Invasive Breast Cancer

Question 1

Invansive breast carcinoma:

• Clinical Presentation
• **Mammographic **findings

Answer 1

• Clinical presentation
  
  • Palpable mass
  • Dimpling of the skin
  • Retraction of the nipple
• Mammographic findings
  
  • Mass/density
  • Calcifications

Question 2

What is the distribution of breast carcinoma?

Answer 2

• 50% arise in upper outer quadrant
• 20% in subareolar central area
• 10% in each of the other quadrants

Question 3

Invasive Breast Carcinoma:

Histological Types

Answer 3

• Ductal
  
  • Ductal NOS -Not otherwise specified
  • Tubular
  • Medullary
  • Mucinous (Colloid)
  • Adenoid cystic
  • Hypersecretory
  • Metaplastic
• Lobular

Question 4

What are the molecular subtypes of breast carcinoma?

Answer 4

• Identified 4 molecular subtypes:
  
  • Luminal A
  • Luminal B
  • HER2 positive
  • Basal-like
• These are associated with different clinical outcomes and different therapies

Question 5

Invasive Ductal Carcinoma

• Incidence:
• Appearance:
• Associated with ….
• Molecular Subtypes:

Answer 5

• Majority of carcinomas (70% -80%)
• Usually firm, white masses with indistinct borders
  
  • Range from well to poorly differentiated
• Usually associated with DCIS, and rarely LCIS
• Molecular subtypes:
  
  • 2/3 express ER/PR
  • 1/3 overexpress Her2/Neu

Question 6

**Invasive Lobar Carcinoma **(ILC)

• Age predilection:
• Incidence:
• Appearence:

Answer 6

• Relatively more common in postmenopausal women
• Account for 20% of all breast cancers
• Appearence:
  
  • Multicentric more often than other carcinomas
  • Bilateral 20%
  • Contralateral carcinoma:
    
    • Prior or concurrent: 6 - 47%
    • Subsequent: 10 - 15%

Question 7

• What is the pattern of metastases for ILC?
• What does it stain negatively for?
• How is its prognosis compared to ductal NOS?

Answer 7

• Distinctive pattern of metastases:
  
  • CSF, serosal surfaces, GI, ovary, uterus, bone marrow
• E-cadherin negative
• Slightly better prognosis than ductal NOS

Question 8

• What can be seen on mammography for ILC?
• What are the gross features of ILC?

Answer 8

• Mammography (often negative)
  
  • Asymmetric, ill defined
  • Spiculated mass/density
• Gross features
  
  • ​Hard tumor
  • Irregular borders
  • No distinct margin, blends with surrounding tissue

Question 9

What are the **microscopic features **of ILC?

Answer 9

• Small cells
• Single file pattern
• Targetoid growth pattern
• No gland formation
• Intracytoplasmic mucin vacuoles
• Signet ring cells

Question 10

Medullary Carcinoma

• Age predilection:
• Increased incidence in ….
• Prognosis:
• Genetic expression:

Answer 10

• Younger age group
• Rare subtype; less than 1%
• Increased incidence in women with BRCA1 gene
• Better prognosis than invasive ductal carcinoma NOS
  
  • Metastases infrequent
• Genetic expression:
  
  • Do not overexpress Her2/Neu
  • Negative for ER/PR

Question 12

Medullary Carcinoma:

• Mammographic findings
• Gross findings

Answer 12

• Mammographic findings
  
  • Oval circumscribed mass
  • Can be mistaken for fibroadenoma
• Gross findings
  
  • Soft, fleshy
  • Circumscribed border
  • Lobulated, bulging cut surface

Question 13

Meduallry Carcinoma: Microscopic criteria for diagnosis

Answer 13

• Syncytial growth pattern in 75% of tumor cells
• High nuclear grade
• Lymphoplasmacytic infiltrate
• Pushing (non-infiltrative) border

Question 14

Tubular Carcinoma

• Median Age:
• Focality:
• Most common location:
• Prognosis:

Answer 14

• Median age: mid to late 40’s
• Multifocal in 10 - 56% of cases
• Periphery of the breast
• Excellent prognosis
  
  • Axillary metastasis

Question 15

Tubular Carcinoma

• Mammographic findings
• Gross findings

Answer 15

• Mammographic findings
  
  • Small stellate lesion in an asymptomatic woman
• Gross findings
  
  • Ill-defined stellate mass
  • Gray-white, firm
  • 80 –90% are 1 cm or smaller in size

Question 16

What are the microscopic findings in tubular carcinoma?

Answer 16

• Single layer of epithelial cells lining glands
• No myoepithelial layer
• Glands scattered in desmoplastic stroma

Question 17

Colloid (Mucinous) Carcinoma:

Clinical Features

Answer 17

• Usually postmenopausal
• Slow growing mass
• Good prognosis
• Axillary metastases:
• Incidence is slightly higher in women with BRCA1 mutation

Question 18

Colloid (Mucinous) Carcinoma:

• Mammographic findings
• Gross
• Microscopic findings

Answer 18

• Mammographic findings
  
  • Well circumscribed and lobulated
• Gross
  
  • Circumscribed mass
  • Soft, pale blue, gelatinous surface
• Microscopic findings
  
  • Tumor cells and nests in pools of mucin

Question 19

What is inflammatory carcinoma of the breast?

Answer 19

• Clinical diagnosis: 6-9% of carcinomas
• Not a specific histological subtype
• Skin erythema, peau d’orange
• DDx: acute mastitis

Question 20

Inflammatory carcinoma

• Gross features:
• Microscopic:
• Prognosis:

Answer 20

• Gross features
  
  • ​Diffuse induration of breast parenchyma
  • Thickening of the skin
• Microscopic: skin biopsy
  
  • Lymphatic tumor emboli
• Bad prognosis
  
  • 10-year survival is 30%

Question 21

What is the difference between grade and stage?

Answer 21

• Stage (TNM)
  
  • Tumor size
  • Nodal status
  • Metastasis
• Grade (modified Bloom-Richardson)
  
  • Architectural grade
  • Nuclear grade
  • Mitoses

Question 22

Histological grade of invasive breast carcinoma correlates with _______

Answer 22

Histological grade of invasive breast carcinoma correlates with prognosis

Question 23

What is the breast carcinoma grade system?

Answer 23

Question 24

What is the prognosis for a large breast cancer tumor?

Answer 24

• Decreased survival
• Increased rate of nodal metastasis
  
  • • 0.6-1.0cm ⇒ 10%
  • 1.1-1.5cm ⇒ 21%
  • 1.6-2.0cm ⇒ 35%

Question 25

How can axial node status affect the 10 year survival rate?

Answer 25

• Negative nodes: 70-80%
• 1 - 3 positive nodes: 30-40%
• > 10 positive nodes: 10-15%

Question 26

\_\_\_\_\_\_\_ lymph node status is the **most important prognostic factor** for invasive carcinoma in the absence of distant metastases

Answer 26

**Axillary** lymph node status is the **most important prognostic factor** for invasive carcinoma in the absence of distant metastases

Question 27

What are the **prognostic markers** for breast cancer (3)?

Answer 27

1. Estrogen receptor 2. Progesterone receptor 3. HER2Neu FISH/IHC

Question 28

When is **oncotype** a useful test for prognisticating breast cancer?

Answer 28

* Applicable only for patients with **early carcinoma, small, node negative, ER+** * Expression of a set of genes **predicts patient’s response to chemotherapy**

Question 29

What is the **treatment** for breast carcinoma?

Answer 29

* **Surgery** * Conservative; lumpectomy * Mastectomy * **Radiation** * **Systemic treatment** * Chemotherapy * Hormonal therapy