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1

Who would you find inflammtory carcinoma in

Young black women

2

Tx for intraduct pupilloma

Excision of whole duct system

3

What is associated with mucinous (colloid) carcinoma

solid/non-invasive papillary carcinoma

4

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-)

5

Age cystocarcoma phyllodes

5-6th decade female

5

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

6

Risk factors for heriditary breast ca

germline mutations Known breast ca gene

6

Clinic- Unilateral pruritic erythematous eruption with scale crust... mistaken for eczema

Pagets

6

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

7

Age for galactocele

Young women

8

Minor prognostic factors of breast ca

histo subtype, grade, ER/PR receptors HER2/neu, LVI, proliferative rate

9

Clinic Older women Gross- soft pale/blue/grey node Well differentiated

Mucinous (colloid) carcinoma type of lobular carcinoma in situ

10

What is noted to be protective to sporadic breast CA

Early preganancy age

10

Breast ca lab tests

FNAC, needly bx, lumpectomy Nipple aspiration, ductal lavage, random periareolar FNA Core needle biopsy

10

Basal like

13-25% ductal carcinoma Trip negative BRCA1+ younger females, Higher grade, aggressive -> mets to brain cure possible in ctx group

10

Prognosis for mucinous carcinoma

Good prognosis

10

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%)

11

Micro- Branching papillae in lumen FIbrovascular core Double layer of epithelial cells No atypia/mitosis

Intraduct papilloma

12

Benign phyllodes tumour

13

Galactocele

Cystic dilatation of obstructed duct (during lactation) • Painful fluctuant lump

13

Prognosis of Paget

Related to underlying carcinoma

14

What does intraduc papilloma arise from

Lumen of large duct

14

MArkers for Paget

ER negative Overexpression of HER2NEU

15

Late stage traumatic fat necrosis presents with

Lymphocytes, fibrosis, cysts and CALCIFICATIONS

16

CLinic- Hard irregular lump on breast Boarders not well defined

Sclerosing adenosis RR1.5-2

17

Ductal carcinoma types

Comedo (high grade) Non comedo (solid, cribriform, papillary, micropapillary) Pagets

18

Amastia

Congenital absence of breast-

19

Proliferative dz w/o atypia

RR- 1.5-2.0 Sclerosing adenosis Florid benign hyperplasia Radial scar Papilloma Fibroadenoma w/ complex features

19

Clinical- Skin retraction Upper outer quadrant Axillary lymphadenopathy Skin thick around hairfollicles

Breast ca

20

Multiple papillomas located deeper within ductal system

Small duct papillomas

20

CLinic- Single mobile encapsulated nodule 1-10 cm Gets larger in later part of menstrual cycle, pregnancy Mam- Popcorn calcification

Fibroadenoma

22

Clinic- Periareolar mass Thick white nipple secretion Skin retraction

Duct Ectasia

23

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

24

HER2/Neu status determines

Response to herceptin (humanized monoclonal antibody directed against cells that express Her2/neu Herceptin does not cross BBB

25

Most common benign tumor of breast

Fibroadenoma

26

Solitary Situated in lactiferous sinuses of nipple Bloody discharge

Large duct papilloma

27

What are the types of noninfiltrating breast ca

Ductal carcinoma in situ Lobular carcinoma in situ (based on architecture)

28

Peak age of breast ca

75-80

29

Equivocal (score 2+) HER2 result

complete intense circumferential membrane staining

30

Lobular carcinoma in situ types

Infiltrating carcinoma Ductal (80%) Lobular (10%) Tubular/Cribiform (6%) Mucinous, medullary, papillary, metaplastic (4-5%)

31

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

31

How to diff fibroadenoma from CA

DX

31

What group is at increased risk for genetic breast ca

Ashkenazi

32

Histo Necrotic center (toothpaste) Intraduct tumor

Comedocarcinoma (high grade DCIS)

33

Major prognostic factors of breast ca

Distant mets In absence of distant mets- axillary lymph node presence

35

Is intraduct papilloma Benign or malignant

Benign

37

Staph infection on breast

Small Localized inflammation under nipple May leave scar

38

Clinic Ipsilateral node Entire lobule distended Lack E-cadherin Noncohesive cells, no pleomorphism or mitoses

Lobular carcinoma in situ

38

Most common lobular carcinoma in situ

Infiltrating duct Ca NST (no special type) (75%)

40

• 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

41

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

41

Positive (score 3+) HER2 result

Complete, intense, circumferential membrane staining >10% of invasive tumor cells

43

Benign cysts filled by serous fluid often have this blue color when viewed from the outside.

Blue dome cysts found in FCC

44

Where does breast ca metastasize to

Lungs, Bones, Liver, Adrenals may appear 15 years after tx of primary lesion

46

Histo Compressed glands in middle Dialated glands in the periphery Fibrous stroma Double layer of myoepithelial cells

Sclerosing adenosis

47

Simple FCC (no epithelial hyperplasia), FA

Non-proliferative Epithelial lesions (RR – 1)

47

Luminal A

40-55% of ductal carcinomas ER+, HER2/NEU -ve Postmenopausal Slow growing Well differentiation Responds to hormonal tx not ctx

47

Grading based on

Tubule formation Nuclear atypia Mitosis Score these from 1-3

49

Modified Radical processing

pectoralis major muscles include Axillary LNs

51

CLinic- Serous discharge Nipple retracted No inflammation Firm subareolar lump

Intraduct papilloma RR 1.5- 2

52

Markers for comedocarcinoma

Less often ER, PR positive, HER2Neu positive High recurrence rate

53

Breast CA age

Over 40, 25% postmenopausal

54

Sclerosing adenosis age

young

54

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

56

Intracanalicular fibroadenoma

Elongated compressed distorted ducts

57

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%

57

Molecular classification of Ductal carcinoma

Luminal A Luminal B Normal breast like Basal like HER2+

58

Pathogenesis of FCC

Exaggerated,distorted cyclical changes associated with hormonal changes of menstrual cycle • Cysts, Fibrosis, Adenosis - Blue dome cysts - “Milk of calcium

58

Other terms for Duct ectasia

plasma cell mastitis Granulomatous mastitis

59

Pagets is associated to what

DCIS

61

Etiology fibroadenoma

Related to excess estrogen, prepubertal and young women, drugs such as cyclosporine

62

What is the prognosis for inflammatory carcinoma

poor

64

Malignant phyllodes tumour

>10 HPF (high power field) inflitrative borders Mod-marked atypia

65

Clinic- Swollen erythematous breast -> d/t dermal lymphatics Underlying carcinoma diffusely infiltrative

Inflammatory carcinoma

66

Age of lobular carcinoma in situ

Younger women Incidental finding

67

ER/PR testing

Estrogen and progesterone receptor testing Done in all newly dx invasive breast ca

68

Histo- Loose edematous myxoid fibroblastic stroma Mixed pattern

Fibroadenoma

69

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

70

Common cause of abnormal nipple discharge

Intraduct papilloma

70

Clinic 2.5cm nodule Upper outer quadrant Firm, ill defined borders Skin dimpling Skin adherent to mass Axillary LN enlarged

Carcinoma

71

Breast ca tx

Lumpectomy Simple mastectomy +/- LN dissection Postop irradiation Chemo Immuno (herceptin) Hormone tx (tamoxifen)

72

Pericanalicular fibroadenoma

Oval ducts, surrounded by stroma

73

Polythelia

Accessory nipples along milk line

74

Pathogenesis of duct ectasia

Dilated duct ruptures causing inflammation, plasma cells repleased with histicytes, giant cells , granulomas

75

Her2 positive

7-12% ER-Her2+ Poorly diff, high freq of brain mets

76

What is the most COD malignancy in woment

Lung

78

What has the same invasive freq as DCIS

Lobular carcinoma in stiu

79

Scirrhous- hard dense desmoplasia 3-4cm infltrative edge Cords and nests of cells Necrosis, calcification

Infiltrating duct Ca

80

Clinic- Large pendulous breast Mimics carcinoma

Traumatic fat necrosis

82

Age of duct ectasia

5-6th decade

83

Gynecomastia

Male analog of FCC Increased estrogen levels Linked to cirrhosis, klinefleter (XXY) drugs Find button like nodule beneath areola Micro: intraductal hyperplasia

85

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

87

Intraduct carcinoma in large duct with spread to skin, areola, nipple

Paget dz

88

ER/PR response tx

ER+/PR+: Respond to tamoxifen ER-/PR+: Upto 50% response rate ER+/PR-: 40% response rate ER-/PR-:

90

Module can grow from small to taking up entire breast

cystocarcoma

91

Histo- Thickened secretion, dilation, rupture of duct Inflammation, granular debris Foamy histocytes, mononuclear cells Plasma cells and granulomas

Duct ectasia

93

Peaud- orange

Lymphedema Skin thick around hairfollicles

95

Milky discharge

pituitary adenoma, hypothyroidism, drugs (birth control)

96

Non preliferative epithelial lesions

RR- 1 Simple FCC

97

Grade I

well differentiated (score 3-5)

98

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

99

Clinical Lumpiness “lumpy bumpy”, pain, tenderness - continuous or cyclical, mammographic densities/calcifications Bilateral Grows with hormones

Fibrocystic changes (FCC)

100

Polymastia

Accessory true mammary gland (can be found in arm pit)

101

Increase risk for CA from fibroadenoma when

Cyst larger than .3 cm Sclerosing adenosis, epithelial calcifications and papillary apocrine change

102

Uncommonly metastasizing lobular carcinomas

colloid, medullary, papillary

103

Are cystocarcoma phyllodes benign or mallignant

benign

104

Luminal B

15-20% ductal carcinomas ER+, HER2Neu (Trip positive tumor) LN mets Respond to ctx

105

mistaken for carcinoma

Congenital inversion of nipple

106

Lab- Large hyperchromic nucleus w/ halo Aggressive underlying intraductal carcinoma

Pagets

107

BRCA2 characteristics

Chrom 13q12 10-20% ovarian ca in carrier Increased risk of male breast ca Prostatic/pancreatic ca

108

Carcinomas in males

.11% lifetime risk Klinefelters BRCA2 mutation rapid infiltration ER+ tumor more common

109

Grade III

Poorly differentiated score >7

111

When does fibroadenoma regress

During menopause

112

What is the most common non skin malignancy in females

Breast carcinoma

113

Borderline phyllodes tumour

Moderate atypia 5-10 HPF (high power field), pushing bordres

114

Implants can lead to

Abscess Foreign body granuloma Fistulae

115

Postive mamograph can indicate

60-80% carcinomas Intraduct carcinoma FCC proliferative, sclerosing adenosis, radial scar

117

Gross- Lobulated clefts leaf like Micro- Leaf like architecture, nuclear pleomorphism, cellularity, mitotic rate, stromal overgroth INFILTRATIVE BORDER

Phyllodes tumour

118

Normal breast like

6-10% ductal carcinomas ER+, HER2/Neu-ve Usually well differentiated

119

Proliferative dz w/ atypia

RR- 4-5 Atypical ductal hyperplasia Atypical lobule hyperplasia

121

Milk of calcium seen in FCC is what

mammographic feature observed when there is dependent calcium layering within breast cysts

122

Grade II

score 6-7

123

Strep

Whole breast Marked swelling Tenderness Heal without scar

124

Fibroadenoma is a tumor of

Stomal cells

125

Age of FCC

Age: Reproductive life, may persist after menopause, almost 50% of females affected

126

Bloody discharge

papilloma, cyst, pregnancy

127

BRCA1 characteristics

Chrom 17q21 More common 20-40% risk ovarian ca in carrier Prostatic/pancreatic ca Associated Breast ca are poorly differentiated

128

Clinic Young Nursing Sudden enlargement of single breast Reddish Nipple cracked pain/tenderness

Acute mastitis (Abscess) From infection of Stay or strep

129

Another term for phyllodes tumor

Cystocarcoma phyllodes

130

What kind of dx is inflammatory carcinoma

clinicopatholigic dx