Rosen's Breast Pathology, 4e

PRE FACE TO THE F I RST ED I T I ON

1997 He will manage to cure best who has foreseen what is to happen from the present state of matters. —Hippocrates 1 The management of diseases of the breast is a multidisci- plinary endeavor dependent on the skill and expertise of an array of clinical specialists. In this complex effort, the im- portance of one or another member of the team for a given patient will vary depending upon the clinical circumstances. At the outset and often at later critical points, an accurate pathologic diagnosis is the crucial element for determining the course of treatment and for estimating prognosis. A thor- ough knowledge of the pathology of the breast is essential for physicians and other medical personnel who take care of patients with breast diseases. Conversely, the pathologist cloistered in a laboratory, out of touch with patient care, will not be able to provide the clinically meaningful information currently expected of practitioners of this specialty. The breast appears structurally and functionally to be relatively uncomplicated, but it is the site of a surprisingly broad array of pathologic alterations, many of which are organ-specific. New entities continue to be identified. Our understanding of breast pathology has been substantially amplified by the application of new technology to this effort. Particularly rapid progress has occurred in the past decade as a result of the availability of immunohistochemistry and in situ hybridization, which have made it possible to observe the tissue-specific and cell-specific localization of molecular and genetic processes associated with physiologic and patho- logic conditions. Yet, it is important not to be blinded by the blizzard of information and to avoid being swept away in the annual flood of “hot topics.” All too often, today’s hot topic becomes tomorrow’s footnote. Ultimately, our understand- ing of breast pathology is remodeled and enriched by the ongoing process of discovery and thoughtful analysis that contributes to a growing body of knowledge composed of many bits of information from innumerable contributors. This vision embodies the precept of Hippocrates, who wrote: But all these requisites belong of old to Medicine, and an origin and way have been found out, by which many and elegant dis- coveries have been made, during a length of time, and others will yet be found out, if a person possessed of the proper ability, and knowing those discoveries which have been made, should proceed from them to prosecute his investigations . 2 This book provides a comprehensive, extensively illus- trated description of breast pathology in a clinical context. Most of the chapters are devoted to specific diseases or disease groupings. The discussion of each topic consists, where rele- vant, of sections detailing clinical presentation and mammog- raphy, epidemiology, gross pathology, microscopic pathology, including electron microscopy and immunohistochemistry,

differential diagnosis, treatment, and prognosis. Several chap- ters deal with broad subjects, such as precancerous breast pa- thology, staging of carcinoma, biologic markers of prognosis, the pathologic effects of therapy, cytologic and needle core di- agnosis, and the pathologic examination of breast specimens. Illustrations have been selected not only to demonstrate the standard appearance of lesions but also to emphasize the heterogeneity represented by variant forms. Following the manner in which the pathologist encounters them in daily practice, many entities are shown as they appear grossly, in whole-mount histologic sections and, finally, at progres- sively higher magnification, amplified with immunohisto- chemistry and other diagnostic procedures. It is my hope that there is no “pathomythology” in this book. A myth is defined as “an idea that forms part of the beliefs of a group or class but is not founded on fact.” 3 Pathomythology is a term I use to describe the persistent repetition of hypotheses relating to pathology that are com- pletely contradicted by existing data. Perpetrators of this activity frequently reinforce their myth by quoting them- selves or other followers of their belief, eschewing facts that can easily be confirmed by direct observation. One example of pathomythology is the seemingly indestructible idea that the carcinomatous cells of mammary Paget disease arise by transformation of squamous cells in the squamous epi- thelium that harbors Paget disease. Intraductal carcinoma, which is the source of these carcinoma cells, is detected in virtually every patient with Paget disease, but the pathomy- thologists rest their case on the very few instances in which duct carcinoma is not discovered. A reasonable explanation for these exceptional cases is offered in this book. Another example of pathomythology is the inaccurate statement that an intraductal component is not found in true medullary carcinoma. Intraductal carcinoma can be found at the pe- riphery of most medullary carcinomas, but the presence or absence of intraductal carcinoma has been shown not to be a criterion for the diagnosis of medullary carcinoma. Despite diligent attention to detail, it is likely that some er- rors of omission or commission have occurred in the prepara- tion of this book. The author is responsible for the selection of references and illustrations, for the citation of data from pub- lished sources, and for conclusions expressed herein, based on his personal experience and his interpretation of the literature. REFERENCES 1. Adams F. The book of prognostics. The genuine works of Hippocrates . Baltimore: The Williams & Wilkins Co., 1939:42. 2. Adams F. On ancient medicine. The genuine works of Hippocrates . Baltimore: The Williams & Wilkins Co., 1939:1–2. 3. Stein J, ed. The Random House dictionary of the English language . New York: Random House, 1973:946. Paul P. Rosen, MD

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