Pa Exam I Breast

Front 1

the glands in the breast are organized into units termed what?

Back 1

lobules
the glands in these lobules empty into a terminal duct

Front 2

the terminal ducts of breast empty into what? then where?

Back 2

collecting duct
from collecting duct to 6-10 major branches called the lactiferous ducts which have lactiferous sinuses at their terminus

Front 3

lactiferous sinuses empty into what?

Back 3

aerola of the nipple

Front 4

what type of lesions do we see in the TDLU?

Back 4

cysts
sclerosing adenosis
small duct papilloma
hyperplasia
atypical hyperplasia
carcinoma

Front 5

what lines the ducts?

Back 5

epithelium

Front 6

structure of gynecomastia?

Back 6

males with large breasts
no lobules
have ducts

Front 7

where do all cysts occur? why?

Back 7

lobule!
b/c expansile

Front 8

what happens to glands in pregnancy?

Back 8

they increase in size and number
expansile, specialized CT

Front 9

cells layers w/n lobules?

Back 9

internal glandular
external peripheral myoepithelial cell

Front 10

what do lobules respond to?

Back 10

cyclic changes in hormones like endometrium

Front 11

how do mammograms appear in young healthy woman?

Back 11

typically dense or white therefore mass forming lesions are easy to detect b/c ST collagen exists and not much fat
*in older women not as dense b/c incrase fat

Front 12

what happens with TDLUs with age?

Back 12

they decrase in size and number and the interlobular stroma is replaced with adipose tissue
mammograms become darker due to increase in adipose

Front 13

when does normal breast involution occur? what can accelerate it? what does it look like?

Back 13

b/n age 30-35 in all women
accelerated by pregnancy
breast sag and lose firmnes
lose breast mass UNLESS gain wt b/c getting older
complete in woman by age 55

Front 14

what is breast involution? what remains after involution?

Back 14

replacement of specialized CT by structural collagen with loss of lobular glands
little remnant glandular acinar tissue..only terminal duct and collecting duct

Front 15

waht can delay breast involution being complete by age 55?

Back 15

supplemental estrogen

Front 16

what are the most common symptoms of breast disease that are reported by women?

Back 16

pain
palpable mass
nipple discharge

Front 17

what is breast pain usually associated with?

Back 17

menstrual cycle
almost always benign

Front 18

when do lesions become palpable? are they usually malignant?

Back 18

at 2 cm diamter
they are usually cysts

Front 19

is nipple discharge malignant?

Back 19

rarely

Front 20

the changes of the breast mimic what?

Back 20

changes of endometrium

Front 21

what cell layer do tumors in the terminal ducts usually occur?

Back 21

from ductal epithelium NOT glandular epithelium

Front 22

how is the breast duct system different than other ducts?

Back 22

whatever is produced is absorbed
when lactating flow is so great that it overcomes absorptive capacity get cystic changes

Front 23

why do cysts occur in lobules?

Back 23

b/c lobules are expansile and ducts arent

Front 24

men have ducts but lack __

Back 24

lobules

Front 25

what is a lobule?

Back 25

aggregate of glands
when pregnant, glands incrase
has specialed CT that is expansile (ducts are NOT expansile)

Front 26

which cells of the lobules and ducts have special stains?

Back 26

myoepithelial cells
actin marker
lactalbumin marker

Front 27

what is the fxn of the Sebaceous glands of Montgomerey?

Back 27

lubrication b/c area prone to trauma and dryness

Front 28

what happens to the amt of fat in secretions near the end of pregnancy?

Back 28

incrase b/c babies have high caloric need and fat is greater calories than protein

Front 29

which cell layer involutes? when?

Back 29

glandular epithelium and is accelerated with pregnancy
30-35

Front 30

why does breast size incrase when glandular epi involutes?

Back 30

b/c wt gain as you get older but breast is sagging b/c glandular epithelum disapears therefore less elastic

Front 31

how does breast cancer spread?

Back 31

hematogenous

Front 32

b/c malignancy usually doesnt produce s/s, what do you need to do?

Back 32

mammography
detects ductal carcinoma in situ

Front 33

to what lymph nodes does adenocarcinoma of breast spread to first?

Back 33

toward axillary lymph nodes (75%)

Front 34

what is the easiest way to biopsy breast? what type of lesions can you perform this on?

Back 34

fine needle aspiration
only on palpable lesions (cystic or solid)
if not palpable use ultrasound-guided

Front 35

what is the most common way to see tissue for breast biopsy?

Back 35

stereotactic breast biopsy
not easy to palpate
gives exact coordinates of lesion

Front 36

what is acute mastitis and when does it occur?

Back 36

inflamm condition of breast
occurs during lactation, particulary first month post-partum

Front 37

waht is the usual cause of acute mastitis?

Back 37

acute bacterial infxn by Staph aureus

Front 38

what is periductal mastitis? in who does it occur?

Back 38

inflamm condition of breast
AKA: Subaerolar abscess
squamous metaplasia of lactiferous ducts
>90% are smokers

Front 39

what is another name for periductal mastitis?

Back 39

subaerolar abscess

Front 40

are acute and periductal mastitis both associated with lactation?

Back 40

no, only acute
periductal is NOT associated with lactation

Front 41

what is the problem in periductal mastitis?

Back 41

the glandular epi changes to squamous (squamous metaplasia) with blocks off the duct forming keratin plug

Front 42

tx for periductal mastitis?

Back 42

surgical
remove fistula tract and drain abscess

Front 43

what does mammary duct ectasia mimic? in who does it occur?

Back 43

carcinoma on mammogram
women in 5th and 6th decades

Front 44

where is mammary duct ectasia localized?

Back 44

periareolar portion of breast

Front 45

what is usually the cause of fat necrosis?

Back 45

secondary to trauma, iatrogenic, or accidental physical trauma
retraction of overlying skin
due to inflammatory rxn

Front 46

what does fat necrosis mimic on mammogram?

Back 46

carcinoma

Front 47

refractile material indicates what?

Back 47

presence of foreign material

Front 48

characteristics of Fibrocystic Change

Back 48

very common
pain
palpable lump
Differential Dx: carcinoma
stops at time of menopause (perimenopausal)
Sx ameliorated with oral contraceptives b/c hormonaly related

Front 49

what is adenosis?

Back 49

increase in number of glands/lobule

Front 50

apocrine cysts are also known as ?

Back 50

blue-dome cysts b/c cells have round nuclei and abundant granular eosinophilic cytoplasm

Front 51

waht are the 2 types of proliferative breast disease w/o atypia?

Back 51

epithelial (ductal) hyperplasia
Sclerosing adenosis

Front 52

what are the risks for cancer in the 2 types of epithelial (ductal) hyperplasia?

Back 52

mild: no increased risk
florid: 1.5-2X incrase

Front 53

what is the risk of cancer in sclerosing adenosis?

Back 53

1.5-2x increase risk

Front 54

sclerosing adenosis is often mistaken for what? but how do you differentiate the 2?

Back 54

invasive carcinoma but acini in sclerosisng are arranged in SWIRLING pattern and the outer border is usually well circumscribed**

Front 55

why types of cells are involved in sclerosing adenosis?

Back 55

both luminal and myoepthelial cells

Front 56

how can you rule out carcinoma with a complex sclerosing lesion?

Back 56

b/c it is a radial scar with central nidus of small tubules entrapped in a densly fibrotic stroma surrounded by radiating arms of epithelium
**has scarring area

Front 57

clinial prsentation of intraductal papilloma?

Back 57

bloody nipple discharge

Front 58

what is the risk of cancer in Atypical hyperplasia? 2 types?

Back 58

5-10x incrase
Atypical Ductal hyperplasia AKA: ductal Intraepithelial Neoplasia, Grade 1
Atypical Lobular Hyperplasia
AKA: lobular intraepithelial neoplasia

Front 59

what is the differnce in cells b/n atypical lobular and ductal hyperplasia?

Back 59

ductal: mixed pop of cells
lobular: uniform cells throughout

Front 60

what is the most common non-skin malignancy in women?

Back 60

carcinoma of female breast
#2 killer (#1 is lung)
highest in caucasians

Front 61

breast cancer is a disease of what population

Back 61

older women

Front 62

risk factors for breast cancer

Back 62

~13% attributable to inheritance (BRCA genes)
early menarche
late menopause
nulliparty
incrased risk if 1st child after age 30
avg age Dx = 64
50% located in upper outer quadrant

Front 63

many of the risk factors for breast cancer are related to what?

Back 63

breast exposure to estrogen

Front 64

what do you use to examine dense breasts?

Back 64

difficul to see on mammography therefore use MRI b/c more sensitive

Front 65

which BRCA gene is more common in breast and ovarian cancers? what are the percentages?

Back 65

BRCA 1: 81%
BRCA 2: 14%

Front 66

male breast cancer is mostly associated with which BRCA?

Back 66

BRCA 2 (76%)

Front 67

what type of breast cancers is BRCA 1 mostly associatd with?

Back 67

medullar carcinomas
poorly differentiated carcinomas
ER-
PR-
Her2/Neu -

Front 68

of the total breast cancers, what percent are in situ? invasive?

Back 68

in situ: 15-30%
invasive: 70-85%

Front 69

waht is the most common type of invasive carcinoma?

Back 69

ductal (80%)
lobular (10%) is the most common non-ductal

Front 70

what are the 2 different in situ carcinomas? most common?

Back 70

ductal carcinoma in situ (most common-80%)
lobular carcinoma in situ

Front 71

Paget disease of the breast falls into what breast cancer category?

Back 71

in situ group

Front 72

50% of all mammographically detected cancers are what?

Back 72

DCIS

Front 73

what percent of low grade and high grade DCIS will progress to invasive cancer?

Back 73

low grade: 32% w/n 30 yrs
high grade: 70-90%

Front 74

high grade DCIS is also known as?

Back 74

comdeo DCIS or comedocarcinoma
marked necrosis and atypia

Front 75

low grade DCIS is aslso known as?

Back 75

Noncomedo DCIS
minimal necrosis or atypia

Front 76

how can you differentiate Comedo DCIS and noncomedo DCIS?

Back 76

comedo: microcalcifications, large central zones of necrosis w/ calcified debris b/c outgrowing blood supply and is confined by BM
noncomedo: no central area of necrosis

Front 77

when you see multiple clusters of small, irregular calcifications should you tink cancer?

Back 77

no, but they do need tobe examined

Front 78

do both comedo and noncomedo DCIS show calcifications?

Back 78

only comedo has calcifications and central area of necrosis
in noncomedo still have some luminal cells visible

Front 79

do we see calcifications in LCIS? what do we see?

Back 79

rarely asociated with calcifications
see monomorphic pop of small rounded cells

Front 80

waht causes Paget Disease of Nipple?

Back 80

malignant epithelial cells migrating from underlying DCIS

Front 81

how does the nipple appaer in paget disease?

Back 81

roughened red, eczematous but doesnt respond like inflammatory disesae

Front 82

what percent of ppl with paget disease of the nipple will have invasive carcinoma?

Back 82

majority 75%
spreads intraepithelai (pagetoid) w/o crossing the BM disrupting the normally tight squamous epi cells

Front 83

is paget disease of the nipple an inflammatory disease?

Back 83

NO!
see inflammation, but the problem is that underlying DCIS is spreading up into lactiferous ducts into nipple skin w/o crossing BM
malignant cells disrupt tight squamous epi barrier

Front 84

what do Paget cells look like?

Back 84

large cells with clear halo of pale cytoplasm that extend up from ducts and invade epidermis of nipple

Front 85

Infiltrating ductal carcinoma is also known as?

Back 85

no special type (NST)
not otherwise specified (NOS)

Front 86

what is the most common histiologic type of invasive breast malignancies?

Back 86

infiltrating ductal carcinoma (80%)

Front 87

how does infiltrating ductal carcinoma apear on mammography?

Back 87

stellate lesion with irregular border
very dense

Front 88

why must you do mammography to determine if carcinoma?

Back 88

b/c gross appearance deosnt always mean cancer..there are mimicers such as radial scars and fat necrosis

Front 89

what is the gross appearance of infiltrating ductal carcinoma?

Back 89

skin retraction
the "Crab" grabbing and pulling adjacent tissue

Front 90

is the stage or grade of breast cancer more impt?

Back 90

stage is most important
grade is of minor importance in developing a Tx regimen

Front 91

what system is used to grade cancer?

Back 91

Nottingham grading system

Front 92

is axillary lymph node spread of breast cancer the fatal cause of breast cancer?

Back 92

no, hematogenous spread
lymph node involvement indicates metastasis

Front 93

what are the 3 Nottingham grading criteria? minmal score? max score?

Back 93

1. tubule formation
2. nuclear pleomorphism
3. mitotic count
minimal score: 3=Grade 1
max score: 9=Grade 3

Front 94

are high-grade malignancies high-stage?

Back 94

yes
high grade is not independent variable from high stage

Front 95

any in situ carcinoma is what stage?

Back 95

stage 0

Front 96

what are the breast cancer TNM stage groupings?

Back 96

Tumor
axillary lymph Node involvment
distant Metastases

Front 97

TMN for stage 1

Back 97

T: <2cm*
N: none
M: none

Front 98

TMN for Stage 2:

Back 98

T:>5cm* or <5cm
N: none or 1-3
M: none

Front 99

TMN for Stage 3:

Back 99

T: >5cm or local spread*
N: 1-3 or >4
M:none

Front 100

TMN for Stage 4:

Back 100

T: any
N: and
M: present*

Front 101

how do you begin to stage a cancer?

Back 101

start with Stage IV. if no metastasis then it isn't IV
Check lymph node involvement, if there is involvment then it is stage III

Front 102

what percent of all invasive breast cancer is infiltrating lobular carcinoma?

Back 102

10%

Front 103

have incidence for both infiltrating ductal and lobular carcinoma started to level off?

Back 103

infiltrating lobular is rising

Front 104

age of onset for infiltrating lobular carcinoma?

Back 104

45-65 but is rising b/c of increased incidence in females older than 50

Front 105

which carcinoma has been cited for bilateral breast occurence at time of Dx?

Back 105

infiltrating lobular

Front 106

what are the 3 clinical distinxns of infiltrating lobular from ductal?

Back 106

1. different pattern of mets: ILC hematogenous mets to CNS meninges and brain as well as to ovary
2. ILC lower prevalance of microcalcifications therfore mammography is not as sensitive a screening test
3. 80% of lobular carcinomas are postitive for estrogen receptor (50% in IDC)

Front 107

what is mammography not as sensitive a screening test for women with ILC?

Back 107

b/c there is a lower occurence of microcalcifications

Front 108

which carcinoma do you see small clusters of cells?

Back 108

ILC

Front 109

with which carcinoma do you see cells lining up Indian file?

Back 109

ILC

Front 110

13% of familial brest cancers (BRCA 1) are what type ?

Back 110

medullary carcinoma of breast

Front 111

what are the 5 characteristic finding of medullary carcinoma of breast?

Back 111

1. syncitium like sheets of cells
2. lymphoplasmacytic proliferation
3. non-infiltrative
4. all poorly diff** no tubles seen
5 no lymphatic, vascular invasion

Front 112

what is the prognosis for mucinous (colloid) and tubular carcinoma of the braast?

Back 112

they are both of excellent prognosis

Front 113

soft gelatinous tumor with large pools of mucin?

Back 113

mucinous (colloid) carcinoma

Front 114

are mucious carcinoma and tubular carcnoma invasive?

Back 114

yes but with excellent prognosis (ILC and IDC are usual prognosis)

Front 115

what type of cells are missing in tubulur carcinoma?

Back 115

myoepithelial cells (single layer of cells)

Front 116

in what age group do we see inflammatory carcinoma of breast? how does it appear?

Back 116

younger pts
freq misDx iniitally
appears swollen, red and inflammed

Front 117

cause of inflamm carcinoma of breast?

Back 117

diffuse spread of tumor cells to dermal lymphatics and sometimes to blood vssls

Front 118

what is the usual stage of inflammatory carcinoma of bresat?

Back 118

High Stage (III or IV) IDC

Front 119

ominous prognosis for inflam carcinoma of breast?

Back 119

3 year survival of 3-10%

Front 120

what are the 2 specific diagnostic studies done on malignant tumor tissue samples at time of removal?

Back 120

estrogen/progesterone receptor assays
HER2/neu

Front 121

what is HER2/new?

Back 121

proto-oncogene that encodes epidermal GF R
overexpressed in 20-25% of primary breat cancers

Front 122

what is effective in improving overall prognosis in HER2/neu postitive pts?

Back 122

Herceptin

Front 123

what does it mean if a breast cancer is unresponsive to Herceptin?

Back 123

it is HER2/neu negative

Front 124

what percent of invasive carcinomas are palpable masses? what is the avg size of these palpable masses?

Back 124

20%
2 cm

Front 125

what percent of invasive carcinomas have mammographic density?

Back 125

28%

Front 126

wht percent of DCIS have calcifications?

Back 126

22%

Front 127

at what age should you have an annual mammography?

Back 127

>40

Front 128

what are considered high risk individuals for breast cancer? waht type of annual screening should they receive?

Back 128

previous radiation therapy
family/genetics
atipical
MRI examination annually (esp for very dense breasts)

Front 129

fibroadenoma and phyllodes tumors are found where?

Back 129

lobular stroma

Front 130

what is a fibroadenoma? how does it present?

Back 130

benign, common neoplasm of breast composed of fibrous CT adn glandular elements
presents as a palpable mass or "lump"

Front 131

what age group do we see fibroadenomas in?

Back 131

reproducitive age: 15-30

Front 132

gross or visible appearance of fibroadenoma?

Back 132

bulging, circumscribed white, firm nodule 1-5cm in diameter
*rubbery or solid but typically NOT rock hard

Front 133

what does this describe: well circumscribed mass, rubbery, white, does not contain adipose tissue, bulges from the surface?

Back 133

fibroadenoma
diff from maligant b/c bulges from the surface instead of causing retraxtion

Front 134

what 2 problems arise from intralobular stroma?

Back 134

fibroadenoma
phyllodes tumor
stroma NOT epithelial

Front 135

what is the spectrum associated with phyllodes tumors?

Back 135

fibroadenoma
phyllodes tumor, benign
phyloodes tumor, malignant

Front 136

are cystosarcoma malignant phyllodes tumors common? how do they spread?

Back 136

NO! very rare
spread hematogenously, NOT typicaly to axillary lymph nodes

Front 137

waht is the mean age or presentation of malignant phyllodes tumors

Back 137

45-51 which is earlier than breast carcinomas (60's)

Front 138

what is the diff b/n fibroadenoma and phyllodes tumors?

Back 138

phyllodes have incraesed stromal cellularity, cytologic atypia, and stromal overgrowth giving rise to "leaflike" architecture

Front 139

hyperplasia of the ducts in men is called what?

Back 139

gynecomastia

Front 140

what are the 3 major groups of causes of gynecomastia?

Back 140

1. idiopathic..usually resolves spontaneaouly
2. hyperestrogen states (males with hepatic cirrhosis)
3. males who purposely take estrogen for feminization b/c ductal epithelium in males is estrogen sensitive

Front 141

how is the stage for stage prognosis of male breast carcinoma different?

Back 141

same as for women except men tend to present at higher stage

Front 142

where does male breast carcinoma typically occur? common symptom?

Back 142

rare..1%
occurs predom next to nipple and surrounding areola
nipple discharge is common symptom

Front 143

what are the risk factors for male breat carcinomas?

Back 143

1st degree relatives with breast cancer
Klinefelter syndrome: decreaed testicular fxn
BRCA2 mutations
exposure to exogenous estrogens
(gynecomastia in adolescents does NOT confer increased risk)