L31 - Pathology of the breast

Question 1

Define the breast tissue type?

Answer 1

modified sweat gland

three major components consist of  the skin
 the subcutaneous adipose tissue
 the functional glandular tissue.

Question 2

Describe the internal structure of the breast?

Answer 2

15-25 lobes with own terminal duct-lobular unit (milk secreting)

Each lobe has 20-40 lobules

Nipple > Lactiferous sinus > Lactiferous duct > Segmental duct > Terminal duct lobular unit

Question 3

Correlate the diseases that arise from segmental duct, adipose tissue, terminal duct lobular unit of the breast?

Answer 3

Segmental duct = Papillomas

Adipose tissue = fat necrosis

Terminal duct lobular unit:

• Fibroadenoma, cysts
• Hyperplasia, Most carcinoma

Question 4

Explain why the breast is predisposed to many pathological conditions?

Answer 4

High sensitivity for ovarian hormones, sex hormones and growth factors

Question 5

General clinical presentation of breast diseases?

Answer 5

Pain
Presence of dominant lump
Abnormal nipple discharge

Question 6

Define the most common breast pathologies.

Answer 6

40% - Fibrocystic change **

30% - No disease
13% - Benign lesions
10% - Cancer
7% - Fibroadenoma

Question 7

List 4 main categories of benign breast pathologies?

Answer 7

Inflammatory lesions

Fibrocystic disease

Proliferative lesions

Benign tumors

Question 8

List 4 inflammatory lesions of the breast?

Answer 8

Acute mastitis and breast abscess

Mammary duct ectasia

Fat necrosis

Granulomatous mastitis

Question 9

Typical cause of Acute mastitis and breast abscess?

Answer 9

infection via the nipple due to abrasion or crack from baby’s mouth

Not common except during lactation and breastfeeding

Question 10

Pathogenesis of mammary duct ectasia?

Answer 10

Ulceration of ducts liberate LIPID into connective tissue stroma

> > Chronic granulomatous inflammatory reaction**

> > Dilated ducts with cheesy material adjacent to aerola

> > Fibrosis, nipple retraction

Question 11

Pathogenesis of fat necrosis in breast?

Answer 11

Trauma/ obesity

> > Traumatic rupture of fat cells
Foreign-body granulomatous reaction and fibrosis
Localized firm/ hard mass

Question 12

List some causes of Granulomatous mastitis?

Answer 12

• Paraffin wax or silicone fluid for breast enhancement
• Pulmonary tuberculosis (uncommon)
• Idiopathic granulomatous mastitis (autoimmune)

Question 13

List 3 Fibrocystic diseases of the breast?

Answer 13

Cystic formation and fibrosis

Apocrine metaplasia

Epithelial hyperplasia

Question 14

Typical clinical presentation and epidemiology of Fibrocystic disease of the breast?

Answer 14

• 30 years old female, rarely postmenopausal
• PAINFUL, firm, fixed clusters of nodules
• Large cysts CHANGE SIZE with menstrual cycle

Question 15

Define causes of Fibrocystic disease of the breast?

Answer 15

Hormone imbalance: HIGH ESTROGEN, LOW PROGESTERONE

• Abnormal end-organ hormone metabolism

Question 16

Compare the pathohistological features of the 3 types of fibrocystic disease of breasts?

Answer 16

Cystic formation and fibrosis: Increase in fibrous stroma + cyst formation

Apocrine metaplasia: ductal epithelium change to apocrine type: pink cells with budding

Epithelial hyperplasia: Proliferation of ductal lining epithelium

Question 17

Which type of fibrocystic disease of the breast is most likely to progress into malignancy?

Answer 17

EPITHELIAL HYPERPLASIA

increased chance of malignancy, the more severe and atypical the degree of hyperplasia

Question 18

List 3 proliferative lesions of the breast?

Answer 18

1. Hyperplasia: Ductal or Lobular
2. Sclerosing adenosis
3. Radial scars (complex sclerosing lesions)

Question 19

Etiology and pathogenesis of Sclerosing adenosis?

Answer 19

• Enlarged breast lobules distorted by fibrous tissue = simulate malignancy
• Child-bearing and premenopausal women

Question 20

Which type of proliferative lesion is only detected radiologically?

Answer 20

Radial scars (complex sclerosing lesions)

epithelial hyperplasia and fibrosis = distortion of normal architecture

mimic carcinoma both clinically and radiologically

Question 21

List 2 benign tumours of the breast?

Answer 21

INTRADUCT PAPILLOMA

FIBROADENOMA

Question 22

What is the most common cause of palpable breast lump up to age 30?

Answer 22

Fibroadenoma

Most common under 30, but can occur at any age

Question 23

Pathogenesis and clinical presentation of Fibroadenoma of breast?

Answer 23

Benign glandular epithelium + proliferation of connective tissue/ stroma

> > compress ducts into slits

Present as well-circumscribed firm, mobile and painless lump.

Question 24

What is the most common cause of bloody nipple discharge in women?

Answer 24

Intraduct Papilloma

UNILATERAL discharge if bilateral, consider hormonal origin

Question 25

Define the anatomical location of Intraduct papilloma of the breast. Etiology?

Answer 25

Solitary large ducts or multiple small ducts involved within 4 cm of the nipple Occurs any age

Question 26

Compare Fibroadeoma and Fibrocystic disease clinical presentation?

Answer 26

Fibroadenoma = smooth, painless, mobile, well-circumscribed mass Fibrocystic disease = painful, not solid, not mobile, well-circumscribed mass

Question 27

Which breast tumour closely resembles Phylloides tumour? How to DDx the two?

Answer 27

Fibroadenoma differentiated from a fibroadenoma by a frond-like arrangement of the fibroepithelial element/ overgrowth of stroma

Question 28

Define whether Phylloides tumour of the breast is benign or malignant? How to ddx the two?

Answer 28

- Majority benign - 3-12% metastasize distinguishing the malignant form: (i) increased mitoses (ii) cellular atypia, (iii) invasive edge, (iv) stromal overgrowth.

Question 29

Treatment for phylloides tumour?

Answer 29

Benign = wide excision Malignant = Mastectomy

Question 30

Describe the etiology of breast cancer?

Answer 30

1 in 15 chance Incidence increases with age, highest chance postmenopausal Top cancer in young females

Question 31

Genetic risk factors for breast cancer?

Answer 31

- Positive family history: 3 or more related individuals - BRCA-1 and BRCA-2 breast and ovarian cancer susceptibility genes: 85% chance of breast cancer - Others: HNPCC, Concurrent ovarian tumours

Question 32

Genetic inheritance pattern of BRCA-1 and 2?

Answer 32

autosomal dominant Mendelian inheritance: transmitted by either parent

Question 33

Onset and severity of hereditary breast cancer?

Answer 33

early age of onset bilateral or multifocal breast cancer

Question 34

Criteria of assessment of high risk patients for breast cancer?

Answer 34

1) number of affected relatives 2) presence of ovarian cancer in family 3) relationship of affected relatives 4) age at diagnosis of breast cancer >> 3 or more members of direct lineage with breast and / or ovarian cancer

Question 35

List some hormonal risk factors for development of breast cancer?

Answer 35

Increased exposure to estrogen peaks: 1) long duration of reproductive life: early menache (<12 years) and late menopause (>54 years) 2) nulliparity (no kids) or late age at first child 3) Functioning ovarian tumours

Question 36

List some environmental risk factors for development of breast cancer?

Answer 36

Dietary fats obesity (endogenous hormonal modifications) Radiation exposure (e.g. multiple CXR for pulmonary TB)

Question 37

List all the investigative methods for breast cancer screening?

Answer 37

Mammography Ultrasound and MRI Fine needle aspiration cytology

Question 38

What can mammography identify when investigating breast cancer?

Answer 38

size and extent of lesion presence of DCIS non-palpable abnormalities detection of multifocal disease: check for bi-laterality.

Question 39

Mammography is the definitive Dx test for breast cancer. T or F?

Answer 39

False 10-20% of carcinomas may still be undetectable by mammography

Question 40

Which investigative technique is used for pre-operative Dx of breast cancer?

Answer 40

Fine needle aspiration cytology: detect palpable and non-palpable lesions Core-cut biopsies

Question 41

Most common disease of male breast?

Answer 41

gynaecomastia

Question 42

Causes of Gynaecomastia?

Answer 42

cirrhosis of the liver with failure of oestrogen breakdown Klinefelter's syndrome testicular tumours Drugs: FSH, LH therapy, Dopamine receptor blocker antipsychotics (tuberoinfundibular pathway - Prolactin), K+ sparing diuretics, Aldosterone antagonist