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Flashcards in Pathology-Breast Lecture Deck (44):

What type of lesions can occur in the tissue indicated below?

#1) Terminal duct lobular unit: Cysts, sclerosing adenosis, small duct papilloma, hyperplasia (typical + atypical) and carcinoma. #2) Lobular stroma: fibroadenoma and phylloides tumor. #3) Large ducts and lactiferous sinuse: duct ectasia, subareolar abscess, duct papilloma and Paget disease. #4) Interlobular stroma: fat necrosis, lipoma, fibrous tumor, fibromatosis, sarcoma.


What is the normal architecture of breast tissue on histology?

Terminal duct lobular units, interlobular stroma, intralobular stroma and benign calcifications.


How does histology of young breast tissue compare to that of a woman in her 30’s?

Young female: Little fat, collagenous interlobular stroma. Late 30’s: more fat, less collagen, calcifications.


Common clinical presentations in breast pathology?

Pain, palpable mass, lumpiness, nipple discharge and mammogram abnormality.


Calcifications seen in DCIS?

Small, irregular numerous, clustered, linear and branching. Note that DCIS rarely presents as a mass.


Non-proliferative epithelial breast changes

Duct ectasia, cysts, apocrine change, mild hyperplasia, adenosis and fibroadenoma.


Proliferative epithelial breast disease without atypia. Which ones have increased relative risk for breast cancer of 1.5-2.0 RR?

Hyperplasia, sclerosing adenosis, papilloma, complex sclerosing lesions (radial scar) and fibroadenoma with complex features. Sclerosing adenosis, radial scar and papillomas may mimic carcinoma and have increased risk.


Proliferative epithelial breast disease with atypia

Atypical ductal and lobular hyperplasia


Carcinoma in situ of the breast

Lobular CIS and Ductal CIS.


A 20-40 year old woman presents with a lumpy-bumpy breast. Biopsy is shown below. What is the most likely cause of her condition?

Fibrocystic changes: note the cyst with apocrine metaplasia (granular eosinophilic cells w/retained myoepithelial cells) and larger cyst. These occur in women in their reproductive years because they are estrogen sensitive. Note that theses are NOT associated with an increased risk of cancer.


Gross appearance of cysts with apocrine metaplasia

Blue dome appearance.


What cells are found in a normal lobular duct?

Luminal epithelial cell and myoepithelial cells.


What is your diagnosis of this breast biopsy?

Note that the duct is distended by a heterogenous population of cells and slit-like penetrations around the periphery. This is typical of ductal hyperplasia.


A 30 year old woman presents with a palpable breast mass and mammogram abnormality. Biopsy of the mass is shown below. What is causing her condition?

Note the enlarge terminal duct lobular units, distorted acini, dense stroma and calcifications. This is characteristic of sclerosing adenosis.


A 34 year old woman presents with a radiodense irregular central breast mass. Biopsy of the mass is shown below. What is causing her condition?

Radial scar. The tumor has irregular borders, a dense fibrotic stroma w/hyalinized entrapped tubules and cysts at the periphery.


A 40 year old woman presents with bloody nipple discharge. Biopsy is shown below. What is causing her condition?

Intraductal papilloma. These are benign, papillary lesions with multiple branching vascular cores and arise in large lactiferous ducts near the nipple. Note that they will still have the normal 2 cell layers of the ducts.


What is the increase in relative risk for developing breast cancer if you have atypical ductal or lobular hyperplasia?



A patient presents with the breast biopsy shown below. What is your diagnosis?

Atypical ductal hyperplasia. Note the monomorphic cells, evenly spaced in the lumen with some slit-like spaces at the periphery and cookie cutter spaces in the middle. This is different from DCIS due to partial, instead of full, involvement of the ducts.


A patient presents with the breast biopsy shown below. What is your diagnosis?

Atypical lobular hyperplasia. Note the small monomorphic cells filling the lumens. This is different from LCIS due to limited involvement in of the lobules. Note that these cells become dyscohesive and invade in lines.


What is the most common carcinoma in situ of the breast? Which carries a risk for invasive carcinoma in either breast?

DCIS = 80%. LCIS = 20%. DCIS carries 30% risk of invasive ductal CA in same area if left untreated. LCIS carries 30% risk of invasive CA in either breast.


Subtypes of DCIS. What is the increase in relative risk of invasive CA if you are diagnosed with any of these lesions?

Comedocarcinoma (high grade w/nuclear atypia and central necrosis), Non-comedocarcinoma (solid, cribriform, papillary, micro papillary) and Paget disease. These lesions increase relative risk for invasive CA by 8-10x.


A 45 year old woman presents with an irregular mammography shown below. The biopsy is shown below. What is your diagnosis?

Note the branching and linear calcifications, this is a sign of DCIS. The chalky, tan-white areas hint at fat necrosis or DCIS. The calcifications and central necrosis in the lumen of the ducts indicate Comedo type DCIS and nuclear atypia would be seen on higher power.


A 45 year old woman presents with an irregular mammography and the biopsy is shown below. What is your diagnosis?

Noncomedo DCIS - cribriform type. Note the monomorphic cells w/cookie cutter spaces distending the entire duct. Calcifications and low to high grade cells are also present.


What variants of noncomedo type DCIS are shown below?

Solid type on the left and micro papillary (no fibrovascular cores) type.


A 45 year old woman presents with an incidental finding on biopsy of a fibroadenoma. Biopsy is shown below. What is your diagnosis? What is the increased relative risk for invasive carcinoma?

LCIS, these are always found incidentally. Note the monomorphic cells filling the ducts and lobular cells infiltrating the surrounding stroma (w/E-cadherin stain showing loss of E-cadhedrin in invasive cells that are non-cohesive). Relative risk is increased 8-10x and LCIS is bilateral in 20-40% of cases.


What conditions are associated with Paget disease of the nipple?

Underlying DCIS and/or carcinoma in situ. The ductal system is continuous with the squamous cells of the nipple. Note that the cells never invade the basement membrane, but do get into the squamous level of the nipple.


A 45 year old woman presents with scaling and bleeding of the nipple. Biopsy is shown below. What is your differential for this patient?

Bowen’s disease (Squamous CIS), malignant melanoma and Paget disease of the nipple.


What is the most common type of breast cancer and what age range is it most typically seen in?

ER +, HER2/neu -. Peak incidence is about 60 years old.


What race is breast cancer most often seen in?

Highest incidence in white females. Highest mortality in black females.


Risk factors for breast cancer?

Age (late 30s - 70s), estrogenic stimulation (early menarche, late menopause, nulliparity, hormone therapy), germline mutations (only 5-10% of cases), family history (>2 1st degree relatives), dense breast tissue and endometrial or contralateral breast cancer.


Chromosomes affected in most familial breast cancers

80-90% on BRCA 1/2. BRCA1 on 17q21, BRCA2 on 13q12. Note that these mutations do not have 100% penetrance, this is partly due to the second hit hypothesis. 


What familial mutation is more often associated with male breast cancer?



Treatment for ER + breast cancer

Tamoxifen or aromatase inhibitors


Treatment for Her2 + breast cancer



A woman presents with a hard, firm breast mass. Mammography is shown below. How do you grade this tumor?

Note the irregular borders on mammography, indicating an invasive breast CA. Well differentiated shows tubules w/lumens. Poorly differentiated has more pleomorphism, mitoses and sheets of cells without tubules.


How do you stage invasive breast carcinoma? How does 5-year survival change with each stage?

0) = DCIS/LCIS. 1) = < 2cm. 2) = > 2cm OR 5cm w/1-3 nodes OR any size w/ > 4 nodes OR skin/chest wall involvement OR inflammatory CA 4) Any size w/distant metastasis. Note the dramatic decrease in prognosis w/node metastasis.


What are the most common histological subtypes of breast cancer?

#1) 80% Not otherwise specified ductal #2) 10% lobular #3) Tubular, mucinous and medullary make up the last 10%.


What is your diagnosis of this breast biopsy?

Note the grey-purple tissue surrounding the invasive malignant cells (desmoplastic response). This started as DCIS but is now invasive breast CA.


Hallmark of invasive lobular CA

Little desmoplastic response (can’ palpate readily) and dyscohesive cells that infiltrate in a line (loss of E-cadherin).


What is your diagnosis of this invasive breast cancer? What is the prognosis?

Tubular CA. Note the well-differentiated angulated glands with no myoepithelial cells. Note that these are often small, multifocal/bilateral and have a good prognosis.


A patient presents with this well-rounded invasive breast CA. Biopsy is shown below. What is your diagnosis?

Medullary (A,B,C) or Mucinous (D) CA. These have a better prognosis than ductal carcinoma not otherwise specified (NOS). Note that medullary is poorly differentiated and mucinous has mucinous background w/islands of malignant epithelial cells floating around in the mucin.


A 25 year old woman presents with bilateral palpable masses that grow as she gets pregnant. On biopsy it is a sharply circumscribed, rubbery, moveable mass. What is your diagnosis?



A 45 year old woman presents with a small palpable breast mass. Biopsy is shown below. What is your diagnosis?

Phyllodes tumor. Note the leaf-like architecture. This differs from fibroadenoma because it has more cellularity, mitosis, stromal overgrowth and infiltrative borders.


A man presents with subareolar enlargement of the breast tissue. Biopsy is shown below. What causes this condition?

Gynecomastia can be caused by hormonal imbalance of estrogen and androgen. Note epithelial hyperplasia and increase in collagenous connective tissue.