History Lesson

An 83 year old woman underwent an ultrasound guided needle localized excisional biopsy. The submitting pathologist questioned the presence of invasion.

Image 1.  A partially circumscribed nodule is surrounded by a collar of fibrous tissue. 

Image 3.  Abrupt disruption of encircling fibrous duct wall and presence of granulation tissue are characteristic of previous biopsy procedure.

Image 5.  Granulation tissue contains occasional degenerating epithelial cells, characteristic of previous biopsy procedure.

Image 2.  The right side of the image shows ductal carcinoma in situ, bounded by intact duct wall.  The left side of the image shows irregular nests of neoplastic cells mixed with hyalinized material, and disruption of the encircling fibrous tissue.

Image 4.  Irregular nests are associated with disrupted fibrovascular cores of intraductal papilloma

Diagnosis:  High grade ductal carcinoma in situ, solid type with disruption secondary to previous fine needle aspiration procedure.

Discussion:  The abrupt disruption of the encircling duct wall and associated granulation tissue are paramount in recognizing the changes associated with a previous sampling procedure.  Also helpful is the presence of degenerating epithelial cells within the granulation tissue.  Evidence of previous core biopsy procedure is usually more easily recognized than fine needle aspiration because of the linear path of reactive changes that a core biopsy procedure creates.  Immunohistochemical analysis for myoepithelial markers may be helpful if myoepithelial cells are associated with disrupted fibrovascular cores, but ultimately it is the pattern of disruption that holds the key to the correct diagnosis.  Occasionally it takes a bit of delving into the medical record, or a few phone calls to confirm that a previous needle biopsy or aspiration has been performed, as occurred in this case.