Breast biopsy or excision

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Author: Mikael Häggström [notes 1]

Gross processing

Selection and trimming

  • Determine total specimen size. Optionally, determine weight[1]
  • Ink margins.[notes 2] If sample orientations are marked, use different colors for different directions.[1]
  • Palpate specimen for masses. Compare with radiograph if available[1]
  • Make 3-4 mm thick slices.[1]
  • Submit:[1]
  • Entire specimen if it can fit in 3-5 slices.
  • If larger, 1 slice per cm of tumor (minimum of 3 slices of tumor), including both center and periphery of tumor.
  • Additional suspicious areas, including those indicated by mammography
See also: General notes on gross processing

Report

  • Size of original tissue sample, preferably in 3 dimensions.
  • Tumor properties, at least:
  • Size in 3 dimensions.[1]
  • Distance from margins[1]
  • Consistency[1]

Staining

Usually H&E staining.

Routine immunohistochemistry usually include estrogen and progesterone receptors (ER, PR) and HER2.[2]

Microscopic evaluation

If tumor is found, determine:

  • Tumor size
  • Malignancy
  • Distance from excision margin

Malignancy

The most important is to classify a sample as either of the following:

  • Benign
  • Carcinoma in situ
  • Invasive cancer

Most common types

Women seeking evaluation of a breast lump[3]
Finding Relative
incidence
Histopathology Image
Fibrocystic breast changes 40%
No disease 30%
Fibroadenoma 7% Proliferation of both stromal and epithelial components,[notes 3] arranged into either a pericanalicular pattern (stromal proliferation around epithelial structures), or an intracanalicular pattern (stromal proliferation compressing the epithelial structures into clefts). Fibroadenomas characteristically display hypovascular stroma compared to malignant tumors.[4][5][6] Furthermore, the epithelial proliferation appears in a single terminal ductal unit and has duct-like spaces surrounded by a fibroblastic stroma. The basement membrane is intact.[7] Micrograph of a fibroadenoma.jpg
Atypical ductal hyperplasia 7%[8] Epithelial proliferations which are not qualitatively or quantitatively abnormal enough to be classified as ductal carcinoma in situ.[8] Micrograph of atypical ductal hyperplasia.jpg
Other benign mammary dysplasias and neoplasms 5%
Breast cancer (in situ or invasive) 10% See next section.

Breast cancer types

Breast cancer types, with relative incidences and prognoses.
Cancer type Histopathology Image
Invasive ductal carcinoma Carcinomatous cells are seen below the basement membrane of lactiferous ducts. Otherwise, there are no specific histologic characteristics, essentially making it a diagnosis of exclusion.[9] Invasive ductal carcinoma, with occasional entrapped normal ducts.jpg
Ductal carcinoma in situ Malignant epithelial cells confined to the ductal system of the breast, without invasion through the basement membrane.[10] DCIS - Intraductal carcinoma of the breast.jpg
Invasive lobular carcinoma The "classic" pattern is round or ovoid cells with little cytoplasm in a single-file infiltrating pattern, sometimes concentrically giving a targetoid pattern. Classic Invasive Lobular Carcinoma of the Breast (6813147194).jpg
Further information: Evaluation of tumors

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
  2. Inking can be done with India ink, and will specify the serosa or resection margin in later histopathologic evaluation.
  3. The proliferation of two histological components is called "biplasia", from Latin bis (“twice”) and -plasia (“formation”), or "biphasic proliferation"

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Monika Roychowdhury. Grossing (histologic sampling) of breast lesions. Pathologyoutlines.com. Topic Completed: 1 August 2012. Revised: 19 September 2019
  2. "Immunohistochemical detection of estrogen and progesterone receptor and HER2 expression in breast carcinomas: comparison of cell block and tissue block preparations ". Int J Clin Exp Pathol 2 (5): 476–80. 2009. PMID 19294006. 
  3. Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson (2007). Robbins Basic Pathology (8th ed.). Philadelphia: Saunders. p. 739. ISBN 978-1-4160-2973-1. 
  4. Tavassoli, F.A., ed (2003). World Health Organization Classification of Tumours: Pathology & Genetics: Tumours of the breast and female genital organs . Lyon: IARC Press. ISBN 978-92-832-2412-9. 
  5. Jaya Ruth Asirvatham, M.B.B.S., Carlos C. Diez Freire, M.D., Cansu Karakas, M.D., Belinda Lategan, M.D., Nat Pernick, M.D., Emily S. Reisenbichler, M.D., Monika Roychowdhury, M.D., Mary Ann Gimenez Sanders, M.D, Ph.D., Gary Tozbikian, M.D., Hind Warzecha, M.D. Senior Authors: Julie M. Jorns, M.D., Shahla Masood. Breast nonmalignant, Fibroepithelial neoplasms, Fibroadenoma. Retrieved on 2019-11-04. Revised: 31 October 2019
  6. Rosen, PP. (2009). Rosen's Breast Pathology (3rd ed.). ISBN 978-0-7817-7137-5. 
  7. . Fibroadenoma of the breast.
  8. 8.0 8.1 David J. Myers; Andrew L. Walls.. Atypical Breast Hyperplasia. StatPearls, National Center for Biotechnology Information. Last Update: February 15, 2019.
  9. Peter Abdelmessieh. Breast Cancer Histology. Medscape. Retrieved on 2019-10-04. Updated: May 24, 2018
  10. Siziopikou, Kalliopi P. (2013). "Ductal Carcinoma In Situ of the Breast: Current Concepts and Future Directions ". Archives of Pathology & Laboratory Medicine 137 (4): 462–466. doi:10.5858/arpa.2012-0078-RA. ISSN 0003-9985.