The Breast - Chapter 23

Question 1

Accessory breast tissue can often be found in what two locations?

Answer 1

Axillary chest wall and axillary fossa

Question 2

Describe the embryologic development of supernumerary nipples/breasts.

Answer 2

These result from the persistence of epidermal thickenings along the milk line, extending from the axilla to the perineum.

google:
During the second and third months of embryonic development, the glandular elements of the breast are formed near the fourth and fifth ribs, with regression of the rest of the thickened ectodermal streaks. In the case of failure of a complete regression, some foci may remain, resulting in a supernumerary nipple.

Question 3

Describe the pathogenesis of acute mastitis and list the two most common etiologic agents.

Answer 3

During the first month of breastfeeding, the breast is vulnerable to bacterial infection by the development of cracks and fissures in the nipples. From the portal of entry, staphylococcus aureus usually, or streptococci less commonly, invade the breast.

Question 4

Describe the pathogenesis of fat necrosis and its clinical significance.

Answer 4

May present as a palpable mass, skin thickening or retraction or mammographic densities or calcifications. Histologically acute lesions may be hemorrhagic and contain central areas of liquefactive fat necrosis with neutrophils and macrophages. Eventually resolves to scar tissue that may be walled off by fibrous tissue. Grossly, ill-defined, firm, gray-white nodules with small chalky-white foci are seen

google:
Breast fat necrosis is nonviable adipose cells from injured or ischemic breast tissue that is replaced with scar tissue and presents as a palpable nodule. Breast fat necrosis has various etiologies and implications; therefore, a careful patient history is imperative to properly evaluate the patient.

The most common etiology of fat necrosis is recent breast surgery; however, in non-operative patients, cancer or mechanical trauma to the breast tissue is often the culprit. Breast fat necrosis can be confusing on breast imaging with malignancy (it can mimic malignancy on radiologic studies, as well as clinical presentation)

Question 5

What are the three principal morphologic changes in fibrocystic changes of the breast?

Answer 5

Cysts, fibrosis, and adenosis

google: Adenosis is a benign (non-cancerous) breast condition in which the lobules (milk-producing glands) are enlarged, and there are more glands than usual. Adenosis is often found in biopsy samples of women who have fibrocystic changes in their breasts

Question 6

What are the three dominant patterns of morphologic change seen in fibrocystic condition?

Answer 6

Cystic change often with apocrine metaplasia, fibrosis, and adenosis

google: Adenosis is a benign (non-cancerous) breast condition in which the lobules (milk-producing glands) are enlarged, and there are more glands than usual.

Apocrine metaplasia of the breast, i.e. the transformation of breast epithelial cells into an apocrine or sweat‐gland type of cells, often occurs in the peripheral parenchyma, particularly among premenopausal women and it is usually associated with gross cysts in fibrocystic breast disease, the most common non‐cancerous disease of the breast

Question 7

A blue-dome cyst of the breast is associated with ______ changes.

Answer 7

Fibrocystic

Question 8

Nonproliferative breast changes do or do not elevate the risk of developing cancer.

Answer 8

Do not; increased risk of developing cancer is associated with proliferative breast disease.

Question 9

Papillomas of the breast are most frequently found in the ________, and present with what three clinical features?

Answer 9

Principal lactiferous ducts or sinuses
Unilateral serous or bloody nipple discharge
Small palpable masses
Mammographic densities or calcifications

Question 10

Gynecomastia is/is not a risk factor for male breast cancer

Answer 10

Is not

Question 11

Describe two types of proliferative breast disease with aytpia?

Answer 11

Atypical ductal hyperplasia is recognized by its histologic resemblance to ductal carcinoma in situ (DCIS). It consists of a monomorphic proliferation of regularly spaced cells, sometimes with cribiform spaces. Distinguished from DCIS by being limited in extent and only partially involves ducts.

google:
Atypical ductal hyperplasia (ADH) is generally considered a direct precursor of low-grade ductal carcinoma in situ (DCIS) and thus, low-grade invasive ductal cancer, whereas the precursor(s) of higher-grade DCIS and invasive ductal cancer remain unknown

Atypical lobular hyperplasia refers to proliferation of a population of cells identical to those of lobular carcinoma in situ(LCIS), but the cells do not fill or distend more than 50% of the acini within a lobule. (p. 1050)

Question 12

not a question- link for malignant breast cancer explanation

https://www.slideshare.net/VarugheseGeorge/tumors-of-the-breast

Question 13

Briefly describe the pathogenesis of gynecomastia of the breast, including some of the major clinical conditions where it occurs.

Answer 13

Gynecomastia may occur as a result of an imbalance between estrogens, which stimulate breast tissue, and androgens, which counteract these effects. It may be found at the time of puberty or in the very aged, or at any time during adult life when there is a cause for hyperestrinism, the most important of which is cirrhosis of the liver. It is one manifestation of Klinefelter syndrome and it may occur in those with functioning testicular neoplasms.

google:
hyperestrinism, -a condition marked by the presence of excess estrins in the body and often accompanied by functional bleeding from the uterus

what is estrin: any of several steroid hormones, that are secreted chiefly by the ovaries and placenta, that induce oestrus, stimulate changes in the female reproductive organs during the oestrous cycle, and promote development of female secondary sexual characteristics.

Question 14

Describe the incidence and etiology of carcinoma of the breast.

Answer 14

One of 8 women in the US will develop breast cancer in her lifetime; In 2012, 226,000 women were diagnosed and almost 40,000 women died of the disease. Cancer of the female breast is rarely found before the age of 25 years. The major risk factors for the development of breast cancer are genetic, exposure to estrogen and environmental/lifestyle factors

Question 15

What two genes are responsible for 80 to 90% of “single gene” familial breast cancers?

Answer 15

BRCA1 and BRCA2

Question 16

What are the classifications of adenocarcinoma of the breast?

Answer 16

Carcinoma is divided into noninvasive or in situ carcinoma, and invasive carcinoma

Question 17

Name and define the 2 architectural subtypes of ductal carcinoma in situ.

Answer 17

Comedo DCIS - usually identified on mammography as clusters or linear, branching areas of calcification. Defining characteristics are cell with pleomorphic, high grade nuclei and areas of central necrosis

Noncomedo DCIS - lacks high grade nuclei and necrosis. Several sub-categories: cribiform (with cookie-cutter, uniform spaces), micropapillary (bulbous protrusions without a fibrovascular core)

Question 18

not a question but helpful

what is DCIS

Answer 18

google:
DCIS (ductal carcinoma in situ) is non-invasive breast cancer that starts in the milk ducts. In situ means in its original place. DCIS is non-invasive because it hasn’t spread beyond the milk ducts into other healthy tissue.

DCIS is considered the earliest form of breast cancer. DCIS doesn’t typically spread to other parts of the body.

DCIS isn’t life-threatening, but if you’re diagnosed with DCIS, you have a higher-than-average risk of developing invasive breast cancer later in life.

This information is provided by Breastcancer.org.
Donate to support free resources and programming for people affected by breast cancer: https://give.breastcancer.org/give/294499/#!/donation/checkout?c_src=clipboard&c_src2=text-link

Question 19

Why is Paget disease important?

Answer 19

50 to 60% of women with Paget disease have a palpable mass and almost all of these women have an underlying invasive carcinoma.

google:
Paget disease of the breast (also known as Paget disease of the nipple and mammary Paget disease) is a rare type of cancer involving the skin of the nipple and, usually, the darker circle of skin around it, which is called the areola. Most people with Paget disease of the breast also have one or more tumors inside the same breast. These breast tumors are either ductal carcinoma in situ or invasive breast cancer

google
Doctors do not fully understand what causes Paget disease of the breast. The most widely accepted theory is that cancer cells from a tumor inside the breast travel through the milk ducts to the nipple and areola.

Question 20

What is the cause of lobular carcinoma in situ?

Answer 20

An acquired loss of tumor suppressive adhesion protein E-cadherin

Question 21

What are the markers used to group breast cancers into the clinical subgroups? What are the clinical subgroups?

Answer 21

ER, PR and HER2
1 - ER positive, HER2 negative - majority of cancers in men and older women
2 - HER2 positive - more common in young women and non-white women. About half of these cancers are ER positive
3 - ER negative, HER2 negative - “triple negative” - more common in young premenopausal women, African American and Hispanic women. Mostly arise from BRCA1 mutation

google:

what are receptors? Normal breast cells and some breast cancer cells have receptors that attach to the hormones estrogen and progesterone, and need these hormones for the cells to grow.

Knowing the hormone receptor status of your cancer helps doctors decide how to treat it. If your cancer has one or both of these hormone receptors, hormone therapy drugs can be used to either lower estrogen levels or stop estrogen from acting on breast cancer cells. This kind of treatment is helpful for hormone receptor-positive breast cancers, but it doesn’t work on tumors that are hormone receptor-negative (both ER- and PR-negative).

Hormone receptor-positive cancers tend to grow more slowly than those that are hormone receptor-negative. Women with hormone receptor-positive cancers tend to have a better outlook in the short-term

breast cancers have no estrogen or progesterone receptors. Treatment with hormone therapy drugs is not helpful for these cancers. These cancers tend to grow faster than hormone receptor-positive cancers. If they come back after treatment, it’s often in the first few years. Hormone receptor-negative cancers are more common in women who have not yet gone through menopause.

breast cancer cells don’t have estrogen or progesterone receptors and also don’t make any or too much of the protein called HER2. These cancers tend to be more common in women younger than 40 years of age, who are Black, or who have a mutation in the BRCA1 gene. Triple-negative breast cancers grow and spread faster than most other types of breast cancer. chemo can still be useful

Question 22

Describe the gross appearance of invasive carcinoma, no special type.

Answer 22

Most tumors are firm to hard and have an irregular border. When cut or scraped, they produce a characteristic grating sound due to small, central pinpoint foci or streaks of chalky white desmoplastic stroma and occasionally small foci of calcification. Less frequently, carcinomas have a well-circumscribed border and a soft consistency.

Question 23

Inflammatory carcinoma of the breast is manifested by_______ of the breast.

Answer 23

Breast swelling and skin thickening

google:

inflammatory breast cancer is a rare and very aggressive disease in which cancer cells block lymph vessels in the skin of the breast. This type of breast cancer is called “inflammatory” because the breast often looks swollen and red, or inflamed. t is a type of invasive ductal carcinoma, its symptoms, outlook, and treatment are different.

All inflammatory breast cancers start as stage III (T4dNXM0) since they involve the skin. If the cancer has spread outside the breast to distant areas it is stage IV.

IBC doesn’t look like a typical breast cancer. It often does not cause a breast lump, and it might not show up on a mammogram. This makes it harder to diagnose.
IBC tends to occur in younger women (younger than 40 years of age).

Peau d’orange (French for orange peel) is characterized by edema and pitting and results from blockage of lymphatic drainage with or without associated stromal infiltration. The most common cause of breast peau d’orange is inflammatory breast cancer.

Question 24

What is the cause of the peau d’orange appearance of the skin in carcinoma of the breast?

Answer 24

Lymphatics may become so involved as to block the local area of skin drainage and cause lymphedema and thickening of the skin. Tethering of the skin to the breast by Cooper ligaments creates the appearance of an orange peel

Question 25

what is the most important prognostic factor for invasive carcinoma in the absence of metastases

Answer 25

Axillary lymph node status

google:

A sentinel lymph node is defined as the first lymph node to which cancer cells are most likely to spread from a primary tumor. Sometimes, there can be more than one sentinel lymph node.

side effects of removing lymph nodes : Lymphedema, or tissue swelling (removal causes buildup/ swelling)

Question 26

AJCC staging of breast cancer

Answer 26

Stage 0 DCIS or LCIS
Stage I Invasive carcinoma 2 cm or less in size without nodal involvement and no distant metastases
Stage II Invasive carcinoma between 2 and 5 cm in size with 1-3 positive axillary nodes and no distant metastases, OR a tumor greater than 5 cm without nodal involvement or distant metastases Stage III Carcinoma greater than 5 cm in size with nodal involvement; OR any size cancer with more than 4 involved lymph nodes and no metastasis OR any breast cancer with skin or chest wall involvement; inflammatory cancer, if distant metastases are absent
Stage IV any size, invasive carcinoma with distant metastases

Question 27

What is the most common benign tumor of the breast and describe its gross appearance. Describe the histologic appearance of these lesions as they relate to the gross appearance.

Answer 27

Fibroadenoma –vary in size from less than 1 cm to large tumors that mostly replace the breast. Well circumscribed, rubbery, grayish white nodules that bulge above the surrounding tissue and may contain slit-like spaces.
Histologic - delicate and often myxoid stroma resembles intralobular stroma (

Question 28

What tumor, often occurring in the 6th decade, is distinguished from fibroadenomas on the basis of cellularity and mitotic rate, nuclear pleomorphism, stromal overgrowth, and infiltrative borders?

Answer 28

Phyllodes tumor