Intro to Breast Cancer

Question 1

How do the breast change during life?

• Pre-pregnancy
• Pregnancy
• Post-menopausal

Answer 1

• Pre-pregnancy
  
  • Neonatal
  • Pubertal
  • Menstrual cycle
• Pregnancy
  
  • Lactational change
• Postmenopausal
  
  • Atrophy

Question 2

What can be done to diagnose a breast lesion?

Answer 2

• Self examination
• Imaging
  
  • Mammography
  • Ultrasound
  • MRI
• Biopsy
  
  • Fine needle aspiration
  • Core needle biopsy
  • Vacuum assisted or mammotome
  • Excisional

Question 3

Screening vs. Diagnostic Mammograms (differences?):

Answer 3

• Screening occurs in asymptomatic women
  
  • 40-50 years: every year or every other year
  • >50 years: yearly screening
  • 1st degree relative with breast cancer: screening begins 10 years before the age at diagnosis in the 1st degree relative
• Diagnostic mammograms are used to evaluate a palpable lesion

Question 4

What are suspicious mammographic findings?

Answer 4

• Density
  
  • These carcinomas are ½ the size of palpable ones
• Microcalcifications
  
  • Picks up even smaller lesions
  • May herald an in situ carcinoma
• Magnification or compression views may aid in the evaluation of mammographic abnormalities

Question 5

When is an ultrasound used to evaluate breast tissue?

Answer 5

• Often used in women younger than 35 years especially if the lesion is clinically benign
• Can differentiate solid from cystic masses
• Often used in conjunction with mammography

Question 6

What are the indications for a breast MRI?

Answer 6

• Pre-operative evaluation of extent of malignant disease/contralateralprocess
• Evaluate tumor response to neo-adjuvant chemotherapy
• Axillarylymph node positive for metastatic carcinoma with unknown primary
• Evaluate integrity silicone breast implant
• High risk screening

Question 7

What are different types of breast pathology specimens?

Answer 7

• FNA
• Core biopsy
• Excisional biopsy
• Excision / lumpectomy
• Mastectomy
• Lymph nodes:
  
  • sentinel node
  • axillary dissection

Question 8

What are the advantages/disadvantages of a fine needle aspirate (FNA)?

Answer 8

• Safe, accurate and well tolerated
• Requires subspecialty expertise for interpretation
• Cannot distinguish between in situ and invasive lesions
• Higher rate of false negative results

Question 9

How is a core needle biopsy obtained?

Answer 9

• 8, 11 or 14 gauge needles
• Several cores are usually obtained
• False negatives are usually due to sampling error
• Can be obtained using radiologic guidance if the mass is small, deep, mobile, vaguely palpable or multiple

Question 10

• What is a lumpectomy?
• What is used for orientation?

Answer 10

• Needle localization biopsy
• Oriented with clips

Question 11

• What is the “triple test”?
• How is it interpreted?

Answer 11

• Combination of physical examination, imaging studies and biopsy
• If all three tests point to a benign diagnosis,
  
  • it is likely that the process is benign
  • can be followed without requiring surgical removal (95% sensitive)
• If there is any discordance among the three tests,
  
  • further studies are indicated

Question 12

Most common lesion best on age group:

• **15-25: **
• **25-35: **
• **35-50: **
• **Over 50: **
• Pregnant or lactating:

Answer 12

• 15-25
  
  • Fibroadenoma
• 25-35
  
  • Fibroadenoma (cyst or cancer possible but uncommon)
• 35-50
  
  • Fibrocystic changes, cancer, cyst
• Over 50
  
  • Cancer until proved otherwise
• Pregnant or Lactating
  
  • Lactating adenoma, cyst, mastitis, cancer

Question 13

What are the inflammatory conditions of the breast?

Answer 13

• Acute mastitis
• Periductal mastitis
• Mammary duct ectasia
• Fat necrosis
• Other (lymphocytic mastopathy, granulomatous mastitis, plasma cell mastitis, galactocele)

Question 14

What are the benign** epithelial lesions** of the breast?

Answer 14

• Non-proliferative breast changes (fibrocystic changes)
• Proliferative breast disease without atypia
• Proliferative breast disease with atypia

Question 15

What are the different types of non-proliferative breast changes (Fibrocystic Changes)?

Answer 15

• Cysts
• Fibrosis
• Apocrine metaplasia

Question 16

Non-proliferative Breast Changes (Fibrocystic Changes):

Clinical Presentation

Answer 16

• May present as lumpy breast, mass, calcifications, nipple discharge
• Pain, tenderness, pain may occur in the premenstrual phase of the cycle
• Masses may be multiple and/or bilateral and may fluctuate in size

Question 17

Non-proliferative Breast Changes (Fibrocystic Changes)

• Age predilection
• Incidence

Answer 17

• Age predilection
  
  • Premenopausal (30 –50 years old)
• Incidence
  
  • May be part of normal spectrum
  • Most common benign condition of the breast

Question 18

Proliferative Breast Disease Without Atypia:

Clinical Findings

Answer 18

• Mammographic densities (rarely form masses)
• Calcifications
• Incidental

Question 19

Different Types of Proliferative Breast Disease Without Atypia

Answer 19

Includes:

• Moderate, florid hyperplasia
• Sclerosingadenosis
• Complex sclerosing lesions
• Papillomas

Question 20

What is ductal hyperplasia?

Answer 20

• Lumen filled by heterogeneous population of cells
• Different morphologies –myoepithelial and epithelial
• Irregular slit-like fenestrations, prominent at periphery

Question 22

Describe sclerosing adenosis:

Answer 22

• Enlarged lobule, circumscribed edge
• Preserved background lobular architecture
• Compressed and distorted acini
• Dense stroma, calcifications

Question 23

What is the clinical presentation of complex sclerosing adenosis?

Answer 23

• Most common between 40 and 60 years of age
• Rarely palpable
• Usually detected by mammography
• Mammogram shows a stellate or spiculated lesion with a central core
• Biopsy is needed for confirmation of diagnosis
• Complete excision is warranted

Question 24

How does a complex sclerosing adenosis (radial scar) appear microscopically?

Answer 24

• Stellate lesion
• Central hyalinized stroma with entrapped glands
• Dilated ducts at periphery

Question 25

What is the clinical presentation of papilloma?

Answer 25

• May occur at any age
• Majority are located in the central breast
• Nipple discharge is the primary symptom in up to 80% of cases (less common in peripheral lesions)
  
  • Bloody discharge occurs in 71% of central papillomas
• Subareolar mass may be present

Question 26

How does a papilloma appear microscopically?

Answer 26

* Branching fibrovascular cores within duct * Epithelial hyperplasia often present

Question 27

List the types of **Proliferative Breast Disease With Atypia** (2):

Answer 27

1. **Atypical ductal hyperplasia** 2. **Atypical lobular hyperplasia**

Question 28

What is the microscopic appearence of atypical hyperplasia?

Answer 28

* Resembles in situ carcinoma * Lacks quantitative or qualitative features for this diagnosis

Question 29

Relative risk for invansive carcinoma for the following group: 1. Adenosis 2. Fibroadenoma 3. Fibrosis 4. Hyperplasia without atypia 5. Cysts 6. Apocrine metaplasia

Answer 29

**no increased risk**

Question 30

Relative risk for invansive carcinoma for the following group: 1. Complex fibroadenoma 2. Florid hyperplasia without atypia 3. Sclerosing adenosis 4. Solitary papilloma

Answer 30

**Slightly increased risk** (1.5 - 2.0)

Question 31

Relative risk for invansive carcinoma for the following group: 1. Atypical ductal hyperplasia 2. Atypical lobular hyperplasia

Answer 31

**Moderately increased risk** (4.0 - 5.0)

Question 32

Relative risk for invansive carcinoma for the following group: 1. DCIS (ipsilateral breast) 2. LCIS (both breasts)

Answer 32

**Significantly increased risk** (8.0-10.0)

Question 33

List the **stromal breast tumors:**

Answer 33

* Fibroadenoma * Phyllodes tumor * Sarcomas

Question 34

What is the most common breast tumor in young adults?

Answer 34

**Fibroadenoma**

Question 35

**Fibroadenoma** * Peak incidence: * Clinical Presentation: * Regression?

Answer 35

* Peak incidence: **3rd decade** * Less than 5% postmenopausal * Solitary, well-circumscribed, **movable,** painless nodule * Multiple - 15% * Regression during menopause

Question 36

**Phyllodes Tumor:** * Gross appearance: * Peak Incidence: * Palpable? * Aggressive?

Answer 36

* **Large, fibroepithelial tumor** * Benign or malignant * Most in **5th, 6th decade** * \< 1% of breast tumors * Latin women 3 -4x increased incidence * Discrete palpable breast mass * **Rapid growth**

Question 37

Phyllodes Tumor: ## Footnote **Benign features**

Answer 37

* **Circumscribed** * **Not encapsulated** * **Gray-tan cut surface** * Interlacing clefts * Cysts * Necrosis * Hemorrhage

Question 38

What are **microscopic findings** of a **benign phyllodes tumor**?

Answer 38

* **Leaf-like or epithelium lined clefts, cysts** * Increase in stromal cellularity * Stromal overgrowth

Question 39

What are the **malignant features** of a phyllodes tumor?

Answer 39

* **Marked stromal cellularity** * **Increased mitoses** * Low grade: 2-5 per 10 hpf * High grade: \>5 per 10 hpf * Cellular pleomorphism * Infiltrating border * Necrosis

Question 40

**Prognosis of Phyllodes Tumor: ** * Benign: * Low grade: * High grade:

Answer 40

* **Benign phyllodes tumor** * May recur * **Low grade phyllodes tumor** * May recur, rarely metastasize * **High grade phyllodes tumors** * Aggressive * Distant mets in 1/3 cases * Axillary node metastases