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76 Cards in this Set
- Front
- Back
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What are 2 characteristics of breast tissue?
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Essentially modified sweat glands. Breast tissue (nipple) can develop anywhere along the "milk line." Most of the time accessory nipples are benign, but can be subject to the same pathologies as breast tissue in normal location.
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What are the lobes of the breast?
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Sections divided by fibrous septae. Within lobes are lobules (milk producing portions of breast). Lobules drain into ducts, then into bigger ducts that all meet in the nipple.
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What is the lymphatic drainage of the breast?
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Ipsilateral axilla. Small portion of superior breast into mammary lymph nodes and a very small portion into supraclavicular nodes (fossa above collar bone). Important in radiation and other surgical procedures.
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What does the non-lactating breast normal histology look like?
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Acini --> Ducts --> Bigger ducts --> surrounded by loose CT
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qWhat is a terminal duct lobular unit?
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Terminal duct and its lobules and their surrounding stroma (all are hormonally responsive)
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What percentages of breast pathologies, etc make up "breast problems" (typically lumps)?
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40% = fibrocystic changes
30% = no disease 13% = miscellaneous benign 10% = cancer 7% = fibroadenoma |
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What are various clinical presentations of potential problems? Any of these can lead to the need for a biopsy.
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Palpable mass (on exam or by patient). Inflammatory lesion (cellulitis, redness, soreness). Nipple secretion (often blockage in the duct -Hard to distinguish btwn benign and malignant). Mammographic abnormality
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What are 3 types of mammographic abnormalities that would lead to the need for a biopsy?
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Thickening or calcification, coarse calcification = malignancy, stellae (star shaped lesions)
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What could nipple inversion indicate?
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Could be an indication of cancer, but difficult to distinguish between benign and malignant
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What are three types of inflammatory conditions?
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Acute mastitis and breast abscess, mammary duct ectasia, and fat necrosis
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What happens in acute mastitis and breast abscesses?
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Nipple cracks and fissures allow bacterial entry. Lactating period, eczema and other skin conditions are risk factors. Normal skin flora can lead to infection.
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What is the clinical presentation of acute mastitis and breast abscesses?
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Redness, scale-like
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What organisms are most commonly the cause of acute mastitis and breast abscesses?
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Staph auerus - abscess, strep
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What is the treatment for acute mastitis and breast abscesses?
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Incision, drainage, abx
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What is mammary duct ectasia?
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Ducts become blocked and secretions build up. Leads to inflammation and dilation of ducts and inspissated secretions (thickened, congealed), granulomatous inflammation, granulomas and plasma cells, cheesy material in ducts. Can mimic a tumor. Age 50-60, multiparous females.
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What is fat necrosis as an inflammatory breast condition?
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Inflammatory reaction of fat. Associated with trauma. Can present as mass lesion clinically (mimics carcinoma). Very unusual.
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What is the histology picture of fat necrosis?
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Homorrhage and acute inflammation --> necrosis --> chronic inflammation --> foamy macrophages --> scar
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What are fibrocystic changes?
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Clinically may present as a mass. Typically bilateral, but can be unilateral. Calcifications may be present. Mammogram may show microcalcifications
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What are the 3 patterns of fibrocystic changes?
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1. Cyst formation and fibrosis (most common!)
2. Epithelial hyperplasia 3. Sclerosing adenosis (less common, but troublesome) |
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What is cyst formation and fibrosis of fibrocytic changes?
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Usually multifocal and bilateral. Because this is due to hormone stimulus, usually seen on both sides. Increased stroma and dilated ducts/cysts. Blue dome cysts (appear blue, filled w/ turbid fluid). Apocrine metaplasia (thicker epi, foamy, almost always sign of benign). No increased risk for cancer.
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What is Epithelial hyperplasia of fibrocystic changes?
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Increased layers of cells beyond normal double layer in ducts (still have tree look). After much stimulation, become papillary (full of cells) or solid. 1.5-2x increased risk for cancer. Can sometimes see atypical ductal hyperplasia.
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What is atypical ductal hyperplasia?
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More layers of cells , nuclei no longer arranged in nice rows, nuclei increasingly atypical shape, start to look like glands w/in glands. Short of malignancy but VERY atypical. 5x increased risk for cancer.
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What is sclerosing adenosis?
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Squeezing of the ducts (lobular arrangement is maintained). Can look like malignancy because everything is so squished together. Small ducts proliferate and are surrounded by fibrous stroma. 1.5-2x increased risk for cancer.
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What are the two broad type of tumors of the breast?
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Stromal tumors and intraductal papillomas
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What are the two types of stromal tumors?
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Fibroadenomas, Phyllodes tumors
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What are fibroadenomas?
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Most common benign breast tumor! New growth of BOTH fibrous and glandular tissue. Only the fibrous part is clonal expansion. Most common in women <30, but any age possible. Can be seen in even as young as high school age.
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What is the clinical presentation of fibroadenomas?
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Palpable mass, well circumscribed, movable, nice edges.
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What is the gross presentation of fibroadenomas?
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Gray-white rubbery, 2-4cm (but sometimes much bigger), may have slit-like spaces: looks like fibroids of the uterus.
**note: this is rubbery and round - rock hard and speculated outlines would indicate malignancy |
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What is the microscopic presentation of fibroadenomas?
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Stromal proliferation w/ round slit-like edges. Duct system squeezed into tiny channels due to expanding connective tissue (lots of CT, very few cells, sparsely populated field)
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What are phyllodes tumors?
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Potentially malignant tumor of stroma. Not all are malignant. There are low grade and high grade.
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What is a low grade phyllodes tumor?
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More common type. Behaves like fibroadenomas, so surgical removal should work well. Still has reasonably circumscribed edges. Can recur locally. Rarely metastaizes.
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What is a high grade phyllodes tumor?
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Rare. Spreads like a sarcoma (full of blown malignancies)
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How does a phyllodes tumor compare to a fibroadenoma?
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Phyllodes tumor has more cellularity (denser), more mitosis, more nuclear pleomorphisms (larger, more atypical and pleomorphic and irregular nuclei).
*Note: BOTH have squished eip cells |
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What are intraductal papillomas?
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Usually in large lactiferous ducts. Sit right below the nipple.
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What is the clinical presentation of intraductal papillomas?
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Nipple discharge (serous or bloody), small subareolar mass rarely >1cm (will see dilated lactiferous ducts w/ papilloma sitting inside), nipple retraction rarely.
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What is the microscopic presentation of intraductal papilloma?
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Papillary epithelial projections w/ vascular connective tissue core. No real atypia or anything that looks malignant.
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How many cases of breast cancer per year in the US? How many deaths per year?
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183,000 cases/year and 41,000 deaths/year
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What percentage of cancer deaths does breast cancer account for in women?
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20%, 2nd to lung cancer
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How many women will develop breast cancer? What is the lifetime risk of death from breast cancer?
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1 in 9, 3.4% lifetime risk of death
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What is the age risk for developing breast cancer?
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Most common over age 50. Peak incidence at or after menopause. Rare before age 25.
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What is the family history/genetic risk of breast cancer?
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Geographic: 5x more in US than Japan or Taiwan. Fam history: 1.5-2x risk w/ 1 1st degree relative, 4-6x risk w/ 2. Genetic disorders account for 5-10% of all breast cancers. BRCA, Li-Fraumeni
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What is the reproductive history risk of breast cancer?
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Longer exposure to estrogen = increased risk, therefore, length of reproductive life determines risk, Parity (# of pregnancy): Nulliparous = higher risk because no break in menstrual cycle. Age at first child: >30 years old = increase risk. Obesity: increase fat = increase risk (adipocytes produce estrogen)
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Do oral contraceptives cause increase risk for developing breast cancer?
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No clear cut increased risk with modern formulations
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What prior abnormal biopsies can be linked to increase risk of breast cancer?
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Atypical hyperplasia (result of high levels of estrogen), history of breast cancer
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What are the risk factors for developing breast cancer?
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Age, family history/genetics, reproductive history, estrogen supplementation, alcohol consumption (+1/day), breast density, prior abnormal biopsies, genetic + environment (estrogen)
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What are the histologic classifications of breast carcinoma?
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Non-invasive or in situ (DCIS, LCIS) and Invasive or infiltrating carcinoma (passed through basement membrane and can invade): invasive ductal and invasive lobular.
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What is DCIS (ductal carcinoma in situ)?
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More common than LCIS. 20-30% of all breast cancers. Carcinomas fill the ducts but doesn't breach basement membrane.
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What is the histologic pattern of DCIS?
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cribiform, solid, papillary
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What is comedo carcinoma?
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DCIS w/ central necrosis. Because malignant cells grow so quickly, the middle of the tissue doesn't get enough blood supply
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What is the microscopic appearance of DCIS?
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Coarse calcifications, epi cells are 5-6 layers thick rather than 1, lumen w/in lumen (glands w/in glands) of one duct
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What is LCIS (lobular carcinoma in situ)?
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Less frequent than DCIS, uniform cells fill lobules but don't breach basement membrane. Frequently multifocal and bilateral compared to DCIS. ALWAYS incidental finding in biopsy because not detectable clinically, radiographically or on surgical specimen. 2x risk for invasive carcinoma.
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What are the types of invasive carcinomas?
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Invasive ductal carcinoma, invasive lobular carcinoma, medullary carcinoma, colloid/mucinous carcinoma, tubular carcinoma, adenoid cystic carcinoma, apocrine carcinoma, invasive papillary carcinoma
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What is invasive ductal carcinoma?
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Most common! Rock hard painless mass, occasionally fixed to underlying muscle or overlying skin, looks like raised starts (stellate look), large, very dense, may show calcifications, don't have round edges. White, fibrous, retracts/pulls at tissue around it, gritty surface. Can be anywhere from well to poorly differentiated. Still see tubules, but not normal tree-like structure. Higher grade = less differentiated.
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What is invasive lobular carcinoma?
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Less common than invasive ductal carcinoma. 5-10% of breast carcinomas. 20% bilateral, more often multicentric tumors, may not be apparent clinically or radiographically. Better differentiated than ductal. More often Estrogen receptor positive. Clinically: no tubules, infiltrates stroma in single file lines.
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What is medullary carcinoma?
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1.2% of total. Have benign behavior as compared to other malignancies. Round edges (rare for carcinomas), can't tell where one cell ends and other begins, infiltrated w/ lymphs, doesn't invade as aggressively. Doesn't metastisize as often.
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What is colloid/mucinous carcinoma?
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2.4% total. Made of ductal cells but are swimming in mucus. Have benign behavior comparatively. Atypical nuclei w/ solid growth pattern. Sitting in mucous pool.
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What is tubular carcinoma?
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1.5% of total. Very well differentiated (may think they're benign). Have benign behavior comparatively. Ducts still made w/ 1-2 layers, no normal architecture, infiltrate as a sheet
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What is adenoid cystic carcinoma?
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Salivary gland type of malignancy
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What percentage of cancers is invasive papillary carcinoma?
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1%
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Why is staging breast cancer important?
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Must stage in order to treat
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What is the tumor size staging of breast cancer?
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pT1: <2cm
pT2: 2-5 cm pT3: >5cm pT4: at that point size doesn't matter |
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What are the node stages for breast cancer?
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pN1mi: metastasis <2mm
pN1a: 1-3 axillary nodes pN2a: 4-9 axillary nodes pN3a: 10+ axillary nodes |
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What are the 4 stages of breast cancer and survival rates?
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Stage I: <2cm, no nodes. 80% 5 year
Stage II: <5cm w/ movable nodes OR >5cm and no nodes. 65% 5 yr Stage III: Any size w/ skin, chest wall fixation and nodes that are fixed. 40% 5 yr Stage IV: Distant metastases. 10% 5 yr |
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What are 4 other prognostic indicators of breast cancer?
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Histologic type, histologic grade, DNA conten, enzyme analysis
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What is a worse prognosis? Higher nuclear grade or lower?
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Higher grade is worse
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What is the worse type of DNA content?
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Aneuploid is worse that euploid
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What is different about men's breast tissue?
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Underneath nipples, there are ducts, but NO lobules
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What are the two types of male breast disease?
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Gynecomastia and ductal carcinoma
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What is gynecomastia?
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Most common pathology of male breast. Benign enlargement of breast (can be seen w/ hormonal levels, increased estrogen, meds)
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What is ductal carcinoma in men?
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Most advanced stage at presentation. Because there is so little tissue for tumor to grow into, it goes to the skin quickly. No lobules carcinoma because men don't have lobules.
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What is a fine needle aspirate?
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Stick a needle into lesion, look at on slide
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What is needle core biopsy?
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Becoming more popular, bigger needles, take out visible core of tissue, can see relationship btwn glandular tissue and stroma, outpt procedure, stick needle into breast, send core to pathology
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What is an excisional biopsy?
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If needle core biopsy is positive, do excisional biopsy. Perform mammography, place wired into breast lesion, remove breast around wire and send to pathology
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What is a radical mastectomy?
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Take off skin and nipple, underlying breast tissue, pec muscles, assoc fat pad in axilla.
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What doe we do now instead of a radical mastectomy?
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Take nice margin around tumor, then radiation and chemo. Less invasive, breast conserving, equal survival. May end up doing partial or total mastectomy, but now, we leave the muscle and fascia. Sometimes have to take fat and axiallry lymph nodes
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What is the most common missed case of breast cancer?
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DCIS, most common lawsuits for clinicians
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