月儿 mmm 知足常乐 sxzyy 小樱 猪猪 xianren leee 血管肉瘤？ 海绵状血管瘤...

• 月儿 • mmm • 知足常乐 • sxzyy • 小樱

• 猪猪 • xianren

• leee

• 血管肉瘤？• 海绵状血管瘤• 乳腺血管肉瘤• 乳腺的血管性肿瘤很少是良性的。• 分化比较好的海绵状区域，和分化较差的

纤维硬化区域，倾向血管肉瘤。• 没见过，学习了• 我没见过这种的 , 猜是血管肉瘤 , 因为在

乳腺良性的血管瘤少见 . 本例肿瘤组织浸润至乳腺及脂肪组织中 , 纵横交叉的血管 ,内衬扁平的内皮细胞 , 核分裂少见 , 要考虑血管肉瘤 .

• zhabglei ：您提的病例真好，很典型，是乳腺的血管肉瘤。图辛不多，从病人表观到大体，再从低倍到高倍，无重复，染色鲜艳、清晰。看者省时，值得提供病例者学习。

• 490918

• hadi

• 马甲 • 高倍镜 • 风雨天使

• 持刀客

• 海绵状血管瘤 ? 总感觉不恶，分化好

• 血管肉瘤 , 镜见很容易被误诊• 形态并不恶性• 你遇见敢报吗？反正我是不敢！• 我记得纪老师说过 , 乳腺的血管肿

瘤无良性，所以我可以放心诊断：血管肉瘤。

• 请用“矛盾的普遍性和特殊性去看问题”，反对讲神话来误导大家，不是所有人都能看得懂神话的。

• csgcsg

• sawu

• 乳腺的血管性肿瘤无良性。

• 乳腺血管瘤少见但的确存在有：– cavernous hemangioma–  capillary hemangioma–  atypical hemangioma–  venous hemangioma–  angiomatosis

Vascular tumor of Breast

Vascular tumor of Breast

term

• VESSEL .n( 船 、容器 、脉管 )• Vascular.a （ 血管的 ） • BLOOD VESSELS • angio （脉管 , 包被 ）• H （ a ） em （血红素 ）• Hemangioma (Mostly hamartomas ) • (Hem)angiosarcomas• Endothelial cells • endothelioma • Hemangioendothelioma• Pericytes (Perivascular cells)• perivascular epithelioid cell tumor (PEComa). • Arteries carry blood from the heart .• aneurysm

α

WHO 2003 classification of Tumours of the Breast

Adapted from WHO, Tumours of the Breast and Female Genital Organ

s. IARCPress, 2003

1. Epithelial tumours• 1.20 Lobular neoplasia•             1.20.1 Lobular ca in situ•       1.21 Intraductal proliferative lesions•             1.21.1 Usual ductal hyperplasia•             1.21.2 Flat epithelial atypia•             1.21.3 Atypical ductal hyper-

                      plasia•             1.21.4 Ductal carcinoma in situ•       1.22 Microinvasive ca•       1.23 Intraductal papillary neoplasms•             1.23.1 Central papilloma•             1.23.2 Peripheral papilloma•             1.23.3 Atypical papilloma•             1.23.4 Intraductal papillary car-

                      cinoma•             1.23.5 Intracystic papillary ca•       1.24 Benign epithelial proliferations•             1.24.1 Adenosis including vari-

                      ants•                   1.24.1.1 Sclerosing

                               adenosis•                   1.24.1.2 Apocrine adenosis•                   1.24.1.3 Blunt duct adenosis•                   1.24.1.4 Microglandular

                               adenosis•                   1.24.1.5 Adenomyoepithelial

                               adenosis•             1.24.2 Radial scar / complex

                      sclerosing lesion•       1.25 Adenomas•             1.25.1 Tubular adenoma•             1.25.2 Lactating adenoma•             1.25.3 Apocrine adenoma•             1.25.4 Pleomorphic adenoma•             1.25.5 Ductal adenoma

•       1.1 IDC•       1.2 ILC•       1.3 Tubular•       1.4 Invasive cribriform•       1.5 Medullary•       1.6 Mucinous ca and other tumours

           with abundant mucin•             1.6.1 Mucinous ca•             1.6.2 Cystadenocarcinoma and

                    col cell mucinous ca•             1.6.3 Signet ring cell ca•       1.7 Neuroendocrine tuomurs•             1.7.1 Solid neuroendocrine ca•             1.7.2 Atypical carcionid tumour•             1.7.3 Small cell / oat cell ca•             1.7.4 Large cell neuroendocrine

                    ca•       1.8 Invasive papillary ca•       1.9 Invasive micropapillary ca•       1.10 Apocrine ca•       1.11 Metaplastic carcinomas•             1.11.1 Pure epithelial

                      metaplastic ca•                   1.11.1.1 Squamous cell ca•                   1.11.1.2 Adenoca with spin-

                               dle cell metaplasia•                   1.11.1.3 Adenosquamous ca•                   1.11.1.4 Mucoepidermoid ca•             1.11.2 Mixed epithlial/ mesen-

                      chymal metaplastic ca•       1.12 Lipid-rich ca•       1.13 Secretory ca•       1.14 Oncocytic ca•       1.15 Adenoid cystic ca•       1.16 Acinic cell ca•       1.17 Glycogen-rich clear cell ca•       1.18 Sebaceous ca•       1.19 Inflammatory ca

2. Myoepithelial lesions

•       2.1 Myoepitheliosis

•       2.2 Adenomyoeithelial adenosis

•       2.3 Adenomyoepithelioma

•       2.4 Malignant myoepithelioma

3. Mesenchymal lesions

•       3.1 Haemangioma•       3.2 Angiomatosis•       3.3 Haemangiopericytoma•       3.4 Pseudoangiomatous st

romal            hyperplasia

•       3.5 Myofibroblastoma•       3.6 Fibromatosis (aggressi

ve)•       3.7 Inflammatory myofibrob

lastic            tumour

•       3.8 Lipoma•             3.8.1 Angiolipoma

•       3.9 Granular cell tumour•       3.10 Neurofibroma•       3.11 Schwannoma•       3.12 Angiosarcoma•       3.13 Liposarcoma•       3.14 Rhabdomyosarcoma•       3.15 Osteosarcoma•       3.16 Leiomyoma•       3.17 Leiomyosarcoma

Breast Tumors with Vascular (and Pseudovascular) Differentiation

• Angiomatosis • Hemangioma • Perilobular Hemangioma • Hemangiopericytoma• Post-irradiation Atypical Vascular Lesion (skin of breas

t) • Venous Hemangioma • (Pseudoangiomatous stromal hyperplasia)

• Angiosarcoma

• Definition– Very rare diffuse benign vascular process of the breast

• Alternate/Historical Names– Diffuse angiomatosis

• Diagnostic Criteria– Very rare, only five cases reported

• Do not make this diagnosis without consultation – Diffuse process

• Surrounds ducts and lobules • No invasion into lobules

– Large irregular vascular spaces • No muscular wall • May have occasional anastomoses

– Lined by flat endothelium without atypia – May have both blood and lymphatic channels

• Differential Diagnosis– Angiosarcoma – Benign breast vascular lesions

Angiomatosis of the Breast

Angiosarcoma of the Breast Angiomatosis of the Breast

Variable patterns: channels, papillae, spindle cells

Uniform pattern of vessels

Usually a t least focal cytologic atypia Cytologically bland

Invades lobules Does not invade lobules

Frequent papillae and tufting No papillae or tufting

• Definition– Benign vascular lesion of the breast large e

nough to be detected clinically

• Alternate/Historical Names– Atypical hemangioma – Capillary hemangioma – Cavernous hemangioma – Venous hemangioma

Hemangioma of the Breast

Diagnostic Criteria • By definition, detectable by palpation or mammography

– Rarely over 2 cm • Grossly circumscribed

– May merge microscopically with surrounding tissue – Does not invade and destroy lobules

• Most are cavernous – Less frequently capillary type

• Anastomoses infrequent, not complex • Fibrous septa divide lesion into lobules

– Stroma may calcify • Large feeder vessels may be seen at periphery • Atypical hemangioma has features as above but with:

– Increased anastomoses, or – Cytologic atypia

• Venous hemangioma – Dilated channels – Walls contain smooth muscle at least partially – May be considered a vascular malformation

Differential Diagnosis

• Angiosarcoma

• Pseudoangiomatous stromal hyperplasia

• Other benign vascular lesions of the breast

Angiosarcoma of the Breast Hemangioma of the Breast

Diffuse Circumscribed

Infiltrates and destroys lobules Adjacent to or surrounds lobules

Rarely <2 cm Rarely >2 cm

No fibrous septa Fibrous septa forming lobules of angioma

No feeder vessels May have feeder vessels

Complex anastomoses Few anastomoses, not complex

Intermediate and high grade tumors are cytologically atypical

Focal atypia at most

Frequent papillae or tufting No papillae or tufting

May have hemorrhage and necrosis No hemorrhage or necrosis

No muscular walls Venous hemangioma may have muscular walls

HemangiomaPseudoangiomatous Stromal Hyperplasia

Endothelial lined spaces

No true lining to spaces

CD31 positive CD31 negative

Red blood cells in some spaces

No red blood cells in spaces

Angiomatosis

Perilobular Hemangioma

Hemangioma

Venous Hemangioma

Mass lesion

Microscopic, incidental lesion

Mass lesion

Mass lesion

Diffuse, infiltrating

Localized Localized Localized

Cavernous Predominantly capillary

Usually cavernous

Cavernous

Perilobular Hemangioma of the Breast

• Definition– Benign microscopic vascular lesion of the breast

• Alternate/Historical Names– Atypical perilobular hemangioma

• Diagnostic Criteria– Incidental microscopic lesion – Frequently within the lobular stroma

• May involve extralobular or periductal stroma – Cluster of vascular channels

• Capillary to small cavernous vessels – Usually no cytologic atypia – Occasional lesions with atypical features

• May have focal anastomoses • May have hyperchromatic nuclei • Must lack extensive complex anastomoses, papillary endothelial tufting, mito

tic figures

Differential Diagnosis

• Angiosarcoma

• Pseudoangiomatous stromal hyperplasia

• Other benign vascular lesions of the breast

Angiosarcoma of the Breast Perilobular Hemangioma

Almost always a hemorrhagic mass >2 cm Microscopic, incidental lesion

Diffuse, infiltrating Localized

Complex anastomoses No complex anastomoses

Intermediate and high grade tumors are cytologically atypical

No significant cytologic atypia

Frequent papillae or tufting No papillae or tufting

Perilobular HemangiomaPseudoangiomatous Stromal Hyperplasia

Endothelial lined spaces No true lining to spaces

CD31 positive CD31 negative

Red blood cells in some spaces

No red blood cells in spaces

Both are usually incidental findings

• Definition– Microscopic or clinically apparent breast lesion of variable cellularity featuring dense collegenous

stroma punctuated by slit like spaces

• Alternate/Historical Names– Nodular myofibroblastic stromal hyperplasia of the mammary gland – Pseudoangiomatous hyperplasia of mammary stroma

• Diagnostic Criteria– May be a circumscribed mass or microscopic incidental finding – Dense hyalinized collagen bundles

• May expand intralobular stroma • Surrounds ducts and lobules • Usually circumscribed but merges with surrounding stroma

– Anastomosing pseudovascular slit like spaces punctuate collagen bundles • No true vascular lining or structure • No erythrocytes in spaces

– Spaces often lined by spindle cells with range of cellularity • Classically almost inconspicuous, discontinuous flat bland cells

– One male case described with multinucleated cells – Classical areas also present in all cellular cases described

• Spectrum of increased cellularity – Cells associated with spaces more numerous and larger

» Nuclei may be larger and vesicular – Increased cellularity may obscure or obliterate pseuovascular spaces – May show marked cellularity with bundles and fascicles of cells

» May predominate over collagenous stroma • CD34 positive but CD31 and Factor VIII negative

Pseudoangiomatous Stromal Hyperplasia （ PASH ）

Clinical

• Age 14-67 years • In males, reported in 63% of cases of gynecomastia, ran

ging from microscopic to extensive • Female cases both palpable masses and microscopic les

ions • Reported as an incidental microscopic lesion in up to 23

% of specimens removed for other purposes in females • 5/40 cases recurred in one series of female patients • None recurred aggressively or metastasized • 1 case with multiple bilateral lesions

PASH Immunohistology

•  CD3416/17  • Vimentin20/20  • Actin12/19  • Desmin4/20  • PR • ER  • CD31 • Factor 8 • S100 • Keratin

• Positive• positive • positive • Positive• Positive• Usually negative• Negative• Negative• Negative• Negative

Differential Diagnosis

• Angiosarcoma

• Myofibroblastoma

• Perilobular hemangioma

• Hemangioma

Low Grade AngiosarcomaPseudoangiomatous Stromal Hyperplasia

Endothelial lined spaces No endothelial lining of spaces

Red blood cells in some spaces

No red blood cells in spaces

Infiltrates fat No infiltration of fat

Infiltrates lobules Merges with lobular stroma

Lining is CD31+ Lining is CD31 negative

Both contain anastomosing spaces containing CD34+ cells

Perilobular HemangiomaPseudoangiomatous Stromal Hyperplasia

Endothelial lined spaces No true lining to spaces

CD31 positive CD31 negative

Red blood cells in some spaces

No red blood cells in spaces

Both are usually incidental findings

Angiosarcoma of the Breast • Definition

– Malignant neoplasm of the breast exhibiting blood vascular differentiation

• Diagnostic Criteria– All grades are characterized by infiltration of breast parenchyma by cells exh

ibiting vascular differentiation – Low grade tumors

• Prominent freely anastomosing vascular channels • Papillary growth and endothelial tufting minimal to absent • Cytologic atypia may be difficult to identify even after extensive sampling

– Intermediate grade tumors • Freely anastomosing vascular channels • Papillary growth and endothelial tufting • May have focal solid areas with polygonal or spindle cells

– High grade tumors • Prominent solid areas of clearly malignant cells

– Polygonal and spindled cells • Blood lakes and necrosis are common • Vascular channels may be difficult to identify

– May require extensive sampling, especially at edge of lesion • Demonstration of vascular nature may require immunohistology

Clinical

• Mean age mid-thirties – Lower age associated with higher grade

• Approximate 5 year survival: – Low grade 76% – Intermediate grade 70% – High grade 15%

GRADING

  Low Grade Intermediate Grade High Grade

Anastomosing channels

Prominent Prominent Frequently inconspicuous

Papillary growthRare to absent Prominent Variable

Endothelial tuftingRare to absent Prominent Variable

Cytologic atypia Mild Mild to prominent Prominent

Mitotic figures Rare Frequent Frequent

Solid areasAbsent Focal or absent Prominent

NecrosisAbsent Absent Present

Blood lakes Absent Absent Often present

Angiosarcoma of the Breast Immunohistology

• CD31 is the most specific vascular endothelial marker – Carcinomas and stromal cells are negative – Reaction with histiocytes may be confused with sheets of neoplas

m – Most sensitive marker in high grade cases

• CD34 is relatively specific – Carcinomas are negative – Frequent, extensive benign stromal cell reactivity may make inter

pretation difficult – Less sensitive than CD31 in high grade cases, but exceptions to t

his rule do occur

• Factor VIII related antigen – Less sensitive than CD31 and CD34 in neoplasms

Differential Diagnosis

• Perilobular hemangioma

• Hemangioma

• Angiomatosis

• Pseudoangiomatous stromal hyperplasia

• High grade carcinoma or other neoplasm

• Post-irradiation atypical vascular lesion

Stewart F. W.Tumors. of the Breast , Washington D.C. A.F.I.P.1950.

p107

• A benign angioma of the breast had never been documented to constitute a palpable or symptom-producing breast tumor.

Steingaszner LC, Enzinger FM, and Taylor HB. Cancer 18:352-361,1965

• That rare exceptions to this bad prognosis do occur even with this vicious tumor is illustrated by two patients who survived seven and 14 years postoperatively; these are the first reported examples of probable cures.

Cancer 24;1021-1026,1969

• Gulesserian & Lawton 搜集了 39 例 angiosarcoma of breast ，其中 14 例开始被误诊为 haemangioma.

• Rosen & Ridolf: 555 例乳腺癌切除标本中发现有 haemangioma 7 例 (1.2% ，镜下发现， 1977)

• Lesueur: 尸检标本中发现 haemangioma32 个（高达 11% ， 1983 ） 25 个 <1.5mm,2 个最大为 4mm.

summary

• 乳腺血管肿瘤良性太少见• 组织学：分化好的难以鉴别良恶• 可靠点：大小（ 5mm? ）

• 月儿 • shubin • xhyong

• 清茶

• 好片子，血管肉瘤（ I 级）。• 血管肿瘤，长在乳腺－－肉瘤• 肿物有边界吗？脂肪是周边的

还是肿瘤组织内的成分，很多薄壁血管，有点充血，可见夹杂很多脂肪细胞，虽然是血管比较小，但是每一个血管都是完整的，并没有出血不完整的血管围成的裂隙样结构。细胞虽然有点异型性，但是我认为不影响诊断考虑：血管脂肪瘤

• 脂肪是肿瘤组织内的，肿瘤边界不清

• 微小一部分 : 血管肉瘤的依据是啥，不敢诊断噢• leee : 乳腺高分化血管肉瘤：

1. 好发于年轻人，平均 34岁，本例 35岁； 2. 乳腺的血管肉瘤一般分化好，或为海绵状血管瘤样，或为毛细血管瘤样，本例为后者； 3. 血管分化虽好，但内皮细胞仍有异型性，有的核明显增大。注意有的仅为单个细胞浸润，且有的有小腔，腔内有一个红细胞，显示为原始的瘤性血管； 4. 良性的毛细血管瘤常呈分叶状分布，本例为弥漫浸润性生长，边界不清。

经全面、仔细观察了清茶发给我的图片，根本未见到乳腺组织，全是皮下脂肪，故说是乳腺的血管瘤，就有点误导了。何况乳腺也有血管脂肪瘤啊。

现认为是胸部皮下血管脂肪瘤，不是乳腺血管肉瘤。

• 清茶 : 重取材及大体标本照相

• Leee: 此例清茶用 Email 给我发了 10 多幅图，再全面、仔细观察，并查阅文献，认为是皮下组织的血管脂肪瘤，不是乳腺的血管肉瘤。详情请清茶再说说。

• 月儿 : 学习，看来得先搞清部位哦 • zhang (zhangshandong) :Histopathology,Volum

e 52(1), January 2008, p 30–44 Vascular proliferations of the breast

Abstract

• Vascular proliferations of the breast are uncommon but potentially diagnostically challenging lesions.

• Clinically apparent processes are more likely to be malignant; however, a range of benign entities which must be differentiated from angiosarcoma also exists.

• This review discusses first, breast lesions of apparent vascular origin, then benign and histologically bland perilobular, cavernous and capillary haemangiomas.

• Subsequently, more diagnostically challenging, atypical haemangiomas, papillary endothelial hyperplasia, angiomatosis and angiolymphoid hyperplasia with eosinophilia (epithelioid haemangioma) are considered.

• In addition, lesions with low-grade malignant potential such as haemangiopericytomas and epithelioid haemangioendotheliomas may rarely present in the breast.

• However, primary angiosarcomas and radiation-associated vascular lesions are reviewed in depth, as these entities are of greatest clinical and pathological significance.

• 怡然 • hongchen2002

• Shubin• 月儿 • 月新

• 王不留行

• zhanglei

• gee

• 血管肉瘤• 境界很清 ----- 良性 ( 不会是血肿机化吧 ?)

• 在大血管内，良性。• 符合血肿机化，良性• 乳头状血管肉皮瘤！

是血栓机休的过程，不是恶性的，恶性血管瘤是指有浸润的血管瘤。

• 良性

• Masson 瘤。

• 周边是否为乳腺组织？

William B. CastleOctober 21, 1897 — August 9, 1990

• "An expert is a person who tells you a simple thing in a confused way, in such a fashion as to make you think the confusion is your fault."

hemangioma well-differentiated

Middle differentiated poorly differentiated