A 40-year-old female presents with irregular breast nodularity that changes with her menstrual cycles. Mother died from cancer at age 53. No nipple discharge. Breasts symmetrical. No swollen axillary nodes, bilaterally. Mammogram shows micro calcifications, presence of these calcifications puts what conditions on your differential?
DCIS, sclerosing adenosis, fat necrosis, intraductal papillomas, fibroadenoma and fibrocystic changes can all present with micro-calcifications.
A 23-year-old African American female with a 1.5 cm, freely moveable RUOQ breast lump. Has a cousin diagnosed with breast cancer 7 years ago. Non-tender breasts. No nipple discharge. Breasts symmetrical. No swollen axillary nodes, bilaterally. Mammogram shows a “popcorn” density with smooth borders. Biopsy is shown below.
Note the smooth border and proliferating intralobular stroma that actually stimulates proliferation of glandular epithelium. As long as you only see the two cell types (shown below) you know it is benign and it is a fibroadenoma.
A 68-year-old female presents with an eczematoid, ulcerated lesion on the nipple and areola. Episodes of bloody nipple discharge. No palpable mass is identified on physical examination. What would you expect to see on biopsy of the nipple and areola if she had an underlying carcinoma?
Malignant cells in the squamous epithelium. Note that these malignant cells could be melanoma, Bowen’s disease (squamous cell CIS) or Paget disease (underlying CIS).
A 50 year-old female presents with a new unilateral breast mammographic abnormality. Her aunt was dx with infiltrating breast carcinoma at the age of 72. Negative for palpable breast masses. How does this condition progress to invasive ductal carcinoma?
Normal -> Epithelial proliferation -> Atypical hyperplasia -> Low/moderate grade DCIS (cookie holes) -> High grade DCIS (cribriform) -> Invasive carcinoma
A healthy 42-year-old woman presents for a routine physical examination. Her family history reveals that her mother died of breast cancer 5 years ago and that an older sister had a radical mastectomy for breast cancer 3 years ago. A mammogram demonstrates a suspicious area in the left breast upper outer quadrant. Based upon the breast biopsy findings you request estrogen/progesterone receptor analysis and Her-2/neu expression analysis. You also request testing for alterations in BRCA-1 and BRCA-2 genes because of her family history. What would you expect to see histologically in a breast tissue biopsy?
DCIS: cords, nests and glands of anaplastic cell in a desmoplastic stroma w/microcalcifications. LCIS: single file cell invasion due to lack of E-cadhedrin.
A 12 year old male presents with bilateral breast enlargement. What populations are at risk for this condition?
People who have hormone imbalances: puberty and old age can get gynecomastia.
Tissue that gives rise to fibroadenomas
Why does nulliparity increase your risk for breast cancer?
You have more cycles of proliferation and regression throughout life than women who get pregnant and don’t cycle for 9 months.
What would you expect this section to look like histologically?
This is fibrocystic change. Histologically you would see apocrine metaplasia (forms calcifications), epithelial and myoepithelial hyperplasia.
Types of fibrocystic changes
Proliferative (more commonly associated with malignancy): hyperplasia, sclerosing adenosis. Non-proliferative: cysts, apocrine metaplasia, fibrosis.
A patient presents with the breast biopsy shown below. What is your diagnosis?
Phylloides tumor. Note that stroma is slightly more cellular than the fibroadenoma and it has leaf-like projections. Pleomorphism, stromal overgrowth and increased cellularity are seen in malignant phylloides tumors.
Where do most breast lesions occur?
Upper outer quadrant, this is the area of most dense breast tissue.
What are they types of DCIS?
Comedo (high grade w/no myoepithelium and central necrosis + calcification), Non-comedo: solid, papillary, micro papillary and cribriform.
Do you need to do a sentinel node biopsy w/DCIS?
No. It is still confined to the duct.
Risk factors for breast cancer
White, late menopause, 1st degree relatives, atypical hyperplasia, increased estrogen exposure, high breast density, radiation exposure and obesity.
Luminal A breast cancer
ER + Her2/neu -
Luminal B breast cancer
ER+ Her2/neu +
Basal-like breast cancer
ER, PR, Her2/neu -
Peau d’ orange
Inflammatory carcinoma from lymphatic obstruction
Most common subtypes of invasive breast CA