Ex. 2.1 -1 & 2 Mediolateral oblique (MLO) projection and detail of the MLO view of the left breast A small cluster of calcifications is seen without an associated tumor mass.

Ex. 2.1-3 Craniocaudal (CC) projection of the left breast. The small cluster of calcifications is located in the retroglandular clear space.

Ex. 2.1-5 & 6 Stereoscopic image pair of a 1 mm-thick slice of the TDLU containing the crushed stone-like calcifications seen on the specimen radiograph. It is apparent from these images that the in situ carcinoma is confined to the acini of the distended TDLU and is not within ducts. Although such cancers are still termed “ductal” carcinoma in situ, 3D histological images show that this is not the case. There were no other malignant foci in the specimen, but several types of hyperplastic changes were found adjacent to the malignant focus (see Figs. 2.1-12 to 17).

Ex. 2.1-8 & 9 Stereoscopic images of the TDLUs containing the in situ carcinoma. The individual acini are markedly distended by the combination of malignant cellular growth, central necrosis, and intraluminal amorphous calcification. The TDLUs measure 6 and 3 mm in diameter, with each individual acinus being larger than a normal-sized TDLU.

Ex. 2.1-10 & 11 Medium- and high-power magnification histological images, with a-smooth-muscle actin immunostaining demonstrating a preserved myoepithelial cell layerthat outlines a single acinus distended by many layers of Grade 2 in situ carcinoma, central necrosis, and amorphous calcification.

Ex. 2.1-12 & 13 Comparison of two adjacent TDLUs. The one on the left is altered by in situ carcinoma and the one on the right is deformed by sclerosing adenosis.

Ex. 2.1-14 & 15 Stereoscopic images of TDLUs distended by fluid. The underlying hyperplastic breast change is apocrine metaplasia (seen as micropapillary growths within the cystically dilated acini).

Ex. 2.1-16 & 17 The fluid produced by the apocrine metaplasia has distended several ducts and their branches. Normal TDLUs surround the dilated ducts.

Ex. 2.2-1 & 2 Detail of the MLO projection in two consecutive screenings with an interval of 18 months. The barely perceptible cluster of discernible, crushed stone-like calcifications (within the circle) has evolved to a mixture of crushed stone-like and casting type calcifications, occupying a much larger volume.

Ex. 2.2-3 & 4 Stereoscopic images of one extremely distended TDLU (22 mm in diameter!). There are a few atrophic TDLUs in the surrounding tissue for comparison of size. The individual cancerous acini measure up to 2-3 mm in diameter, much larger than one entire normal sized TDLU. The central necrotic contents and the intraluminal calcification of some of the acini have fallen out during specimen preparation.

Ex. 2.2-5 & 6 Large-section histological images of the solitary TDLU at two different slice levels. The TDLU is extremely distended by in situ carcinoma, central necrosis, and amorphous calcifications.

Ex. 2.2-7 & 8 Intermediate magnification of the extremely distended acini containing solid cell proliferation, extensive central necrosis, and large intraluminal, amorphous calcifications.

Ex. 2.2-11 Medium-power histological image (H & E) of an acinus with solid cell proliferation, central necrosis, and amorphous calcification.

Ex. 2.2-12 & 13 Higher-magnification stereoscopic subgross, thick-section (3D) images of the acini that have been greatly distended by the in situ carcinoma, necrosis, and amorphous calcifications. Some of the acini measure 2-3 mm, which is two to three times larger than an entire normal TDLU.

Ex. 2.2-15 & 16 Stereoscopic image pair of the surrounding normal breast tissue with pleated ducts and atrophic TDLUs.

Ex. 2.3-1 Left breast, MLO projection. A tiny group of calcifications is seen in the upper portion of the breast.

Ex. 2.3-2 Microfocus magnification image in the MLO projection. The calcifications are tightly packed within a solitary cluster and vary in size and density. Mammographically malignant type calcifications.

Ex. 2.3-3 Microfocus magnification image in the CC projection. The solitary group of crushed stone-like calcifications is surrounded by an ill-defined density.

Ex. 2.3-5 & 6 Histology (H & E) of the vacuum biopsy specimen shows in situ carcinoma with necrosis and amorphous calcifications (encircled).

Ex. 2.3-7 Low-power histological image: Grade 2 in situ carcinoma with cribriform cell architecture, central necrosis, and amorphous calcification

Ex. 2.3-8 & 9 Histological images of this cribriform in situ carcinoma with increasing magnification.

Ex. 2.4-1 & 2 Detail of the MLO and CC projections. There is a tiny cluster of calcifications in the lower-outer quadrant of the breast with no associated tumor mass.

Ex. 2.4-6 & 7 Histology (H & E) images show of a distended TDLU containing Grade 2 in situ carcinoma with a cribriform pattern. The associated calcifications are a mixture of the amorphous and psammoma body-like.

Ex. 2.4-8 Immunochemical demonstration of estrogen receptor expression in the tumor cells.

Ex. 2.4-10 & 11 Additional histological images of this Grade 2 in situ carcinoma.

Ex. 2.5-1 & 2 Right and left breasts, detail of the MLO projections. There is no demonstrable mammographic abnormality on the mammograms.

Ex. 2.5-3 & 4 Next screening examination 2 years later. She is still asymptomatic and is now 54 years old. A group of microcalcifications surrounded by an ill-defined density has developed in the axillary tail of the left breast (rectangle).

Ex. 2.5-7 & 8 Breast ultrasound and microfocus magnification image of the lesion containing the crushed stonelike, mammographically malignant type calcifications.

Ex. 2.5-11 to 13 Histology (H & E) of the vacuum-assisted needle biopsy specimen: Grade 2 in situ carcinoma at increasing magnifications.

Ex. 2.5-15 Large-section histological image. The cancerous TDLU measures 15 mm ⊠ 15 mm. The acini are extremely distended by the malignant cells, intraluminal necrosis and calcifications. There is no sign of invasion.

Ex. 2.5-16 Radiograph of the operative specimen slice demonstrating the characteristic features of malignant type, crushed stone-like calcifications: the individual calcifications are in close proximity to each other and exhibit considerable variation in shape, density, and size.

Ex. 2.5-17 Microfocus magnification of the specimen. The micro-calcifications are in close proximity to each other. The size, shape, and density of the individual calcificationsvary considerably. These features are characteristic of a malignant process.