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143 Cards in this Set

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the glands in the breast are organized into units termed what?
lobules
the glands in these lobules empty into a terminal duct
the terminal ducts of breast empty into what? then where?
collecting duct
from collecting duct to 6-10 major branches called the lactiferous ducts which have lactiferous sinuses at their terminus
lactiferous sinuses empty into what?
aerola of the nipple
what type of lesions do we see in the TDLU?
cysts
sclerosing adenosis
small duct papilloma
hyperplasia
atypical hyperplasia
carcinoma
what lines the ducts?
epithelium
structure of gynecomastia?
males with large breasts
no lobules
have ducts
where do all cysts occur? why?
lobule!
b/c expansile
what happens to glands in pregnancy?
they increase in size and number
expansile, specialized CT
cells layers w/n lobules?
internal glandular
external peripheral myoepithelial cell
what do lobules respond to?
cyclic changes in hormones like endometrium
how do mammograms appear in young healthy woman?
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
what happens with TDLUs with age?
they decrase in size and number and the interlobular stroma is replaced with adipose tissue
mammograms become darker due to increase in adipose
when does normal breast involution occur? what can accelerate it? what does it look like?
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
what is breast involution? what remains after involution?
replacement of specialized CT by structural collagen with loss of lobular glands
little remnant glandular acinar tissue..only terminal duct and collecting duct
waht can delay breast involution being complete by age 55?
supplemental estrogen
what are the most common symptoms of breast disease that are reported by women?
pain
palpable mass
nipple discharge
what is breast pain usually associated with?
menstrual cycle
almost always benign
when do lesions become palpable? are they usually malignant?
at 2 cm diamter
they are usually cysts
is nipple discharge malignant?
rarely
the changes of the breast mimic what?
changes of endometrium
what cell layer do tumors in the terminal ducts usually occur?
from ductal epithelium NOT glandular epithelium
how is the breast duct system different than other ducts?
whatever is produced is absorbed
when lactating flow is so great that it overcomes absorptive capacity get cystic changes
why do cysts occur in lobules?
b/c lobules are expansile and ducts arent
men have ducts but lack __
lobules
what is a lobule?
aggregate of glands
when pregnant, glands incrase
has specialed CT that is expansile (ducts are NOT expansile)
which cells of the lobules and ducts have special stains?
myoepithelial cells
actin marker
lactalbumin marker
what is the fxn of the Sebaceous glands of Montgomerey?
lubrication b/c area prone to trauma and dryness
what happens to the amt of fat in secretions near the end of pregnancy?
incrase b/c babies have high caloric need and fat is greater calories than protein
which cell layer involutes? when?
glandular epithelium and is accelerated with pregnancy
30-35
why does breast size incrase when glandular epi involutes?
b/c wt gain as you get older but breast is sagging b/c glandular epithelum disapears therefore less elastic
how does breast cancer spread?
hematogenous
b/c malignancy usually doesnt produce s/s, what do you need to do?
mammography
detects ductal carcinoma in situ
to what lymph nodes does adenocarcinoma of breast spread to first?
toward axillary lymph nodes (75%)
what is the easiest way to biopsy breast? what type of lesions can you perform this on?
fine needle aspiration
only on palpable lesions (cystic or solid)
if not palpable use ultrasound-guided
what is the most common way to see tissue for breast biopsy?
stereotactic breast biopsy
not easy to palpate
gives exact coordinates of lesion
what is acute mastitis and when does it occur?
inflamm condition of breast
occurs during lactation, particulary first month post-partum
waht is the usual cause of acute mastitis?
acute bacterial infxn by Staph aureus
what is periductal mastitis? in who does it occur?
inflamm condition of breast
AKA: Subaerolar abscess
squamous metaplasia of lactiferous ducts
>90% are smokers
what is another name for periductal mastitis?
subaerolar abscess
are acute and periductal mastitis both associated with lactation?
no, only acute
periductal is NOT associated with lactation
what is the problem in periductal mastitis?
the glandular epi changes to squamous (squamous metaplasia) with blocks off the duct forming keratin plug
tx for periductal mastitis?
surgical
remove fistula tract and drain abscess
what does mammary duct ectasia mimic? in who does it occur?
carcinoma on mammogram
women in 5th and 6th decades
where is mammary duct ectasia localized?
periareolar portion of breast
what is usually the cause of fat necrosis?
secondary to trauma, iatrogenic, or accidental physical trauma
retraction of overlying skin
due to inflammatory rxn
what does fat necrosis mimic on mammogram?
carcinoma
refractile material indicates what?
presence of foreign material
characteristics of Fibrocystic Change
very common
pain
palpable lump
Differential Dx: carcinoma
stops at time of menopause (perimenopausal)
Sx ameliorated with oral contraceptives b/c hormonaly related
what is adenosis?
increase in number of glands/lobule
apocrine cysts are also known as ?
blue-dome cysts b/c cells have round nuclei and abundant granular eosinophilic cytoplasm
waht are the 2 types of proliferative breast disease w/o atypia?
epithelial (ductal) hyperplasia
Sclerosing adenosis
what are the risks for cancer in the 2 types of epithelial (ductal) hyperplasia?
mild: no increased risk
florid: 1.5-2X incrase
what is the risk of cancer in sclerosing adenosis?
1.5-2x increase risk
sclerosing adenosis is often mistaken for what? but how do you differentiate the 2?
invasive carcinoma but acini in sclerosisng are arranged in SWIRLING pattern and the outer border is usually well circumscribed**
why types of cells are involved in sclerosing adenosis?
both luminal and myoepthelial cells
how can you rule out carcinoma with a complex sclerosing lesion?
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
clinial prsentation of intraductal papilloma?
bloody nipple discharge
what is the risk of cancer in Atypical hyperplasia? 2 types?
5-10x incrase
Atypical Ductal hyperplasia AKA: ductal Intraepithelial Neoplasia, Grade 1
Atypical Lobular Hyperplasia
AKA: lobular intraepithelial neoplasia
what is the differnce in cells b/n atypical lobular and ductal hyperplasia?
ductal: mixed pop of cells
lobular: uniform cells throughout
what is the most common non-skin malignancy in women?
carcinoma of female breast
#2 killer (#1 is lung)
highest in caucasians
breast cancer is a disease of what population
older women
risk factors for breast cancer
~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
many of the risk factors for breast cancer are related to what?
breast exposure to estrogen
what do you use to examine dense breasts?
difficul to see on mammography therefore use MRI b/c more sensitive
which BRCA gene is more common in breast and ovarian cancers? what are the percentages?
BRCA 1: 81%
BRCA 2: 14%
male breast cancer is mostly associated with which BRCA?
BRCA 2 (76%)
what type of breast cancers is BRCA 1 mostly associatd with?
medullar carcinomas
poorly differentiated carcinomas
ER-
PR-
Her2/Neu -
of the total breast cancers, what percent are in situ? invasive?
in situ: 15-30%
invasive: 70-85%
waht is the most common type of invasive carcinoma?
ductal (80%)
lobular (10%) is the most common non-ductal
what are the 2 different in situ carcinomas? most common?
ductal carcinoma in situ (most common-80%)
lobular carcinoma in situ
Paget disease of the breast falls into what breast cancer category?
in situ group
50% of all mammographically detected cancers are what?
DCIS
what percent of low grade and high grade DCIS will progress to invasive cancer?
low grade: 32% w/n 30 yrs
high grade: 70-90%
high grade DCIS is also known as?
comdeo DCIS or comedocarcinoma
marked necrosis and atypia
low grade DCIS is aslso known as?
Noncomedo DCIS
minimal necrosis or atypia
how can you differentiate Comedo DCIS and noncomedo DCIS?
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
when you see multiple clusters of small, irregular calcifications should you tink cancer?
no, but they do need tobe examined
do both comedo and noncomedo DCIS show calcifications?
only comedo has calcifications and central area of necrosis
in noncomedo still have some luminal cells visible
do we see calcifications in LCIS? what do we see?
rarely asociated with calcifications
see monomorphic pop of small rounded cells
waht causes Paget Disease of Nipple?
malignant epithelial cells migrating from underlying DCIS
how does the nipple appaer in paget disease?
roughened red, eczematous but doesnt respond like inflammatory disesae
what percent of ppl with paget disease of the nipple will have invasive carcinoma?
majority 75%
spreads intraepithelai (pagetoid) w/o crossing the BM disrupting the normally tight squamous epi cells
is paget disease of the nipple an inflammatory disease?
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
what do Paget cells look like?
large cells with clear halo of pale cytoplasm that extend up from ducts and invade epidermis of nipple
Infiltrating ductal carcinoma is also known as?
no special type (NST)
not otherwise specified (NOS)
what is the most common histiologic type of invasive breast malignancies?
infiltrating ductal carcinoma (80%)
how does infiltrating ductal carcinoma apear on mammography?
stellate lesion with irregular border
very dense
why must you do mammography to determine if carcinoma?
b/c gross appearance deosnt always mean cancer..there are mimicers such as radial scars and fat necrosis
what is the gross appearance of infiltrating ductal carcinoma?
skin retraction
the "Crab" grabbing and pulling adjacent tissue
is the stage or grade of breast cancer more impt?
stage is most important
grade is of minor importance in developing a Tx regimen
what system is used to grade cancer?
Nottingham grading system
is axillary lymph node spread of breast cancer the fatal cause of breast cancer?
no, hematogenous spread
lymph node involvement indicates metastasis
what are the 3 Nottingham grading criteria? minmal score? max score?
1. tubule formation
2. nuclear pleomorphism
3. mitotic count
minimal score: 3=Grade 1
max score: 9=Grade 3
are high-grade malignancies high-stage?
yes
high grade is not independent variable from high stage
any in situ carcinoma is what stage?
stage 0
what are the breast cancer TNM stage groupings?
Tumor
axillary lymph Node involvment
distant Metastases
TMN for stage 1
T: <2cm*
N: none
M: none
TMN for Stage 2:
T:>5cm* or <5cm
N: none or 1-3
M: none
TMN for Stage 3:
T: >5cm or local spread*
N: 1-3 or >4
M:none
TMN for Stage 4:
T: any
N: and
M: present*
how do you begin to stage a cancer?
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
what percent of all invasive breast cancer is infiltrating lobular carcinoma?
10%
have incidence for both infiltrating ductal and lobular carcinoma started to level off?
infiltrating lobular is rising
age of onset for infiltrating lobular carcinoma?
45-65 but is rising b/c of increased incidence in females older than 50
which carcinoma has been cited for bilateral breast occurence at time of Dx?
infiltrating lobular
what are the 3 clinical distinxns of infiltrating lobular from ductal?
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)
what is mammography not as sensitive a screening test for women with ILC?
b/c there is a lower occurence of microcalcifications
which carcinoma do you see small clusters of cells?
ILC
with which carcinoma do you see cells lining up Indian file?
ILC
13% of familial brest cancers (BRCA 1) are what type ?
medullary carcinoma of breast
what are the 5 characteristic finding of medullary carcinoma of breast?
1. syncitium like sheets of cells
2. lymphoplasmacytic proliferation
3. non-infiltrative
4. all poorly diff** no tubles seen
5 no lymphatic, vascular invasion
what is the prognosis for mucinous (colloid) and tubular carcinoma of the braast?
they are both of excellent prognosis
soft gelatinous tumor with large pools of mucin?
mucinous (colloid) carcinoma
are mucious carcinoma and tubular carcnoma invasive?
yes but with excellent prognosis (ILC and IDC are usual prognosis)
what type of cells are missing in tubulur carcinoma?
myoepithelial cells (single layer of cells)
in what age group do we see inflammatory carcinoma of breast? how does it appear?
younger pts
freq misDx iniitally
appears swollen, red and inflammed
cause of inflamm carcinoma of breast?
diffuse spread of tumor cells to dermal lymphatics and sometimes to blood vssls
what is the usual stage of inflammatory carcinoma of bresat?
High Stage (III or IV) IDC
ominous prognosis for inflam carcinoma of breast?
3 year survival of 3-10%
what are the 2 specific diagnostic studies done on malignant tumor tissue samples at time of removal?
estrogen/progesterone receptor assays
HER2/neu
what is HER2/new?
proto-oncogene that encodes epidermal GF R
overexpressed in 20-25% of primary breat cancers
what is effective in improving overall prognosis in HER2/neu postitive pts?
Herceptin
what does it mean if a breast cancer is unresponsive to Herceptin?
it is HER2/neu negative
what percent of invasive carcinomas are palpable masses? what is the avg size of these palpable masses?
20%
2 cm
what percent of invasive carcinomas have mammographic density?
28%
wht percent of DCIS have calcifications?
22%
at what age should you have an annual mammography?
>40
what are considered high risk individuals for breast cancer? waht type of annual screening should they receive?
previous radiation therapy
family/genetics
atipical
MRI examination annually (esp for very dense breasts)
fibroadenoma and phyllodes tumors are found where?
lobular stroma
what is a fibroadenoma? how does it present?
benign, common neoplasm of breast composed of fibrous CT adn glandular elements
presents as a palpable mass or "lump"
what age group do we see fibroadenomas in?
reproducitive age: 15-30
gross or visible appearance of fibroadenoma?
bulging, circumscribed white, firm nodule 1-5cm in diameter
*rubbery or solid but typically NOT rock hard
what does this describe: well circumscribed mass, rubbery, white, does not contain adipose tissue, bulges from the surface?
fibroadenoma
diff from maligant b/c bulges from the surface instead of causing retraxtion
what 2 problems arise from intralobular stroma?
fibroadenoma
phyllodes tumor
stroma NOT epithelial
what is the spectrum associated with phyllodes tumors?
fibroadenoma
phyllodes tumor, benign
phyloodes tumor, malignant
are cystosarcoma malignant phyllodes tumors common? how do they spread?
NO! very rare
spread hematogenously, NOT typicaly to axillary lymph nodes
waht is the mean age or presentation of malignant phyllodes tumors
45-51 which is earlier than breast carcinomas (60's)
what is the diff b/n fibroadenoma and phyllodes tumors?
phyllodes have incraesed stromal cellularity, cytologic atypia, and stromal overgrowth giving rise to "leaflike" architecture
hyperplasia of the ducts in men is called what?
gynecomastia
what are the 3 major groups of causes of gynecomastia?
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
how is the stage for stage prognosis of male breast carcinoma different?
same as for women except men tend to present at higher stage
where does male breast carcinoma typically occur? common symptom?
rare..1%
occurs predom next to nipple and surrounding areola
nipple discharge is common symptom
what are the risk factors for male breat carcinomas?
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)