Pathology-Breast

Front 1

What is a breast and where can it develop?

Back 1

-modified sweat gland
-can develop anywhere along the milk line

Front 2

How is the breast divided?

Back 2

Into lobes (by fibrous septae)

Front 3

What are within the lobes and what do they produce?

Back 3

lobules (milk producing portions of the breast)

Front 4

What do the lobules drain into?

Back 4

ducts, into bigger ducts (that all meet in the nipple)

Front 5

Where does breast sit?

Back 5

on top of fascia for the pectoralis muscle (and beneath that muscle is more muscle and ribs)

Front 6

Where does most breast tissue drain into?

Back 6

ipsilateral axilla

Front 7

Where does a small portion of breast tissue drain into?

Back 7

-small portion of the superior breast drains to mammary lymph nodes (internal thoracic)
-very small portion drains to supraclavicular nodes

Front 8

Typical appearance of a non-lactating breast (histology)

Back 8

acini-->ducts-->bigger ducts
-surrounded by loose CT

Front 9

Terminal Duct Lobular Unit

Back 9

-terminal duct and its lobules and their surrounding stroma
-ALL are hormonally responsive

Front 10

In a series of women presenting with 'breast problems'

Back 10

-40% fibrocystic changes
-30% no disease
-13% miscellaneous benign
-10% cancer (small!)
-7% fibroadenoma

Front 11

Is it difficult or easy to distinguish between a benign or malignant disease of the breast?

Back 11

difficult

Front 12

Clinical Presentation of Breast Pathology

Back 12

-palpable mass
-inflammatory lesion (cellulitis)
-nipple secretion (not lactation)
-mammographic abnormality (thickening or calcification)

any can lead to the need for a biopsy

Front 13

Nipple Inversion

Back 13

bad sign! often associated with malignancy BUT scars can do the same thing

Front 14

Inflammatory conditions - acute mastitis and breast abscess

Back 14

-nipple cracks/fissures allow bacterial entry (lactating period, eczema and other skin conditions are risk factors)
-normal skin flora can lead to infection if they enter the skin

Front 15

Organisms associated with acute mastitis and breast abscess

Back 15

-staph aureus most common
-strep

Front 16

Treatment of acute mastitis and breast abscess

Back 16

incision
drainage
antibiotics

Front 17

What are 3 inflammatory conditions of the breast?

Back 17

acute mastitis and breast abscess
mammary duct ectasia
fat necrosis

Front 18

Mammary duct ectasia

Back 18

-5th, 6th decade, multiparous females
-Dilation of ducts and inspissated secretions--granulomas and plasma cells
-Induration with cheesy material in ducts

Front 19

Fat necrosis

Back 19

-"inflammatory reaction of fat"
-associated with trauma
-can present as a mass lesion clinically (mimics carcinoma)

Front 20

Histology of fat necrosis

Back 20

-Hemorrhage and acute inflammation--then necrosis--then chronic inflammation, foamy macrophages---then scar

Front 21

3 types of fibrocystic changes

Back 21

-cyst formation and fibrosis
-epithelial hyperplasia
-sclerosing adenosis

Front 22

Clinical presentation of fibrocystic changes and mammogram

Back 22

-clinically may present as a mass
-mammogram can show microcalcifications

Front 23

Cyst formation and fibrosis

Back 23

-Most common pattern
-Usually multifocal and bilateral (which is opposite to most tumors)
-Increased stroma and dilated ducts/cysts
-“Blue dome cysts”--appear blue grossly, filled with turbid fluid
-Apocrine metaplasia
-No increased risk for cancer

Front 24

Epithelial hyperplasia

Back 24

-Increased layers of cells beyond usual double layer in ducts
-Papillary or solid
-1.5-2 X increased risk for cancer (if moderate to florid)
-If Atypical Ductal Hyperplasia: 5X increased risk

Front 25

Sclerosing adenosis

Back 25

-less common but very troublesome
-squeezing of the ducts (lobular arrangement is maintained)
-small ducts proliferate and surrounded by fibrous stroma
-maintain lobular arrangement
-1.5-2 X increased risk for cancer

Front 26

2 types of stromal tumors of the breast

Back 26

-fibroadenomas (benign)
-phyllodes tumors (have potential to become malignant)

Front 27

What is the most common benign tumor of the breast?

Back 27

fibroadenomas

Front 28

Fibroadenomas

Back 28

-new growth of fibrous and glandular tissue (only the fibrous part is clonal)
-more common in women younger than 30 but any age is possible

Front 29

Clinical presentation of fibroadenomas

Back 29

-Palpable mass, well circumscribed, movable

Front 30

Gross and Microscopic presentation of fibroadenomas

Back 30

-gross: gray-white rubbery, most 2-4 cm, may have slit-like spaces
-microscopic: stromal proliferation with round to slit-like glands

Front 31

Compared to fibroadenomas, phyllodes tumors show:

Back 31

More cellularity
More mitoses
More nuclear pleomorphism
-BOTH have squished epithelial cells

Front 32

Low grade phyllodes tumor

Back 32

More common
Can recur locally
Rarely metastasize
Behave like fibroadenomas (so surgical removal should work fine)

Front 33

High grade phyllodes tumor

Back 33

Rare
Spreads like sarcoma

Front 34

Where are intraductal papillomas typically found?

Back 34

-in large lactiferous ducts

Front 35

Clinical presentation of intraductal papillomas

Back 35

-Nipple discharge (serous or bloody)
-Small subareolar mass--rarely >1cm
-Nipple retraction rarely

Front 36

Microscopic presentation of intraductal papillomas

Back 36

-papillary epithelial projections with vascular connective tissue core

Front 37

Breast Cancer: cases/year and deaths/year

Back 37

-183,000 cases/year
-41,000 deaths/year

Front 38

Breast Cancer: what percentage of cancer deaths in women?

Back 38

20%
(second to lung cancer)

Front 39

Chance of women developing breast cancer in their lifetime and lifetime risk of death from breast cancer

Back 39

-1:9 chance
-3.4% lifetime risk of death from breast cancer

Front 40

Risk factors for Breast Cancer

Back 40

Age
Family History
Reproductive history
Estrogen supplementation
Alcohol consumption: more than a drink a day
Breast density
Prior abnormal biopsies

Front 41

Breast Cancer Risk: age

Back 41

Rare before 25 years old and may occur anytime after
More common over 50 years old
Peak incidence at or after menopause

Front 42

Breast Cancer Risk: geographics

Back 42

5x more common in US than Japan and Taiwan

Front 43

Breast Cancer Risk: family history

Back 43

-1.5-2x risk with one first degree relative with breast cancer; 4-6x risk with two
-Maternal and paternal history, male breast cancer, young age, all cancers
-Genetic disorders: 5-10% (BRCA, Li-Fraumeni)

Front 44

Test Question: (T/F) Most women who get breast cancer DO NOT have inherited genetic risk

Back 44

true!

Front 45

Breast Cancer Risk: reproductive history

Back 45

-length of reproductive life (increased risk with early menarche and late menopause (longer exposure to estrogen))
-parity (nulliparous = no break in pregnancy, increased risk!)
-age at first child (>30 years old, increased risk)
-obesity (fat can lead to increased estrogen

Front 46

Breast Cancer Risk: estrogen supplementation

Back 46

Exogenous Estrogen (moderately increased risk for high dose, unopposed estrogens)
Oral Contraceptives (no clear cut increased risk for modern formulations)

Front 47

Breast Cancer Risk: alcohol consumption

Back 47

more than one drink/day

Front 48

Breast Cancer Risk: Prior abnormal biopsies

Back 48

Atypical Hyperplasia (result in high levels of estrogen)
History of breast cancer (if you've had it once, you are at risk for recurrence)

Front 49

Genetic and Environmental risk factors for BC

Back 49

-big part of genetic=unknown (few genes have been connected)
-big part of environmental = estrogen!