Who would you find inflammtory carcinoma in
Young black women
Tx for intraduct pupilloma
Excision of whole duct system
What is associated with mucinous (colloid) carcinoma
solid/non-invasive papillary carcinoma
What are the known breast ca genes a risk factor for heriditary breast ca
BRCA1 (chr 17q21) BRCA2 (chr13q12) Triple negative phenotype (ER-/PR-/HER2 neu-)
Age cystocarcoma phyllodes
5-6th decade female
What are risk factors for sporadic breast ca
Gender most important Early menarche Late menopause Estrogen therapy Radiation exposure Carcinoma of contralateral breast Living in US Fat Enziro toxins
Risk factors for heriditary breast ca
germline mutations Known breast ca gene
Clinic- Unilateral pruritic erythematous eruption with scale crust... mistaken for eczema
Pagets
What are the time restrictions set on ER/PR
Time from tumor removal to initiation of fixation should be kept to one hour or less Fixation to buffered formalin must extend for at least 6 hours and no longer than 72 hours
Age for galactocele
Young women
Minor prognostic factors of breast ca
histo subtype, grade, ER/PR receptors HER2/neu, LVI, proliferative rate
Clinic Older women Gross- soft pale/blue/grey node Well differentiated
Mucinous (colloid) carcinoma type of lobular carcinoma in situ
What is noted to be protective to sporadic breast CA
Early preganancy age
Breast ca lab tests
FNAC, needly bx, lumpectomy Nipple aspiration, ductal lavage, random periareolar FNA Core needle biopsy
Basal like
13-25% ductal carcinoma Trip negative BRCA1+ younger females, Higher grade, aggressive -> mets to brain cure possible in ctx group
Prognosis for mucinous carcinoma
Good prognosis
Clinic- Fleshy, soft node Well diff Lab- Synctyial sheets of large oval cells little stroma Lymphoplasmacytic immune response
Medullary carcinoma type of lobular carcinoma in situ (2%)
Micro- Branching papillae in lumen FIbrovascular core Double layer of epithelial cells No atypia/mitosis
Intraduct papilloma
Benign phyllodes tumour
Galactocele
Cystic dilatation of obstructed duct (during lactation) • Painful fluctuant lump
Prognosis of Paget
Related to underlying carcinoma
What does intraduc papilloma arise from
Lumen of large duct
MArkers for Paget
ER negative Overexpression of HER2NEU
Late stage traumatic fat necrosis presents with
Lymphocytes, fibrosis, cysts and CALCIFICATIONS
CLinic- Hard irregular lump on breast Boarders not well defined
Sclerosing adenosis RR1.5-2
Ductal carcinoma types
Comedo (high grade) Non comedo (solid, cribriform, papillary, micropapillary) Pagets
Amastia
Congenital absence of breast-
Proliferative dz w/o atypia
RR- 1.5-2.0 Sclerosing adenosis Florid benign hyperplasia Radial scar Papilloma Fibroadenoma w/ complex features
Clinical- Skin retraction Upper outer quadrant Axillary lymphadenopathy Skin thick around hairfollicles
Breast ca
Multiple papillomas located deeper within ductal system
Small duct papillomas
CLinic- Single mobile encapsulated nodule 1-10 cm Gets larger in later part of menstrual cycle, pregnancy Mam- Popcorn calcification
Fibroadenoma
Clinic- Periareolar mass Thick white nipple secretion Skin retraction
Duct Ectasia
What is HER2 (human epidermal growth factor receptor)
Is a prognostic and predictive marker EGF receptor family Her2/neu oncogene (17q21) regulates cell proliferation, survival, motility, invasion Overexpression has worse clinical outcome
HER2/Neu status determines
Response to herceptin (humanized monoclonal antibody directed against cells that express Her2/neu Herceptin does not cross BBB
Most common benign tumor of breast
Fibroadenoma
Solitary Situated in lactiferous sinuses of nipple Bloody discharge
Large duct papilloma
What are the types of noninfiltrating breast ca
Ductal carcinoma in situ Lobular carcinoma in situ (based on architecture)
Peak age of breast ca
75-80
Equivocal (score 2+) HER2 result
complete intense circumferential membrane staining
Lobular carcinoma in situ types
Infiltrating carcinoma Ductal (80%) Lobular (10%) Tubular/Cribiform (6%) Mucinous, medullary, papillary, metaplastic (4-5%)
Stroma- Fibrosis • Epithelial proliferation -Mild simple severe atypical ± cysts (micro, macro) • Mammography may show microcalcifications in concretions of secretions or necrosed epithelial cell heaps- mistaken for carcinoma
FCC
How to diff fibroadenoma from CA
DX
What group is at increased risk for genetic breast ca
Ashkenazi
Histo Necrotic center (toothpaste) Intraduct tumor
Comedocarcinoma (high grade DCIS)
Major prognostic factors of breast ca
Distant mets In absence of distant mets- axillary lymph node presence
Is intraduct papilloma Benign or malignant
Benign
Staph infection on breast
Small Localized inflammation under nipple May leave scar
Clinic Ipsilateral node Entire lobule distended Lack E-cadherin Noncohesive cells, no pleomorphism or mitoses
Lobular carcinoma in situ
Most common lobular carcinoma in situ
Infiltrating duct Ca NST (no special type) (75%)
• Sclerosing adenosis • Florid benign hyperplasia • Radial scar/Complex sclerosing lesion • Papilloma • Fibroadenoma with complex features
Proliferative disease without atypia (RR - 1.5-2.0) Epithelial lesions
Staging - In situ and pagets
I- up to 2cm, no LN 80% II- 2-5cm + regional LN 65% III >or =5 CM +other LN 40% IV any size + distant met 10% Percentages are 5 year survival
Positive (score 3+) HER2 result
Complete, intense, circumferential membrane staining >10% of invasive tumor cells
Benign cysts filled by serous fluid often have this blue color when viewed from the outside.
Blue dome cysts found in FCC
Where does breast ca metastasize to
Lungs, Bones, Liver, Adrenals may appear 15 years after tx of primary lesion
Histo Compressed glands in middle Dialated glands in the periphery Fibrous stroma Double layer of myoepithelial cells
Sclerosing adenosis
Simple FCC (no epithelial hyperplasia), FA
Non-proliferative Epithelial lesions (RR – 1)
Luminal A
40-55% of ductal carcinomas ER+, HER2/NEU -ve Postmenopausal Slow growing Well differentiation Responds to hormonal tx not ctx
Grading based on
Tubule formation Nuclear atypia Mitosis Score these from 1-3
Modified Radical processing
pectoralis major muscles include Axillary LNs
CLinic- Serous discharge Nipple retracted No inflammation Firm subareolar lump
Intraduct papilloma RR 1.5- 2
Markers for comedocarcinoma
Less often ER, PR positive, HER2Neu positive High recurrence rate
Breast CA age
Over 40, 25% postmenopausal
Sclerosing adenosis age
young
Clinic- Spread to leptomeninges, GIT, Gyne, peritoneum May present with duct carcinoma Histo- Single file lines Bulls eye pattern (tumor cells around normal acini and ducts
Lobular carcinoma
Intracanalicular fibroadenoma
Elongated compressed distorted ducts
Characteristics of Ductal carcinoma in situ
Calcifications Vague palpable mass Malignant clonal population of cells to ducts and lobules, preserved myoepithelial cells Bilateral 10-20%
Molecular classification of Ductal carcinoma
Luminal A Luminal B Normal breast like Basal like HER2+
Pathogenesis of FCC
Exaggerated,distorted cyclical changes associated with hormonal changes of menstrual cycle • Cysts, Fibrosis, Adenosis - Blue dome cysts - “Milk of calcium
Other terms for Duct ectasia
plasma cell mastitis Granulomatous mastitis
Pagets is associated to what
DCIS
Etiology fibroadenoma
Related to excess estrogen, prepubertal and young women, drugs such as cyclosporine
What is the prognosis for inflammatory carcinoma
poor
Malignant phyllodes tumour
>10 HPF (high power field) inflitrative borders Mod-marked atypia
Clinic- Swollen erythematous breast -> d/t dermal lymphatics Underlying carcinoma diffusely infiltrative
Inflammatory carcinoma
Age of lobular carcinoma in situ
Younger women Incidental finding
ER/PR testing
Estrogen and progesterone receptor testing Done in all newly dx invasive breast ca
Histo- Loose edematous myxoid fibroblastic stroma Mixed pattern
Fibroadenoma
Breast ca proliferation stages
I proliferative dz w/o atypia- 2 layers II Atypical ductal hyperplasia- 2 layers w/ nuclei changes III Ductal Carcinoma in situ- multiple layers for epi cells but within meoepithelial cells IV Invasive ductal carcinoma- Epi cells break from myoepithelial cell and spread
Common cause of abnormal nipple discharge
Intraduct papilloma
Clinic 2.5cm nodule Upper outer quadrant Firm, ill defined borders Skin dimpling Skin adherent to mass Axillary LN enlarged
Carcinoma
Breast ca tx
Lumpectomy Simple mastectomy +/- LN dissection Postop irradiation Chemo Immuno (herceptin) Hormone tx (tamoxifen)
Pericanalicular fibroadenoma
Oval ducts, surrounded by stroma
Polythelia
Accessory nipples along milk line
Pathogenesis of duct ectasia
Dilated duct ruptures causing inflammation, plasma cells repleased with histicytes, giant cells , granulomas
Her2 positive
7-12% ER-Her2+ Poorly diff, high freq of brain mets
What is the most COD malignancy in woment
Lung
What has the same invasive freq as DCIS
Lobular carcinoma in stiu
Scirrhous- hard dense desmoplasia 3-4cm infltrative edge Cords and nests of cells Necrosis, calcification
Infiltrating duct Ca
Clinic- Large pendulous breast Mimics carcinoma
Traumatic fat necrosis
Age of duct ectasia
5-6th decade
Gynecomastia
Male analog of FCC Increased estrogen levels Linked to cirrhosis, klinefleter (XXY) drugs Find button like nodule beneath areola Micro: intraductal hyperplasia
What are the non breast ca genes increase your risk for heriditary breast ca
Li Fraumeni syndrome (p53) Li Fraumeni varient (CHEK2) Peutz Jeghers syndrome Cowden syndrome Ataxia telengectasia
Intraduct carcinoma in large duct with spread to skin, areola, nipple
Paget dz
ER/PR response tx
ER+/PR+: Respond to tamoxifen ER-/PR+: Upto 50% response rate ER+/PR-: 40% response rate ER-/PR-:
Module can grow from small to taking up entire breast
cystocarcoma
Histo- Thickened secretion, dilation, rupture of duct Inflammation, granular debris Foamy histocytes, mononuclear cells Plasma cells and granulomas
Duct ectasia
Peaud- orange
Lymphedema Skin thick around hairfollicles
Milky discharge
pituitary adenoma, hypothyroidism, drugs (birth control)
Non preliferative epithelial lesions
RR- 1 Simple FCC
Grade I
well differentiated (score 3-5)
ER/PR testing is done how
immunohistochemistry Considered positive test if at least 1% of tumor in the sample tests positive Predicts benefit with endocrine tx
Clinical Lumpiness “lumpy bumpy”, pain, tenderness - continuous or cyclical, mammographic densities/calcifications Bilateral Grows with hormones
Fibrocystic changes (FCC)
Polymastia
Accessory true mammary gland (can be found in arm pit)
Increase risk for CA from fibroadenoma when
Cyst larger than .3 cm Sclerosing adenosis, epithelial calcifications and papillary apocrine change
Uncommonly metastasizing lobular carcinomas
colloid, medullary, papillary
Are cystocarcoma phyllodes benign or mallignant
benign
Luminal B
15-20% ductal carcinomas ER+, HER2Neu (Trip positive tumor) LN mets Respond to ctx
mistaken for carcinoma
Congenital inversion of nipple
Lab- Large hyperchromic nucleus w/ halo Aggressive underlying intraductal carcinoma
Pagets
BRCA2 characteristics
Chrom 13q12 10-20% ovarian ca in carrier Increased risk of male breast ca Prostatic/pancreatic ca
Carcinomas in males
.11% lifetime risk Klinefelters BRCA2 mutation rapid infiltration ER+ tumor more common
Grade III
Poorly differentiated score >7
When does fibroadenoma regress
During menopause
What is the most common non skin malignancy in females
Breast carcinoma
Borderline phyllodes tumour
Moderate atypia 5-10 HPF (high power field), pushing bordres
Implants can lead to
Abscess Foreign body granuloma Fistulae
Postive mamograph can indicate
60-80% carcinomas Intraduct carcinoma FCC proliferative, sclerosing adenosis, radial scar
Gross- Lobulated clefts leaf like Micro- Leaf like architecture, nuclear pleomorphism, cellularity, mitotic rate, stromal overgroth INFILTRATIVE BORDER
Phyllodes tumour
Normal breast like
6-10% ductal carcinomas ER+, HER2/Neu-ve Usually well differentiated
Proliferative dz w/ atypia
RR- 4-5 Atypical ductal hyperplasia Atypical lobule hyperplasia
Milk of calcium seen in FCC is what
mammographic feature observed when there is dependent calcium layering within breast cysts
Grade II
score 6-7
Strep
Whole breast Marked swelling Tenderness Heal without scar
Fibroadenoma is a tumor of
Stomal cells
Age of FCC
Age: Reproductive life, may persist after menopause, almost 50% of females affected
Bloody discharge
papilloma, cyst, pregnancy
BRCA1 characteristics
Chrom 17q21 More common 20-40% risk ovarian ca in carrier Prostatic/pancreatic ca Associated Breast ca are poorly differentiated
Clinic Young Nursing Sudden enlargement of single breast Reddish Nipple cracked pain/tenderness
Acute mastitis (Abscess) From infection of Stay or strep
Another term for phyllodes tumor
Cystocarcoma phyllodes
What kind of dx is inflammatory carcinoma
clinicopatholigic dx
