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Pathology > Breast > Flashcards

Breast Flashcards

1
Q

Milkline Remnants

A
  • produce hormone-responsive supernumerary nipples or breast tissue from axilla to perineum.
  • find secondary to painful pre-menstrual enlargement.
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2
Q

Accessory Axillary Breast Tissue

A
  • normal ductal tissue extends into subQ tissue of axilla or chest wall.
  • presentation: lump in setting of lactational hyperplasia.
    • can cause carcinoma outside breast.
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3
Q

Congenital Nipple Inversion

A
  • spontaneously corrects during pregnancy or with traction.
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4
Q

Acquired Nipple Inversion

A
  • concern for carcinoma or inflammatory conditions.
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5
Q

Presentation of Breast Disease

A
  • pain. cyclic has no pathologic correlate.
    • non-cyclic = localized, secondary to infection, trauma or ruptured cyst.
    • 95% painful masses benign.
    • 10% cancer presents with pain.
  • discrete palpable mass. when <2cm. usually cysts, fibroadenomas, and carcinoma.
    • 10% dominant masses in women <40yrs are cancer.
    • 60% in women >50yrs malignant.
  • nipple discharge. see in cancer when unilateral and spontaneous.
    • 7% malignancies in women <60yrs.
    • 30% in women >60yrs.
    • bloody or serous due to cysts or intraductal papillomas. benign in pregnancy.
  • milky discharge = galactorrhea. outside pregnancy related to prolactin-producing pituitary adenomas, hypothyroidism, anovulatory cycles, or meds.
  • mammographic signs with carcinomas = densities and calcifications.
    • neoplasms typically denser than breast tissue.
    • detect as small as 1cm.
    • calcifications on secretions, necrotic debris, hyalinized stroma.
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6
Q

Acute Mastitis

A
  • during 1st month lactation when breast vulnerable to bacterial infections (Staph and strep) thru nipple cracks and fissures.
  • tx: antibiotics and breastfeeding.
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7
Q

Periductal Mastitis

A
  • aka recurrent subareolar abscess, squamous metaplasia of lactiferous ducts, and Zuska disease.
  • squamous metaplasia of nipple ducts ⇒ keratin shedding and ductal plugging.
  • ductal dilation and rupture ⇒ intense chronic and granulomatous inflammation.
  • associated with smoking (90%).
  • can get bacterial infections.
  • recurrent causes periareolar fistulous tracts and/or nipple inversion.
  • presentation: painful subareolar mass in both sexes.
  • tx: surgery
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8
Q

Mammary Duct Ectasia

A
  • inspissation of secretions, ductal dilation without squamous metaplasia, periductal inflammation causes fibrosis and skin retraction.
  • presentation: ill-defined, painless periareolar mass with viscous white nipple secretions.
    • multiparous women ages 50-70yrs.
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9
Q

Fat Necrosis

A
  • associated with prior trauma or surgery.
  • go from hemorrhage with acute inflammation and liquefactive fat necrosis to chronic inflammation with giant cells and hemosiderin to scar tissue.
  • presentation: painless palpable mass, skin thickening or retraction, or mammographic density and/or calcifications.
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10
Q

Lymphocytic Mastopathy (Sclerosing Lymphocytic Lobulitis)

A
  • collagenized stroma around atrophic ducts with prominent lymphocytic infiltrate.
  • associated with type 1 diabetes and autoimmune thyroid disease.
  • presentation: single or multiple, rock-hard, palpable masses.
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11
Q

Granulomatous Mastitis

A
  • associated with systemic diseases (sarcoidosis, Wegener granulomatosis), foreign bodies, granulomatous infections.
  • granulomatous lobular mastitis = in parous women, from hypersensitivity responses to lactational epithelium.
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12
Q

Monoproliferative Breast Changes (Fibrocystic Changes)

A
  • benign. usually seen in lumpy breasts.
  • morphology: cysts from lobular dilation and unfolding, coalesce. lined by flattened atrophic epithelium or metaplastic apocrine cells. have calcifications.
    • fibrosis from cyst rupture and inflammation.
    • adenosis = ↑ numbers of acini per lobule. in normal pregnancy, focal finding in non-pregnant breast.
      • enlarged but not distorted, lined by columnar epithelium. can have atypia. have calcifications.
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13
Q

Proliferative Breast Disease without Atypia

A
  • epithelial and stroma proliferation without cytologic or architectural atypia.
  • morphology: epithelial hyperplasia = more than 2 cell layers around ducts and lobules.
    • sclerosing adenosis = ↑ numbers of acini per lobut with central distortion and compression and peripheral dilation.
    • complex sclerosing lesions = have sclerosing adenosis, papillomas, epithelial hyperplasia.
    • papillomas = epithelial growth, associated with fibrovascular cores within dilated ducts.
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14
Q

Proliferative Breast Disease with Atypia

A
  • include atypical ductal and atypical lobular hyperplasia, sometimes with calcifications.
  • morphology: lacks sufficient features to diagnose carcinoma but look like carcinoma in situ.
    • atypical ductal hyperplasia = limited extent but looks like ductal carcinoma in situ.
    • atypical lobular hyperplasia = looks like lobular carcinoma in situ but <50% of acini in lobule.
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15
Q

Carcinoma of Breast

A
  • most common non-skin malignancy in women.
  • 1/8 chance by age 90.
  • <20% mortality
  • epidemiology: 1% in men, rare before 25yrs.
    • caucasians around 61 yr, hispanic 56yr, black 46yr.
    • in younger women = ↓ estrogen receptors or ↑ HER2/neu expression.
    • ↑ risk with 1st degree relatives.
    • atypical hyperplasia ↑ risk
    • 7% in whites, 5% blacks, 4% hispanics.
      • ↑ malignancy and mortality in blacks and hispanics.
    • ↑ risk from hormone replacement.
    • ↑ risk from breast density, radiation exosure, carcinoma of endometrium or contralateral breast.
    • risk from: diet (↑ by alcohol, ↓ by caffeine); obesity (reduces risk by anovulatory cycle), breastfeeding (reduces risk)
    • most ER positive, comes from ER expressing luminal cell
    • ER negative come from myoepithelial cells.
    • proliferative changes, atypical ductal/lobular hyperplasia = ER expression.
    • final step = in situ to invasive
  • predictive factors: invasive vs in situ; distant metastases; lymph node metastases (most important without distant metastases); tumor size; locally advanced disease; inflammatory carcinoma.
    • overexpressed HER2/neu = worse prognosis but better response to trastuzumab.
    • lymphovascular invasion = poor prognosis, risk for recurrence.
    • aneuploidy = worse prognosis
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16
Q

Hereditary Breast Cancer

A
  • germline mutations in 12%.
  • BRCA1 and BRCA2 are majority of mutations, 3% breast cancers.
    • poorly differentiated.
    • ↑ risk of ovarian, prostatic, and pancratic cancers.
  • mutated CHEK2, p53, PTEN, LKB1/STK11 = 10%.
17
Q

Sporadic Breast Cancer

A
  • risk factor: hormone exposure
    • ↑ number of target cells by stimulating breast growth.
    • risk for stablizing DNA mutations.
18
Q

Ductal Carcinoma In Situ (DCIS)

A
  • 15-30% breast cancers.
  • present with calcifications.
  • bilateral in 10-20%.
  • morphology: comedocarcinoma = ducts and lobules dilated by sheets of high grade pleomorphic cells with zones of central necrosis.
    • noncomedo DCIS = monomorphic populations of cells, varying nuclear grades. patterns are cribriform, solid, papillary, and micropapillary.
    • Paget disease = of nipple. malignant cells extend from ductal DCIS into nipple skin without crossing basement membrane. create erythematous eruption with scaly crust.
    • microinvasion = stromal invasion <0.1cm
  • tx: mastectomy cures 95%.
19
Q

Lobular Carcinoma In Situ

A
  • 1-6% breast cancers, incidental finding.
  • no calcifications or stromal response.
  • bilateral in 20-40%, most in premenopausal women.
  • untreated ⇒ invasive cancer 1% per year.
  • morphology: discohesive cells (loss of E-cadherin expression), with intracelular mucin forming signet ring cells. most express ER and PR.
20
Q

Invasive (Infiltrating) Carcinoma

A
  • present as palpable masses or radiodense mammographic lesions.
    • radiodense are 1/2 size of palpable, only 20% involve nodes.
    • 50% palpable have nodal metastases.
  • large can be fixed to chest wall, cause skin dimpling or nipple retraction.
  • invade dermal lymphatics ⇒ lymphadema ⇒ peau d’orange appearance.
  • inflammatory carcinoma = tumors that present with swollen, erythematous breast due to lymphatic invasion and destruction. poor prognosis.
21
Q

Invasive Carcinoma, No Special Type (NST; Invasive Ductal Carcinoma)

A
  • 70-80% breast cancers.
  • ‘Luminal A’ = 40-55% NST. ER positive, HER2/neu negative. well differentiated, in postmenopausal women. slow-growing, respond to hormone therapy.
  • ‘Luminal B’ = 15-20% NST. ER positive, high grade, HER2/neu over-expression = triple positive.
    • present with nodal metastases, respond to chemo.
  • ‘Normal breast-like’ = 6-10% NST. well differentiated, ER positive, HER2/neu negative.
  • ‘Basal-like’ = 13-15% NST. lack ER, PR, or HER2/neu = triple negative. express myoepithelial cell markers.
    • many have mutated BRCA2.
    • many high grade, proliferative, aggressive.
    • 15-20% respond to chemo.
  • ‘HER2 positive’ = 7-12% NST. ER negative, over-express HER2/neu from 17q21 amplification. poorly differentiated, aggressively metastatic.
  • ER pos respond to hormone blockade.
  • HER2/neu respond to combo of chemo and monoclonal Ab (trastuzumab).
  • morphology: firm to hard, irregular border, gritty sensation on cutting.
    • range from well differentiated with tubules, small round nuclei, rare mitoses to poorl differentiated with sheets and nests of cells with enlarged irregular nuclei, multiple mitoses, focal necrosis.
22
Q

Invasive Lobular Carcinoma

A
  • palpable mass or mammographic density.
  • 25% invade with little desmoplasia.
  • well-differentiated and mod differentiated = diploid, ER pos, associated with LCIS, similar genes to luminal A.
  • poorly differentiated = aneuploid, lack hormone receptors, over-express HER2/neu.
  • lobular = metastasize to peritoneum and retroperitoneum, GI tract, leptomeninges, ovaries, uterus.
  • morphology: hallmark = discohesive infiltrating tumor cells, single-file or loose clusters. signet ring appearance, minimal desmoplasia.
23
Q

Medullary Carcinomas

A
  • after age 60yr.
  • rapidly growing, well circumscribed masses.
  • ‘basal-like’ expression pattern.
  • 2/3rds have hypermethylation of BRCA1 promoter.
  • better prognosis than NST.
  • over-expression of intercellular adhesion molecules and E-cadherin ⇒ limit metastatic spread.
  • morphology: soft and fleshy, pushing border, little desmoplastic response.
    • solid sheets of large cells with vesicular pleomorphic nuclei, prominent nucleoli, multiple mitoses, lymphoplasmocytic infiltrate.
24
Q

Mucinous (Colloid) Carcinoma

A
  • slow-growing, well-differentiated, ER pos.
  • around age 71yr.
  • nodal metastases common.
  • morphology: soft to rubbery, gel-like consistency.
    • malignant cells in cluster within large mucin lakes.
25
Q

Tubular Carcinoma

A
  • found as small irregular mammographic densities, women in 40’s. multifocal and/or bilateral.
  • associated with atypical lobular hyperplasia, LCIS, low-rade DCIS.
  • 95% well-differentiated, diploid, ER pos, HER2/neu neg.
  • good prognosis.
26
Q

Fibroadenomas

A
  • most common benign tumor of female breast.
  • during reproductive years, calcify after menopause.
  • present as rubbery, well circumscribed palpable masses, ovoid densities, calcifications.
  • hormone responsive, grow during pregnancy.
  • polyclonal hyperplasias of lobular stroma, respond to cyclosporine.
27
Q

Phyllodes Tumor

A
  • most common >60yrs.
  • palpable mass.
  • stroma overgrows epithelial component, form clefts and slits and create bulbous protrusions.
  • ↑ cellularity, mitotic activity, stromal overgrowth, infiltrative borders
  • high grade have EGF receptor amplification
  • cured by wide lcoal excision.
28
Q

Benign Stromal Lesions

A
  • tumors of interlobular stroma, made of stromal cells without epithelial components.
  • ex: pseudoangiomatous stromal hyperplasia and fibromatosis, myofibroblastoma, lipomas.
29
Q

Malignant Stromal Tumors

A
  • rare.
  • angiosarcoma = most common. primary tumor in young women after radiation therapy for breast cancer or in skin of chronically edematous arm after mastectomy (Stewart-Treves syndrome).
    • high grade, poor prognosis.
30
Q

Gynecomastia

A
  • in men.
  • uni- or bilateral.
  • button-like subareolar enlargement.
  • indicator of estrogen and androgen imbalance.
  • during puberty, Klinefelter syndrome, hormone-producing tumors, men with cirrhosis, drug side effect.
  • ductal epithelial and stromal hyperplasia.
31
Q

Male Breast Carcinoma

A
  • rare.
  • risk factors: 1st degree relatives, estrogen exposure
  • associated with BRCA2 mutation.
  • tend to invade skin and chest wall earlier and present at higher stages.

Pathology (9 decks)

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