r. PAUL-RAMSEY HOSPITAL and MEDICAL CENTER ST. PAUL, MINNtSOTA 55101

Anat om i c Patho logy Sem inar

Spring Breast- Fest

St. Paul-Ramsey Hosp i tal and Med ica l Cen te r

Moderator: Jack Uecke r, M.D .

Aud i tor i um - 6 :00p.m. - June 4, 1975 Buffet .,; 11 be served CASE /1 1

Thi s 87 year old female presented with a nontender breast nodul e present for about one year. On exam ination the left breast contained a fi rm thick 1 em. tumor. A simpl e mastectomy 1·1as performed and the gross examination of the tumo r shoHed a hard nodu l e of c risp white fi brous tissue flecked with smal l yel l O\~ areas.

Subm I tted by: Centra l Reg iona l Pa thology Laborat ~ry St. Paul, Minnesota

CAS E #2

Thi s 42 year o ld fema l e presen ted with a fi rm mass of t he ri ght breast. The clinical di agnosis was "fibroma ". At a 10 em. in greatest diameter mass of s oft rubbo fibrous appearing tissue was submitted.

Subm itted by: Department of Pathology University of North pako ta Grand Forks, Nor th Da kota

CASE /13

Thi s 18 year ol d unmarried 1·1oman presented wi t h a four ~1eek hi story of an enl

Subm itted by: Wayn e Schrade r, t~. D. Or 1an do, Florida

CASE #4

Thi s 48 year old female p resented with a ri ght . The mass l

Submitted by: Jerry Baldwin, M.D. Hil ler Hosp ita l St. Paul, Minnesota

CASE /IS

This 36 year o ld ·~as seen because of a protruding n ipple which had previously been inve rted, A biopsy wa s performed with a pre-op diagnos is of "Pogets di sease".

Submitted by: Section of Surgical Pathology St. Paul-Ramsey Hospital St. Paul, Minnesota

CA SE #6

This 60 year old female presented to her physician with a history of "serous" disch< from her right nipple. A b iopsy was performed and the specimen consisted of a fragr of flbrofatty t i ssue showing a ' I ined by a fibrous capsul e . Within the cyst there was a tan-brown solid tumol' measuring up to I em . in diameter.

Submitted by: Department of Pathol ogy University of North Dakota Grand Forks , No r t h O~kota CASE //7

This 68 year old femal e present ed wi th mu l t ipl e nodules of the b reast. Ex tens ive biops ies . ,ere per forme d and they cons i sted of fi brofa tty tissue wh ich Included mu l t ip containing intraductal nodul es. In add ition, t he re we re mu l t i p l e areas of st indu ration.

Submitted by: Department o f Pathology Mt . Sinai Hosp ita l Mi nneapolis, Minnesota

CASE 118

This 65 year o ld l ady had a long hi story of f ibrocys tic disease wi t h mul t ipl e prior breast aspirations and biopsies . Sh e presente d with a palpabl e ma ss ln t he outer quadran t of t he l eft breast. It wa s non tende r and nonfixed but mammag rams we re "suggesti ve" of ma li gnancy. su bm i t ted by: Donn Leaf', M.D . Red Wing, Minne sota

CASE #9

This 61 year o l d fema l e p resented with multiple bilatera l sma ll rubbery nodules of t he b reasts. She had mul tip l e p revious b iopsies f or "fib rocyst ic disease". The b rea st~ were large. The current biopsy tissue cons i s ts of a 12 em . mass of rub be ~ , fibrofatty t i ssue >lhi ch contained mult iple cysts measuring up to I em. i n diame ter. One cyst contai ned an intralumi nal pap ill oma a nd throughout the br.east t he t·e •1a s seve ral dilated duc ts filled 1•1i th a creamy ma t e rial, surrounded by firm gri tty nodule•

Submitted by: Central Regional Pathol ogy Laboratory St. Paul, Minnesota

CA SE /110

Th is middle aged femal e p resented wi th a left breast ma ss.

Submitted by: Jerry Baldw"in, M. D. Mi l ler Hospi tal St . Paul , Minnesota

CA SE /Il l

Thi s 18 year o ld had a small left breast mass for 4· to 5 years . I t ha d been note d by nume rou s examine r s including the pa tien t . An exc lsional biopsy 1•as perfo rme d and the tumor cons Isted o f a we l l circums cribe d I em. no dule of yel l ow ti.., ssue • Submitted by: Se ction of Surgical Patho logy St. Paul-Ramsey Hospita l No s l ide avai l able St. Pau l , Minneso ta .

CASE /112

This 32 year o l d patient presented to the surgery cl lnic; with a raised 1 ight tan 8 m. papi l l<•ry lesion of the nipple. This had been present for several months and the pa · had treated the l esion loca l ly wi th hand c ream and a banda id . Exam inat ion of the sub' b reast t i ssue rev('a l ed no abnormal i ties. II biopsy wi t h f rozen sect ion examination lia performed ,

Submi t t e d by : Section of Surgical Patho l ogy St . Pa ul - Ram sey Hospi tal S l. Pau 1 , Hi nn csote CASE #13

This 45 year .o 1d fema 1e has "s i 1 i eone" i nj ec t ions in to both breasts 1

Submitted by: ·sectron of Surgical Pathology ·st. Paul-Ramsey Hospi tal St. Paul, ~innesota ' 1- ~~ ~~. w Yi~ ~-~...&_ \.MV

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tz. ... l>l~ ~ 13 - ~ll' CAJ'W. ~ hh·.s - ;T. PAUL-RAMSEY HOSPITAL and MEDICAL CENTER • ST. PAUl.. MINNESOTA SSlOl

BREAS T PATHOLOGY SENINAR

DIAGNOSES AND DISCUSSION

1. Infiltrating with elastosis. This rather ordinary case was included because of the striking elastosis pres ent around islands of tumor and around vessels. It turned out thnt mos t of the pathologists attending· the meeting had not hea·rd of or did not recognize the elastosis. Elastosis is relatively common in breast , both ductal and lobular. One series has elastosis in in up to 85% of the cases. See the article by Lund.mar k in CANCER, November, 1972 and the article by Azzopardi in CANCER, January, 1974.

2. Undifferentiated with chondroid metaplasia. Dr. l~asdahl , who submitted this case , had originally diagnosed the lesion as an extraskeletal chondrosarcoma but after reflection upon the case and after rather direct instructions by his residents he changed t he diagnosis to undifferentiated carcinoma. This was the concensus diagnosis of the group in attendance at the meeting. See the paper by Smith and Taylor in t he American Journal of Clinical Pathology, May , 1969 and the article by Norris and Taylor in Cancer, July, 1968.

3. . The general subject of breast' cancer in younger patients was discussed. Axillary lymph nodes in this part icular patient were negative. The possibility of reticulum cell sarcoma was suggested by several participants.

4. Angiosarcoma. This case was also presented in the MSCP Sr'minar i n Novem­ ber, 1974 . The general subject of vascular tumors of the breast was discussed and numerous participants stressed the fact that angiosarcomas of the breast often, if not usually, appear harmless, at least in some areas of t he neoplasm. However, tbese are highly malignant tumors, generally of younger women , and the average survival is about two years following diagnosis. We inquired whether or not any of the participants had ever made the diagnosis of heman­ gioma of the breast and Dr. Rosai volunteered the informat ion that he had recently made that.diagnosis as a small incidental finding.

5. Nipple or subareolar adenomatosis. This turned out to be a relatively con·troversial case. The lesion had been called adenocarcinoma on frozen section and a simple mastectomy "as performed. However, upon reviewing the permanent sections it was felt that the diagnosis was more likely a nipple adenoma. Nearly every author who writes about this lesion mentions that it is frequently mistaken for a carcinoma. As a matter of fact, as we photographed this case for the seminar serious doubts arose concerning this case. I still felt that it was a nipple adenoma but that it was somewhat atypical. Dr. Dehner made a strong case for malignancy with this case but the majority- of!Participants fe!t-rfiat it was benign. Certainly this patient has been adequately treated. See the ori ginal article by David Jones in CANCER, ~la r ch, 1955 and a review of Perzin and Lattes in CANCER, April, 1972. ·6. Papillary adenoca-r;cinoma wit;h areas .of 1ll11Cinous and cribriform .change. Dr. Hellerman volunteered the lnformat.ion that some areas of the neoplasm were typically papillary. f!o«ever, the b l ock submitted showed a rather solid cribriform pattern on one side of the slide and a mucinous area on the other. Many participants felt that this was· a mucinous carcinoma; I felt that it was probably a cribriform or adenoid cys tic car cinoma with mucinous degeneration. It was stressed that both papillary carcinoma and , as well as mucinous carcinoma, have a . good prognosis.

7. Papil·lary adenocarcinoma with early invasion. This was a-lso a controversial case, particularly since most of the slides cut from the block did not sho« any evidet~ce of invasion. However, there- were many sections from the original material ,.,.hich did show invasion. Th~ general subject of papillary carcinoma of the breast was discussed and debated. The criteria for malignancy in breast lesions of a papillary nature were reviewed. Dr. Nard officially blessed ·the diagnosis.

8. Sclerosing . Most of "the participants agreed that the papillary portion of this' lesion appeared benign. Howeve.r, at the base of the lesion there were proliferating cells which «ere closely packed and somewhat atypical, I interpreted this as an example of a sclerosing papilloma. The subject was discussed by Fenoglio and Latte·s in CANCER, }!arch, 1974. Several participants felt that this lesion ,;.as malignant. Follow up ·at this point reveals no­ evidence of tumor but th~ final chapter may well not have been <~ritten . on this patient. •

9. Mammary duct ectasia. This is a relatively classic example o f a lesion which is somewhat uncommon. This lesion was included because several of our resi dents were unfamiliar with this entity. Its gross resembla~ce to carcinoma was also stressed. See the article by Haagens·on in C:A.NCER, 1951.

10. Hetastatic medullary carcinoma with amyloid stroma, thyr oid . Every seminar s hould i nclude at l east one weirdo lesion. l·le are grat~ful co the group at Hiller Hos pital for submitting this case. Many o f the participants suggested metasta~ti c or a variant of of the breast. The diagnosis was easy for everyone, in. r e trospect. I <~as unable to find any reference for medullary carcinoma of the thyroid metastatic to breast but there is a recent revie« of metastatic tumors to the breast in CANCER, June, 1972 by Rajdu and Urban. The tumors which· most frequently metastasize to the breast are melanoma, lung> ovary, and stomach. In addition, we have ·seen a metastasize to the breast.

11. Granular cell tumor. We ran out of tissue for this case so did not include the slide in the seminar set. At any rate, the literature is filled with articles on granular cell tumor, not only of the breast but of nearly every _ other organ in' the body. Refer to any recent journal .

12. Nipple adenoma occurring in a male breast. This is a anique case. None of the people pre~ent at the meeting had every seen a nipple adenoma in a male breast and it seems that there are only a few cases in the literature. Taylor and Robertson from the AFIP reviewed nipple in CANCER, August, 1965 and three of their t~Tenty-nine cases were in males.· There is also ·a single case reported in the American Joumal of CLinical Pathology, also in August, 1965. This was called the first case reported in a man. 13. Silicone and paraffin granuloma, breast. He though that everyone would appreciate seeing the end resu~ts of adulterated silicone ·after injection into breast tissue. This entity was nicely reviewed by N.osanchuk in the Archives of Surgery, October, 1968. This case i s es.sentially identical to their material. If you dim the light source on your microscope you can readily see the cracked silicone material present i n the breast.