Module 3: Breast: Cancer Flashcards Preview

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Flashcards in Module 3: Breast: Cancer Deck (42):
1

Now moving onto breast cancer. What are the pre-disposing factors?

Female
Increased Age
BRCA 1 and 2
Her2Neu
p53
Obesity (due to increased estrogen)
Early Menarche
Late Menopause
Family History
Race/Ethnicity
ERT
Granulosa Theca ovarian tumor (due to increased estrogen)

2

What is the most important pre-disposing factor in elderly women?

Age

3

What is the most important pre-disposing factor in middle aged women?

Family history and then nulluparity

4

Why are breast carcinoma lumps hard and fixed?

Fixed to underlying skin and pectoralis major
--extremely desmoplastic (fibrotic)
--non tender

5

What is the most common location for breast carcinoma?

Upper outer quadrant

6

What is the origin of all types of breast cancer?

Terminal Duct Lobular Unit (TDLU)

7

Breast carcinoma is spread through lymphatics, what is the order?

Axillary , Supraclavicular and Internal Mammary (thoracic)

8

Once breast carcinoma has infiltrated the lymphatics, what is a key symptom? what are other symptoms?

Peau d'orange: due to lymph edema or lymph obstruction
nipple retraction (Ductal carcinoma -- desmoplasia -- fibrosis of cooper's ligaments)
Bloody nipple discharge

9

What is the most accurate test for all breast cancers?

Biopsy

10

Eventually from the lymphatics there will be metastasis from to the blood, then where?

Lung
Liver
Brain
Bone
--most common cancer in lung

11

In regards to prognosis what are indicators of a poor prognosis?

1. Greater than 2cm bad prognosis
2. Lymph node spread and Peau d orange
3. Invasion
4. Her2New (EGFR) positive bad = extremely aggressive and herceptin is used to treat but does not cross blood brain barrier
5. Cathepsin D: (enzyme destroys basement membrane) is bad because allows invasion and metastasis
6. Aneuploidy is always bad

12

In regards to good prognosis what are indicators of a good prognosis?

1. ER/PR positive: can treat with tamoxifen
--tamoxifen increases chances of endometrial carcinoma

13

Now moving onto the types of breast cancer. There are two types Ductal and Lobular. Give some general features

Non-Infiltrating (Carcinoma in Situ)
--Ductal Carcioma in Situ (DCIS)
***comedo (high grade)
** Non-comedo (Solid, cribiform, papillary, micropapillary)
**Paget's Disease
--Lobular Carcinoma In Situ (LCIS)
Infiltrating Carcinoma
-Ductal (no special type): 80%
--Lobular: 10%
--Tubular/Cribiform: 6%
--Mucinous, medullary, papillary, metaplastic: 4-5%

14

First discussion will be on Lobular Carcinoma in Situ, which again is a non-infiltrating carcinoma. What is the origin and general features?

Origin: Terminal Duct Lobular Unit
Predisposing factors are the same for breast cancer
Asymptomatic most commonly: incidental finding without a mass
Usually unilateral but can be bilateral
Dyscohesive lacking E-cadherin

15

What is the histology for lobular carcinoma in Situ (slide 6 to the left)?

Atypical terminal duct lobular unit in an entire lobule
***atypical proliferation of inner cuboidal epithelial cells (response to estrogen)
Overall architecture of lobule is preserved
Ducts all still have single layer of outer myoepithelial cells (hence why its In-situ)

16

Now moving onto invasive lobular carcinoma, what are the general histological features?

Slide 7c:
--No intact lobule architecture
***due to loss of outer myoepithelial cells
***therefore invasion into the stroma
--invades interlobular first

17

What is the presentation for a patient with invasive lobular carcinoma?

No distinct mass
Usually unilateral and can be bilateral
--poorly outlined and indurated
TDLU origin with E-cadherin mutation

18

There are three types of invasive lobular carcinoma seen on biopsy, each card will go through one.

1. Indian File Cells: intralobular invaded first then interlobular -- malignant cells in the stroma
---single file of tumor cells, round and uniform (Seen in slide 6)

19

What is the second type of invasive lobular carcinoma?

2. Bull's Eye Pattern: tumor cells around normal acini and ducts

20

What is the third type of invasive lobular carcinoma?

3. Signet Ring Histology
--Mucin within cytoplasm
--PAS positive with metastasis to ovaries (Krukenberg)
--E-cadherin mutation

21

Moving onto Ductal Carcinoma first we will discuss ductal carcinoma in situ (which again in non infiltrating). What are some features?

Slide 6b (right):
Obstruction of lactiferous duct: with intact single outer myoepithelial layer
**Origin: terminal duct lobular unit (TDLU)
More common calcification and no mass not yet cancer
Proliferation of Inner cuboidal epithelial cells

22

What is seen on mammogram in a patient with ductal carcinoma in situ?

Large amounts of calcification and necrosis
--asymptomatic found on mammogram; no mass

23

There are two types of ductal carcinoma in-situ. The first is Comedo, what are some features?

Comedo (intraduct tumor):
--high grade cells with necrotic center and dystrophic calcification
**less often ER,PR positive, Her2Neu positive
**Necrotic Center= cells inspissated materials (toothpaste secretions from the nipple)
--no mass because not yet invasive

24

The second type of ductal carcinoma in situ is Paget's Diease. What are some features?

Type of DCIS almost always associated with underlying intraductal carcinoma

25

What kind of cells are seen in Paget's Disease?

Paget Cells/Toker Cells
--hyperchromatic nucleus, perinuclear halo and mucin filled cytoplasm) migrate retrograde to the nipple
-use PAS stain
--turn into Toker cells once cells get outside the nipple

26

How do patients with Paget's Disease DCIS, present?

No mass
Nasty nipple changes: crusting, fissures, hyperemia, oozing and bloody nipple discharge (patients can get breast infections)
--pruritic erythematous eruption may be mistaken for eczema.
8a: the erythema and ulceration on the nipple due to migration of the cells from ductal carcinoma in situ
8b: migration of the malignant cells (PAS+) towards the epidermis of areola/nipple. Malignant cells have a pale cytoplasm and stand out among compared to the squamous cells in the epidermis (hyperchromatic nucleus with halo)

27

Paget cells in epidermis =?

DCIS

28

Paget cells in DERMIS =?

Malignant
--invasive ductal cancer (this is a complication)

29

The last topic to cover is invasive ductal carcinoma. What are some features?

Origin: Terminal Duct Lobular Unit
From either DCIS or de novo
Scirrhous (Dense demoplasia: thats why stroma looks pink): pictured in lab slide 7b.
Cords/nests of cells

30

There are several different types of Invasive Ductal Carcinoma, each card will go through one.

1. Luminal A (40-55%)
--ER +, PR +, Her2/Neu negative
--Postmenopausal, slow growing, well to moderate differentiation, responds well to hormonal treatment, decreased response to standard chemotherapy
--very low grade so KI67 negative
--Tx with tomoxifin
--best prognosis of all the invasive ductal carcinomas

31

What is the second type of invasive ductal carcinoma?

2. Luminal B: (15-20%)
--ER +,PR+, express Her2New +/-
--more likely to have LN mets, may respond to chemo
--very high grade so KI67+
--Tx: with tomoxifin b/c ER+
--worst prognosis

32

What is the third type of invasive ductal carcinoma?

3. Normal Breast like (6-10%)
--ER +, Her2/New negative
--Usually well differentiated
--less than 2cm usually
--best prognosis because of size

33

What is the fourth type of invasive ductal carcinoma?

4. Basal Like (13-25%)
--Triple negative (ER-/PR-/HER2/Neu-)
--BRCA 1+, younger females, medullary/metaplastic/cancer with fibrotic core
--High grade, aggressive, mets to brain, 15-20% complete response to chemo, cure possible in chemo responsive group
--more common in African Americans
--lots of p53 mutations
--tx with anything

34

What is the fifth type of invasive ductal carcinoma?

5. Her2 Positive (7-12%)
---ER negative; Her2 +; PR-
---Poorly differentiated and high frequency of brain mets, which makes herceptin use hard
--lots of p53 mutations and very aggressive

35

Mucinous (Colloid) Carcinoma is another carcinoma of the breast. What are some features?

Colloid:
--rare, well differentiated tumor in older women
--associated with solid/noninvasive papillary CA
--good prognosis

36

Medullary Carcinoma of the Breast is another carcinoma. What is the appearance on histology?

Fried Egg Appearance
--sheet of monomorphic cells with prominent nucleus, nucleolus, cytoplasm contains glycogen
--fried egg cells are the neoplastic cells
Scanty fibrous stroma containing reactive lymph nodes
--tumor cells attracting lymphocytes
Outer myoepithelial lost

37

All fried egg cells are radiosensitive. what are the tumors?

Seminoma
Dysgerminoma
Oligodendroma

38

Who do you see Medullary carcinoma in?

Young patients with BRCA mutations

39

Finally what are some features of Inflammatory cirrhosis?

Young Black Women
---swollen, erythematous breast due to dermal lymphatics obstruction by tumor
---underlying carcinoma diffusely infiltrative ---poor prognosis
--clinically mimics an abscess

40

What are some features of male breast cancer?

Gynecomastia = male analog of FCC
--relative or absolute increase in estrogen, reduced androgens/testicular androgen loss
---cirrhosis, Klinefelter syndrome, estrogen therapy, drugs, alcohol, marijuana, heroin, retroviral and anabolic steroids
Button Like Nodule Beneath Areola
Intraduct hyperplasia

41

The mammography (BIRAD) score stratifies patients into risk groups. it assesses what?

Microcalcifications
Masses
Architectural Distortions

42

Which carcinoma is the most common female carcinoma?

Breast
--20% of women with breast carcinoma will die

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