Breast nodule

1. 28 year old female with left
breast nodule
Dr. Dipendra Pradhan
First year resident
Mod: Lt. Col. Dr. Kavita Karmacharya

2. Case history
• 28 years female
• Single left breast nodule measuring approx. 1
x 1 cm.
• No history of nipple discharge

3. USG findings
• Fibroglandular tissue appear homogenous
bilaterally
• A hypoechoic lesion with lobulation in the
left breast, measuring 1.8 x 0.9 cm. Minimal
intralesional vascularity seen. BIRADS-4a
• No significant axillary lymphadenopathy.

4. Procedure
• USG guided biopsy was done from the left
breast.
• Submitted for HPE
Gross findings
• Received three linear tissue bits grayish white
in color measuring from 0.4 to 1.3 cm.

5. 3 linear tissue cores comprising of fibrofatty
tissue

6. Normal terminal ductal lobular unit comprising of inner
luminal epithelial and outer myoepithelial cells

7. Adenosis seen as proliferation of acini, with 2 layers
without distortion of lobular architecture

8. Intraductal proliferation
of papillary structures
with fibrovascular cores

9. IHC: p63 stain uptake by myoepithelial cells

10. Summary
• Section shows three linear tissue cores composed of fibrofatty
tissue with terminal ductal-lobular unit comprising of inner luminal
epithelial cells and outer basal myoepithelial cells. These epithelial
cells have oval to round, normochromatic nuclei.
• Some foci shows adenosis in the form proliferation of acini, with 2
layers, surrounded by basement membrane, without distortion of
lobular architecture
• Some foci shows intraductal proliferation of papillary structures
lined by outer luminal cells and inner myoepithelial cells with
fibrovascular core.
• No atypical ductal hyperplasia. No metaplasia.
• No areas of necrosis or hemorrhage seen. No mitosis seen.
• No foamy macrophages.
• Slide stained with p63 marker shows presence of myoepithelial cells
surrounding the fibrovascular cores.

11. Diagnosis
• Intraductal papilloma with adenosis
Differential diagnosis
1. Usual ductal hyperplasia
2. Intraductal papillary carcinoma

12. Intraductual papilloma with adenosis
Favorable
• Can occur in women of all age groups (30-50 years)
• A solitary nodule
• Size less than 3 cm
• Papillary fibrovascular cores
• lined by outer layer of luminal cells and an inner layer of myoepithelial
cells
• Presence of foci of adenosis
• Absence of necrosis and mitotic activity
• Positive myoepithelial cell marker in IHC : p63 positive
Unfavorable points
• Absence of apocrine metaplasia
• Absence of fibrosis

14. Usual ductal hyperplasia
Favorable
• Proliferation of cells of luminal and myoepithelial
lineages
• Absence of necrosis.
Unfavorable
• Young age (mean age for UDH is 54 years)
• Presence of the fibrovascular cores.
• Absent streaming growth pattern and nuclear
grooving
• Absence of foamy macropahges.

15. Intraductal papillary carcinoma
Favorable points
• papillary architecture
• arborizing fibrovascular stalks lined by epithelial cells
• Uncommon mitotic figures and necrosis
Unfavorable points
• Absence of cytologic atypia and stratification.
• Presence of myoepithelial cells in the fibrovascular
cores
• Positive myoepithelial cell marker in IHC : p63 positive

16. IHC markers : p63
• Member of p53 gene family at 3q27-29
• Myoepithelial marker
• Rule out invasion in breast tumors by
determining presence of myoepithelial cells

17. IHC markers : ck5
• Identify breast myoepithelial cells
• Distinguish breast usual ductal hyperplasia
(UDH) and papillary lesions (mosaic-like
pattern) from DCIS (usually negative, rarely
diffusely positive)
• Prognostic factor : CK5+ / p63+ breast
intraductal papillomas show less risk of
subsequent invasive carcinoma.

18. Other IHC markers : p40, Calponin

19. References:
• Goldblum JR, Lamps LW, Mckenny JK, Myers
JL. Rosai and Ackerman's Surgical pathology,
Elsevier, 11th Edition, pg 1452-65