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Pathoma: Breast Pathology Flashcards

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1
Q

General

Breast

Mammary Gland

A
  • Modified sweat gland embryologically derived from skin
    • Breast tissue (and pathology) can develop anywhere along the milk line
    • Milk line runs from axilla to vulva
  • Functional unit of breast: terminal duct lobular unit (TDLU)
    • Lobules make milk that drains via ducts to nipple
  • Lobules & ducts are lined by 2 layers of epiehlium
    • Luminal layer: inner layer; responsible for milk production
    • Myoepithelial layer: outer layer; contractilons propel milk towards nipple
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2
Q

Breast

A

Terminal duct lobular unit (TDLU)

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3
Q

General

Breast

Hormone Sensitivity

A

Breast tissue is hormone sensitive
* Before puberty, male & female breast tissue primarily consists of large ducts under nipple
* Development after menarche is primarily driven by estrogen & progesterone
* Lobules & small ducts form and are present in highest density in the upper outer quadrant
* Breast tenderness during menstrual cycle is a common complaint, especially prior to menstruation
* During pregnancy, breast lobules undergo hyperplasia
* Hyperplasia is driven by estrogen & progesterone produced by the corpus luteum (early 1st trimester), fetus, and placenta (later in pregnancy
* After menopause, breast tissue undergoes atrophy

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4
Q

General

Galactorrhea

A

Milk production outside of lactation
* Not a symptom of breast cancer
* Causes include:
* Nipple stimulation
* Normal, physiologic cause
* Prolactinoma of anterior pituitary
* Common pathologic cause
* Drugs

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5
Q

Inflammatory Conditions

Bacterial infection associated with breast-feeding
* Fissures develop in nipple providing route of entry for microbes

Pathophysiology

A

Acute mastitis

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6
Q

Inflammatory Conditions

Usually due to S. aureus

Etiology

A

Acute mastitis

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7
Q

Inflammatory Conditions

Presents as a warm, erythematous breast with purulent nipple discharge
* May progress to abscess formatiom

Clinical Presentation

A

Acute mastitis

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8
Q

Inflammatory Conditions

Treatement of acute mastitis

Approach to Therapy

A
  • Continued drainage
    • e.g., feeding
  • Antibiotics
    • e.g., dicloxacillin
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9
Q

Inflammatory Conditions

Inflammation of subareolar ducts

Pathophysiology

A

Periductal mastitis

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10
Q

Inflammatory Conditions

Usually seen in smokers
* Relative Vit A deficiency results in squamous metaplasia of laciferous ducts producing duct blockage & inflammation

Epidemiology

A

Periductal mastitis

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11
Q

Inflammatory Conditions

Presents as a subareolar mass with nipple retraction

Clinical Presentation

A

Periductal mastitis

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12
Q

Inflammatory Conditions

Inflammation with dilation (ectasia) of subareolar ducts

Pathophysiology

A

Mammary duct ectasia

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13
Q

Inflammatory Conditions

Rare; classically arises in multiparous post-menopausal women

Epidemiology

A

Mammary duct ectasia

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14
Q

Inflammatory Conditions

  • Presents as a periareolar mass with green-brown nipple discharge (inflammatory debris)
  • Chronic inflammation with plasma cells seen on biopsy

Clinical Presentation

A

Mammary duct ectasia

Green-brown nipple discharge = hallmark symptom

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15
Q

Inflammatory Conditions

Necrosis of breast fat

Pathophysiology

A

Fat necrosis

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16
Q

Inflammatory Conditions

Usually related to trauma

Etiology

A

Fat necrosis

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17
Q

Inflammatory Conditions

  • Presents as a mass on physical exam or abnormal calcification on mammography
    • Calcification due to saponification
  • Biopsy shows necrotic fat associated with calcificatins & giant cells

Clinical Presentation

A

Fat necrosis

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18
Q

Inflammatory Conditions

Usually related to trauma

Etiology

A

Fat necrosis

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19
Q

Benign Tumors & Fibrocystic Changes

Development of fibrosis & cysts in breast

Pathophysiology

A

Fibrocystic change

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20
Q

Benign Tumors & Fibrocystic Changes

Most common change in premenopausal breast
* Thought to be hormone driven

Pathophysiology

A

Fibrocystic change

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21
Q

Benign Tumors & Fibrocystic Changes

Presents as vague irregularity of breast tissue (“lumpy breast”), usually in upper outer quadrant

Clinical Presentation

A

Fibrocystic change

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22
Q

Benign Tumors & Fibrocystic Changes

Cysts have blue-done appearance on gross exam

Gross Appearance

A

Fibrocystic change

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23
Q

Benign Tumors & Fibrocystic Changes

Benign, but some fibrocystic-related changes are a/w increased risk for invasive carcinoma
* Fibrosis, cysts, apocrine metaplasia: 0
* Ductal hyperplasia; sclerosing adenosis: 2x
* Atypical hyperplasia: 5x

Potential Complications

A

Fibrocystic change

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24
Q

Benign Tumors & Fibrocystic Changes

A

Fibrocystic change

Apocrine metaplasia, abundant pink cytoplasm; no increased cancer risk

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25
# Benign Tumors & Fibrocystic Changes Papillary growth, usually into large duct * Characterized by FV projections lined by epithelial (luminal) & myoepithelial cells | Histopathology
Intraductal papilloma | Papilloma = benign
26
# Benign Tumors & Fibrocystic Changes Classically presents as bloody nipple discharge in premenopausal woman | Clinical Presentation
Intraductal papilloma
27
# Benign Tumors & Fibrocystic Changes Intraductal papilloma | Approach to Diagnosis
* Must be distinguished from papillary carcinoma * Papillary carcinoma also presents as bloody nipple discharge * Histology: no underlying myoepithelial cells * Epidemiology: more common in postmenopausal women
28
# Benign Tumors & Fibrocystic Changes Tumor of fibrous tissue & glands * Estrogen sensitive: grows during pregnancy; may be painful during menstrual cycle | Histopathology
Fibroadenoma
29
# Benign Tumors & Fibrocystic Changes * Most common benign neoplasm of the breast * Usually seen in premenopausal women | Epidemiology
Fibroadenoma
30
# Benign Tumors & Fibrocystic Changes Presents as a well-circumscribed, mobile marble-like mass | Clinical Presentation
Fibroadenoma
31
# Benign Tumors & Fibrocystic Changes Benign, with no increased risk of carcinoma | Potential Complications
Fibroadenoma
32
# Benign Tumors & Fibrocystic Changes
Fibroadenoma | Fibrous tissue, glands; sharply demarcated from adjacent tissue
33
# Benign Tumors & Fibrocystic Changes Fibroadenoma-like tumor with overgrowth of fibrous componenet * Characteristic "leaf-like" projections seen on biopsy | Histopathology
Phyllodes tumor | "Leaf-like" projections = histological hallmark
34
# Benign Tumors & Fibrocystic Changes Most commonly seen in postmenopausal women | Epidemiology
Phyllodes tumor
35
# Benign Tumors & Fibrocystic Changes Can be malignant in some cases | Potential Complications
Phyllodes tumor | Cancer is more common in post-menopausal women
36
# Benign Tumors & Fibrocystic Changes
Phyllodes tumor | "Leaf-like" projection = hallmark; overgrowth of fibrous component
37
# General Breast Cancer | Epidemiology
* Most common carcinoma in women by incidence (excluding skin cancer) * 2nd most common cause of cancer mortality in women * Risk factors related to estrogen exposure
38
# General Breast Cancer | Risk Factors
* Female gender * Age: cancer usually arises in postmenopausal women, except hereditary breast cancer * Early menarche / late menopause * Obesity * Atypical hyperplasia * First-degree relative with breast cancer
39
# Breast Cancer Malignant proliferation of cells in ducts with no invasion of basement membrane | Histopathology
Ductal carcinoma in situ (DCIS) | Malignant cells are bound by basement membrane
40
# Breast Cancer * Calcifications detected on mammogram * Usually does not produce mass * Biopsy of calcifications required for Dx | Approach to Diagnosis
DCIS | Note: calcifications can also be a/w benign conditions & fat necrosis
41
# Breast Cancer Characterized by high-grade cells with necrosis & dystrophic calcification in center of ducts | Histology
DCIS, comedo type
42
# Breast Cancer
DCIS, comedo type | Duct full of cells with central necrosis & calcification
43
# Breast Cancer DCIS that migrates along duct to involve nipple epidermis | Pathology
Paget's disease of the breast
44
# Breast Cancer Presents as nipple ulceration & erythema | Clinical Presentation
Paget's disease of the breast
45
# Breast Cancer Almost always associated with underlying carcinoma | Complications
Paget's disease of the breast | Unlike Extramammary Paget's disease
46
# Breast Cancer
Paget disease of the breast
47
# Breast Cancer
Paget disease of the breast
48
# Breast Cancer Invasive carcinoma that forms duct-like structures | Histopathology
Invasive ductal carcinoma (IDC)
49
# Breast Cancer Most common type of invasive carcinoma in the breast | Epidemiology
IDC | Accounts for >80% of cases
50
# Clinical Presentation * Presents as a mass detected by physical exam or mammography * Clinically: masses >2 cm * Mammography: masses >1 cm * Advanced tumors may result in dimpling of skin or retraction of nipple | Clinical Presentation
IDC
51
# Breast Cancer Biopsy shows duct-like structures in desmoplastic stroma | Histology
IDC
52
# Breast Cancer Subtypes of IDC | Histology
1. Tubular carcinoma 2. Mucinous carcinoma 3. Medullary carcinoma 4. Inflammatory carcinoma
53
# Breast Cancer Characterized by well-differentiated tubules that lack myoepithelial cells | Histology
Tubular carcinoma | IDC; very good prognosis
54
# Breast Cancer
Tubular carcinoma | Well-differentiated tubules, no myoepithelial cells; desmoplastic stroma
55
# Breast Cancer Characterized by carcinoma with abundant extracellular mucin | Histology
Mucinous carcinoma | IDC; older women (age > 70); very good prognosis
56
# Breast Cancer
Mucinous carcinoma | "Tumor cells floating in pool of mucus"
57
# Breast Cancer Characterized by large, high-grade cells growing in sheets containing lymphocytes & plasma cells | Histology
Medullary carcinoma | IDC; relatively good prognosis
58
# Breast Cancer Increased incidence in BRCA1 carriers | Epidemiology
Medullary carcinoma | IDC
59
# Breast Cancer Well-circumscribed mass that can mimic fibroadenoma on mammography | Morphology
Medullary carcinoma | IDC; relatively good prognosis
60
# Breast Cancer Characterized by carcinoma in dermal lymphatics | Histology
Inflammatory carcinoma | IDC; poor prognosis
61
# Breast Cancer Presents as an inflamed, swollen breast with no discrete mass
Inflammatory carcinoma | Tumor cells block drainage of lymphatics; can be mistaken for mastitis
62
# Breast Cancer
Inflammatory carcinoma | IDC; inflamed, swollen breast; can be mistaken for acute mastitis
63
# Breast Cancer
Inflammatory carcinoma | Tumor cells in dermal lymphatics
64
# Breast Cancer Malignant proliferation of cells in lobules with no invasion of basement membrane * Often multifocal & bilateral * Low risk of progression to invasive carcinoma | Histopathology
Lobular carcinoma in situ (LCIS)
65
# Breast Cancer Discovered incidentally on biopsy * No mass or calcifications | Approach to Diagnosis
LCIS
66
# Breast Cancer Characterized by dyscohesive cells lacking E-cadherin adhesion protein | Histopathology
LCIS | E-cadherin = protein that holds adjacent celsl together
67
# Breast Cancer Treatment of LCIS | Approach to Therapy
* Tamoxifen: reduces risk of subsequent carcinoma * Close follow-up | `
68
# Breast Cancer Invasive carcinoma that characteristically grows in single-file pattern * May exhibit signet-ring morphology | Histopathology
Invasive lobular carcinoma (ILC) | No duct formation due to lack of E-cadherin
69
# Breast Cancer
ILC | Tumor cells growing in single-file pattern = histological hallmark
70
# Prognostic & Predictive Factors Breast Cancer: Prognostic Factors
Prognosis is based on TNM staging * Metastasis is most important factor, but most patients present before metastasis occur * Spread to axillary lymph nodes is most useful prognostic factor * Sentinel lymph node biopsy is used to assess axillary lymph nodes
71
# Prognostic & Predictive Factors Breast Cancer: Predictive Factors
Predictive factors predict response to treatment * Most important factors: estrogen receptor (ER), progesterone receptor (PR), and HER2/neu gene amplification (overexpression) status * Presence of ER & PR: responsive to anti-estrogenic agents (e.g., tamoxifen) * HER2/neu amplification: responsive to trastuzumab (designer Ab against HER2 receptor) * "Triple negative tumors": ER-neg, PR-neg, HER2/neu-neg; poor progrnosis * African-American women have increased risk of triple-negative carcinoma
72
# Breast Cancer
IHC: estrogen receptor (ER) | ER & PR are located in nuclei; ER/PR-pos = resposive to tamoxifen
73
# Breast Cancer
IHC: HER2/neu amplification | GF receptor on cell surface; HER2-pos = responsive to trastuzumab
74
# Breast Cancer Prevalence of hereditary breast cancer | Epidemiology
* 10% of breast cancer cases
75
# Breast Cancer Features suggesting HBC | Epidemiology
* Multiple first-degree relatives with breast cancer * Tumor at early age (premenopausal) * Multiple tumors in a single patient
76
# Breast Cancer BRCA1 & BRCA2 mutations | Etiology
Most important single-gene mutations associated with HBC
77
# Breast Cancer BRCA1 mutation | Etiology
Associated with breast & ovarian carcinoma * Increased propensity for medullary carcinoma * Ovary: classically serous carcinoma
78
# Breast Cancer BRCA2 mutation
A/w breast carcinoma in males
79
# Breast Cancer Male Breast Cancer | Epidemiology
* Rare: 1% of all breast cancers * Presents as subareolar mass in older males * Highest density of breast tissue in males is underneath nipple * May produce nipple discharge * Most common histological subtype = IDC * Lobular carcinoma is rare; male breast develops very few lobules * Associated with BRCA2 mutations & Klinefelter syndrome
80
# Breast Cancer Male Breast Cancer | Epidemiology
* Rare: 1% of all breast cancers
81
# Breast Cancer Male Breast Cancer | Presentation
* Presents as subareolar mass in older males * Highest density of breast tissue in males is underneath nipple * May produce nipple discharge
82
# Breast Cancer Male Breast Cancer | Most common type of carcinoma
* Most common histological subtype = IDC * Lobular carcinoma is rare * Male breast develops very few lobules
83
# Breast Cancer Male Breast Cancer | Most common type of carcinoma
* Most common histological subtype = IDC * Lobular carcinoma is rare * Male breast develops very few lobules

GU / GYN & Renal (23 decks)

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