Breast
Other nonneoplastic
Secretory change
Authors: Eric J. Magnetta, M.D., S. Emily Bachert, M.D.
Board of reviewers: Gary M. Tse, M.B.B.S.
Deputy Editor-in-Chief: Gary Tozbikian, M.D.
Last author update: 5 September 2024
Last staff update: 5 September 2024
Copyright: 2002-2024, PathologyOutlines.com, Inc.
PubMed Search: Secretory change
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Radiology description | Prognostic factors | Case reports | Treatment | Gross description | Microscopic (histologic) description | Microscopic (histologic) images | Positive stains | Sample pathology report | Differential diagnosis | Additional references | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Magnetta EJ, Bachert SE. Secretory change. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/breastpseudolactionalhyperplasia.html. Accessed December 4th, 2024.
Definition / general
- Pregnancy-like lactational changes of glands and terminal ducts in nonpregnant, nonlactating women
Essential features
- Alteration that occurs in nonpregnant, nonlactating women
- Vast majority are incidental findings
- Histologically similar to lactational changes
Terminology
- Pregnancy-like change
- Pseudolactational change
ICD coding
- ICD-10: N64.9 - disorder of breast, unspecified
Epidemiology
- Incidental finding in 2 - 3% of core biopsies
- May be associated with calcifications
- Women, with mean age of 44 years
- May be identified in men (Clin Breast Cancer 2015;15:e171)
Sites
- Breast
Pathophysiology
- Pathophysiology is not known
Etiology
- Exact etiology is not known
- May be associated with exogenous hormone use, antipsychotics, antihypertensives and other medication use (Am J Clin Pathol 1987;87:23, Am J Surg Pathol 2000;24:74, JBR-BTR 2013;96:25)
Clinical features
- May be isolated or multifocal
- Atypical secretory change has been reported (Am J Surg Pathol 2004;28:789)
- May be associated with atypical ductal hyperplasia or ductal carcinoma in situ (Clin Breast Cancer 2015;15:e171)
- Association with invasive carcinoma is rare (Indian J Pathol Microbiol 2016;59:126, Onkologie 2011;34:448)
Diagnosis
- Majority are clinically silent and incidental microscopic findings
Radiology description
- May be associated with calcifications on mammography
Prognostic factors
- Usually an incidental finding with no known impact on prognosis
Case reports
- 45 year old woman with suspicious microcalcifications on screening mammogram and 75 year old woman on antihypertensives with microlobulated mass on mammogram (JBR-BTR 2013;96:25)
- 61 year old man on spironolactone with a unilateral breast mass (Clin Breast Cancer 2015;15:e171)
- 70 year old woman on exogenous estrogen with left breast pain (Onkologie 2011;34:448)
- 31 women with with focal pregnancy-like changes in the breast (Acta Pathol Microbiol Scand A 1977;85:931)
Treatment
- Treatment not indicated unless associated with atypia, in which excision is recommended
Gross description
- Not grossly identifiable
Microscopic (histologic) description
- Dilated and enlarged terminal duct lobular units
- Hobnailed and enlarged luminal cells with prominent cytoplasmic vacuolization
- Luminal cell nuclei will be uniform and may have prominent nucleoli
- Little to no intraluminal secretions
- Reference: Schnitt: Biopsy Interpretation of the Breast, 3rd Edition, 2017
Microscopic (histologic) images
Contributed by S. Emily Bachert, M.D. and AFIP
Expanded glands and terminal ducts
Luminal cells with vacuolated cytoplasm
Hobnailed luminal cells
Luminal cytoplasmic blebbing
Luminal cell nuclei
Expanded acinar glands
Abundant pale cytoplasm
Micropapillary pattern
Positive stains
- Granules in the cytoplasm are positive for S100 and diastase resistant PAS (periodic acid-Schiff)
Sample pathology report
- Right breast, needle core biopsy:
- Breast tissue with focal secretory change
Differential diagnosis
- Lactating adenoma:
- Well circumscribed mass composed of actively secreting glands
- Seen in women during and after pregnancy
- Secretory change tends to lack circumscription and is found outside of the context of pregnancy
- Lobular hyperplasia:
- Not well circumscribed physiologic expansion of lobules
- Features of secretory change such as hobnailed luminal cells with vacuolated cytoplasm are not seen
- Delayed involution of lactation:
- Hyperplastic involuting lobules that may be associated with calcifications and a background of inflammatory cells
- This would be within the context of pregnancy, of which secretory change is not
- Secretory carcinoma of the breast:
- Rare, well circumscribed mass with cytologic atypia and ETV6::NTRK3 gene fusion in 95% of cases
- Secretory change is unlikely to present as a mass, will not have atypia to the same degree and will lack the ETV6::NTRK3 fusion
- Micropapillary pattern of ductal carcinoma in situ (DCIS):
- Neoplastic intraductal epithelial proliferation with micropapillae that project into the duct lumen
- Secretory change is not clonal and will not have a monotonous appearance as seen in low grade DCIS nor will it have atypia as seen in high grade DCIS
- Atypical pregnancy-like change:
- Glandular cells tend to have relatively reduced vacuolated cytoplasm, greater nuclear atypia and a higher N:C ratio than that seen in normal secretory change
- Colloid-like intraluminal secretions are often seen
- Can exhibit micropapillary growth
- Secretory change will have an abundance of vacuolated cytoplasm and a lower N:C ratio without atypia
Additional references
Board review style question #1
A nonpregnant, nonlactating female underwent a core needle biopsy of the breast for calcifications identified on screening mammography. Which of the following features is the pictured lesion typically associated with?
- Abundant vacuolated cytoplasm
- Clinically palpable mass
- Invasive carcinoma
- Pronounced cytologic atypia
Board review style answer #1
A. Abundant vacuolated cytoplasm. The picture demonstrates secretory change of the breast, which has dilated terminal duct lobular units with hobnailed luminal cells and prominent vacuolization of the cytoplasm.
Answer B is incorrect because secretory change is usually an incidental finding or can be associated with calcifications on mammography. Answer D is incorrect because the luminal cells will have uniform nuclei and prominent nucleoli with no significant cytologic atypia. Answer C is incorrect because only rare case reports have been associated with invasive carcinoma. The vast majority of these lesions are incidental findings.
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Board review style question #2
Which of the following features / settings is true of secretory change?
- Circumscribed mass of glands composed of cells with eosinophilic vacuolated cytoplasm and monomorphic round vesicular nuclei with prominent nucleoli, often containing colloid-like intraluminal secretions
- Clonal intraductal proliferation of cells with nuclear atypia arranged in micropapillary architecture
- Noncircumscribed focus of glands with hobnailed cells with abundant vacuolated cytoplasm in a patient with exogenous hormone use
- Well circumscribed mass of glands with hobnailed cells with abundant vacuolated cytoplasm and secretions seen during pregnancy
Board review style answer #2
C. Noncircumscribed focus of glands with hobnailed cells with abundant vacuolated cytoplasm in a patient with exogenous hormone use. This answer is correct because it summarizes the histologic features of secretory change in the breast in a nonlactating patient. Secretory change may be associated with exogenous hormone or other medication use.
Answer D is incorrect because the context of pregnancy and a well circumscribed mass of actively secreting cells describes a lactating adenoma. Answer A is incorrect because monomorphic cells, nuclear atypia and colloid-like intraluminal secretions are seen in secretory carcinoma rather than secretory change. Answer B is incorrect because secretory change is not a clonal intraductal proliferation and does not have atypia. This describes micropapillary ductal carcinoma in situ.
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Reference: Secretory change
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