MLLs are composed of mucin containing cysts which may rupture, with extravasation of mucin into surrounding stroma (Fig. 6).141 The imaging target may be indeterminate calcifications or a nodular mass. The epithelium lining the cysts of MLLs is often attenuated but may range from benign to ADH to DCIS.142 The reason management issues arise in this scenario are the concern as to whether there may be undersampling of areas of mucinous carcinoma. Of note, the presence of epithelial cells floating in pools of mucin may be attributable either to stripped epithelium from a benign MLL in a fragmented CNB specimen or to mucinous carcinoma. One small study reported that 30% of MLLs were found to be mucinous carcinoma on exision,143 though others have claimed that mucinous lesions can be accurately classified on the basis of the CNB.91,144 The largest study to date by Wang et al91 reviewed the CNB and surgical excision of 32 mucinous lesions, of which 29 diagnoses made on CNB were unchanged with excision. The remaining cases were diagnosed as MLL without atypia on CNB and only showed fibrocystic change on excision. In those cases that display disrupted mucin pools, the presence of capillaries within the mucinous stroma may offer a clue to the malignant nature of the lesion.145 Given the very small numbers in these studies, it is recommended that an excision to rule out mucinous DCIS or mucinous carcinoma be performed after the identification of MLL or stromal pools of mucin on CNB.
With the strong emphasis on radiologic-pathologic correlation when interpreting CNB specimens, it is important to keep in mind other entities that may form mass lesions aside from malignancy and those described above. Cysts, pseudoangiomatous stromal hyperplasia, fat necrosis and nodular adenosis can form a palpable mass or a mass lesion identified on imaging studies. Recognition of these lesions and their careful correlation with the imaging findings can prevent an unnecessary surgical excision. Table 5 summarized the non-malignant breast lesions for which excision is recommended.
In conclusion, when rendering an opinion on a CNB of the breast, the pathologist should always correlate the radiologic findings with those seen on the histologic sections and provide sufficient information to ensure the patient is triaged into the appropriate management pathway.
The authors wish to express their thanks to Dr Stuart Schnitt for reviewing and commenting on this manuscript during its preparation.
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