and older women, but can be diagnosed in young adults
and even adolescents.
▫ In Asian countries, it may occur in younger women ages
25 to 30 years old.
▫ Diagnosis can not be excluded on the basis of age
 25

CLINICAL FEATURES
▫ The characteristic presentation of phyllodes tumor is a
unilateral, painless mass that is not attached to the
skin.
▫ If the tumor is large, it may cause the breast skin to
stretch with striking distention of superficial veins.
▫ Bloody nipple discharge has been reported in some
patients but rarely
 26

MORPHOLOGIC FEATURES
▫ Grossly:
- vary in size; some huge, some <5cm in diameter
- cut surface is tan or pink to grey in color
- may be mucoid and fleshy
- whorled pattern with curved clefts best seen in
large lesions
- areas of necrosis, cystic degeneration, and
hemorrhage may be present
 27

MORPHOLOGIC FEATURES
▫ Histopathology:
- intracanalicular growth pattern with leaf-like
projections into variably dilated elongated lumina
- epithelial component consists of luminal epithelial
and myoepithelial cells stretched into arc-like clefts
surmounting stromal fronds
- apocrine or squamous metaplasia is occasionally
present and usual ductal hyperplasia is not rare
 28

MORPHOLOGIC FEATURES
▫ In benign PTs
- stroma is usually more cellular than in fibroadenomas
- spindle-cell stromal nuclei are monomorphic and
mitoses are rare, usually <5 per 10 HPF
- stromal cellularity may be higher in the zone
immediately adjacent to the epithelium
- areas of sparse stromal cellularity, hyalinization or
myxoid changes are common
 29

DIAGNOSTIC WORK-UP
▫ Mammography - rounded non-spiculated mass with
smooth or lobulated borders and homogenous density; a
peripheral halo may present.
▫ Ultrasound - well-rounded oval to lobulated mass, with
cysts and internal echoes with a heterogenous pattern.
▫ MRI - round or lobulated mass with well-defined
margins and heterogenous internal structure with internal
septations.
 30

DIAGNOSTIC WORK-UP
▫ Core needle biopsy - used to differentiate between
fibroadenoma and phyllodes tumor; also to differentiate
between malignant and benign PT.
▫ Excisional biopsy - both diagnostic and therapeutic
 31

TREATMENT AND MANAGEMENT

▫ Phyllodes tumors are treated by complete excision
▫ If they are very large, they may require mastectomy
▫ Benign phyllodes tumors with low risk features can be
managed by limited excision that preserves the size and
shape of the breast
▫ Current guidelines recommend wide local excision (≥ 1 cm
margin) for all breast phyllodes tumours regardless of
classification
 32

GRADING AND PROGNOSIS

▫ *Table ng grading*
 33

GRADING AND PROGNOSIS

▫ Most PTs behave in a benign fashion
▫ Local recurrences occur only in a small proportion of
cases
- 10-17% for benign PTs
▫ Status of surgical margins at previous excision is said to
have the most reliable PPV for local recurrences
 34

GRADING AND PROGNOSIS

▫ Histological parameters with independent impact on
recurrence:
- stromal overgrowth and atypia
- mitotic activity (most significant)