March 2020

A 57-year-old female with right breast pleomorphic microcalcifications on screening mammography.

Contributors: 

Sampson Kwabina Boham, MD

PGY-2 Resident Physician, Anatomic Pathology and Clinical Pathology

Department of Clinical Pathology & Laboratory Medicine

Indiana University School of Medicine

Jingmei Lin, MD, PhD

Associate Professor, Department of Pathology and Laboratory Medicine

Indiana University School of Medicine

Shaoxiong Chen, MD, PhD

Associate Professor, Department of Pathology and Laboratory Medicine

Indiana University School of Medicine

Clinical history: 

The patient is a 57-year-old female with chronic hepatitis C, genotype 1a/1b who was found to have right breast pleomorphic microcalcifications on screening mammography. Patient’s last mammography was about 12 years ago, which showed no suspicious findings or any evidence of malignancy. Based on the current mammography result, a stereotactic breast core biopsy was performed; followed by a right breast mastectomy and sentinel lymph node biopsy.

Gross Examination: 

Macroscopic examination showed a 3.0 x 2.5 x 2.4cm discrete but poorly circumscribed mass/lesion that’s made up of clusters of many small cysts with varying sizes (ranging from 0.1cm to 0.5cm) having granular consistency with fibrous intervening stroma. These small cysts were filled with tan-clear secretions. This mass/lesion grossly abuts the superficial surface, 1.0cm from the deep surface, 4.0cm from the skin and 5.0cm from the nipple. Present within the central aspect of the mass/lesion was a radiographic marker.

Microscopic examination and immunohistochemistry: 

Histologic evaluation of the mass revealed dilated ducts lined by columnar epithelium with micropapillary protrusions into the lumens. Cytologically, the epithelial cells lining the cysts show crowded and overlapping hyperchromatic nuclei and sparse cytoplasm. High magnifications show columnar cells with stratified vesicular nuclei and occasional discernable nucleoli lining the cystic duct walls. The cysts contained luminal proteinaceous eosinophilic secretions, akin to the appearance of thyroid colloid. These secretions show retractions from the epithelial lining of the cysts with scalloped borders. Some areas within the secretions were “pock-marked” admixed with blood and hemosiderophages. Luminal calcification were present. Some secretions also showed parallel cracking, an artifact of histology sectioning that gives the appearance of reminiscent of Venetian blinds. Also seen are intense inflammatory reaction consisting of lymphocytes and histiocytes, possibly due to disruption of cyst resulting in cyst rupture and spillage of cyst contents. The colloid-like secretions are positive for PAS but negative for mucicarmine and thyroglobulin. Immunohistochemistry stain for Androgen receptor, EMA and S100 are positive in the epithelial cells while p63 highlights the myoepithelial cells.  However, ER and PR are negative in the cells of interest.

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Fig. 1:  Cystically dilated glands with colloid-like secretions

   Fig. 1                

   Fig. 2

Fig.3: Micropapillary projections into lumen with cytologic atypia

 Fig. 3

Fig.4:  Micropapillary projections with cytologic atypia

Fig.  4

Fig. 5: Secretions with cracking reminiscent of Venetian blinds. Secretions also show pock-marked appearance. Microcalcifications present.

Fig. 5

Fig. 6: Colloid-like Secretions are PAS Positive

Fig. 6

Fig. 7: Androgen Receptor Positive (weak) in Epithelial Cells

Fig. 7

  Fig. 8: EMA Positive

Fig. 8

Fig. 9: P63 Highlights Myoepithelial Cells

Fig. 9

Fig. 10: S100 Positive in Epithelial Cells

Fig. 10

March 2020 Final Diagnosis and Discussion