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28 Cards in this Set
- Front
- Back
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Relative Anatomy
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Secretory unit of acini, ductules draining to terminal ductules to terminal ducts to 6-10 major duct systems that meet at lactiferous sinus near nipple and arola. About 8-10 lactiferous sinuses extrude seperately through nipple and can be cannulated individually
Terminal duct lobular unit is surrounded by specialized stroma distinct from generalized stroma of breast Adipose throughout breast around and btween ducts. Suspensory ligaments too but adipose main thing between ducts |
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Diseases of breast based on anatomy
a) Terminal duct lobular unit b) Large ducts c) Under nipple d) Skin of nipple |
a) Terminal duct lobular unit - cysts and fibroadenomas, proliferative changes
b) Large ducts - papillomas c) Under nipple - nipple adenoma d) Skin of nipple - Paget's disease |
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Histology of terminal duct lobular unit
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Columnar epithelial cells line acini, myoepithelial layer underneath, intralobular stroma (specialized) is more loose than interlobular stroma
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Changes in breast in
a) Lactation b) Post menarche |
a) Lactation - acini dilated, filled with secretory material. Epithelial cells enlarge and have intracytoplasmic lumina and material, number of acini increases
b) Post menarche - female breasts prior to puberty have ducts but few acini, develop post menarche |
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Breakdown of "breast lumps"
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Before mammography most lesions discovered as lumps
30% had no disease, 40% FCC, 13% misc. benign, 7% fibroadenoma and only 10% cancer MOST lumps are benign |
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Miscellaneous benign breast changes
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Acute mastitis - occurs in lactation, Staph aureus from skin to nipple via fissures. Infection and abscesses. Responds to Abx, can cause fibrosis/scarring that later shows up as an irregularity
Chronic mastitis - occurs in 50s-60s, secretions due to abnormal hormone response NOT lactation leads to obstruction, dilation, GRANULOMAS and PLASMA CELLS. May be mistaken for carcinoma till biopsied Fat necrosis - can occur in fatty tissue anywhere in breast, usually superficial skin, can follow trauma. Histiocytes/fibrous tissue replace adipose. May see calcifications |
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Stromal lesions in the breast
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Fibroadenoma - proliferation of specialized stroma around lobule, most common benign breast tumor. YOUNG women or reproductive age. Usually do not grow after menopause. HORMONE SENSITIVE (size changes with menstrual cycle), well circumscribed, smooth borders. Ducts can be in benign intracanalicular and pericanalicular patterns
Phyllodes tumor - arise from intralobular stroma. Usually present later than fibroadenoma. HAVE MALIGNANT POTENTIAL. "LEAF-LIKE" morphology. Has more cellularity, mitotic rate, nuclear pleomorphism, stromal overgrowth (periductal stroma overgrows loose specialized stroma so all looks same), infiltrative borders. Excise to treat and monitor for recurrence |
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Fibrocystic change, Pathologic findings, Histology
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Often presents as lumps or diffuse
Incidence increases with age and peaks at menopause Most common breast lesion accounting for half of surgeries Pathologic findings a) Stromal fibrosis - both intralobular and interlobular b) Cystic dilation of ducts - associated with apocrine metaplasia (cytoloci) and epithelial hyperplasia (more cells and layers). Eosinophilic cytoplasm and apical secretions. Almost always benign c) Adenosis (more acini per lobule) Variable histology, smaller cysts that are spongy, fat with irregular borders, dense fibrosis, distorted architecture, ductal ectasia (dilated and inflammmed) Not carcinoma in situ because myoepithelial cells still present |
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Sclerosing adenosis
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Increased number of distorted, compressed acini, can have calcifications. Usually involves entire lobule or sometimes confluent lobule units. Acini and stromal cells proliferate
Stromal fibrosis, acinar proliferation and architectural distortion |
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Intraductal papilloma
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fibrovascular core of tissue lined by duct epithelium extending into duct lumen. Projection cant fill duct completely
Occurs in larger ducts closer to nipple Presents with BLEEDING AT NIPPLE but must distinguish from carcinoma |
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Cancer risk associated with FCC
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Moderate to florid epithelial hyperplasia without atypia, intraductal papillomas slightly increase relative risk
Atypical epithelial hyperplasia has a moderate risk increase Carcinoma in situ has a large increase in risk for invasive carcinoma |
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Epidemiology, Risk Factors, Histologic Types of Breast Cancer
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Epidemiology - 2nd most common cause of cancer death in women behind lung. 1/9 chance of getting for women. 1% occur in men
Risk factors - often hormonally driven a) increasing age b) atypical hyperplasia c) nulliparity - more estrogen d) older age at first child e) Obesity f) Family Hx - increases relative risk g) BRCA1 & BRCA1 - 10% of all cases, most common cause of familial (still most familial have no known cause) Histologic types a) Carcinoma in situ - MOSTLY ductal, some lobular b) Invasive carcinoma - crossed BM, invades stroma, MOSTLY ductal, some lobular, rarely tubular, colloid, medullary, papillary |
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BRCA1 vs BRCA2
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Both tumor suppressor genes
BRCA1 has 70% changes of breast cancer by 80, less for BRCA2. BRCA1 common in AShkenazi Jews Men with BRCA mutations at increased risk of prostate cancer, BRCA2 associated with male breast, ovary, bladder, pancreas |
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Carcinoma in situ presentation
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Usually abnormal mammogram (not a lump because usually small)
Malignant cells contained by BM by definition. If have a positive lymph node you have missed invasive lesion somewhere Incidence increasing due to screening, more lesions are small/preinvasive |
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Ductal carcinoma in situ, Presentation, Pathologic findings/patterns
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Arises within terminal ducts, can extend into lobules (cancerization of lobule), UNIL, associated with microcalcifications. Alone indicates risk, can progress to invasive carcinomas
Pathologic findings/Patterns a) Gross - irregular fibrosis through fat, dilated ducts b) Central necrotic material (comedo necrosis) extrudes from cut surface like an acne lesion c) Solid type - obstructs lumen, if necrosis in middle (comedo carcinoma) d) Cribiform pattern - atypical ductal hyperplasia has to be distinguished from this e) Micropapillary pattern - fingerlike pattern of projection into lumen, not papillomas because no fibrovascular stroma Graded according to atypia of nuclei |
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Paget's disease of nipple, Presentation, Histology
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Cells of DCIS or carcinoma extend from ducts into skin of nipple and areola
Presents as oozing, ulcerated area on skin. May have hemorrhage, fissures Associated with underlying DCIS or invasive carcinoma Histology - infiltration of epidermis by large cells with light-staining cytoplasm and large nuclei. Can have mucin, differential includes malignant melanoma (very rare for nipple). Paget cells |
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Lobular carcinoma in situ, Presentation
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Arises in lobules/terminal ductules, cells lining acinus proliferate, expand and fill acinus. Smaller and more regular than DCIS. LCIS can extend to ducts too, may be in Pagetoid pattern
Usually INCIDENTAL finding because not associated with calcifications or FCC so no mass |
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Treatment of carcinoma in situ of breast
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Local excision (lumpectomy)
Determine estrogen and progesterone sensitivity - hormone therapy to lower recurrence risk |
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Infiltrating carcinoma Epidemiology, Presentation, Types
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Epidemiology - rare before 25
Presentation - mass, abnormal mammogram, BLOODY DISCHARGE, occasionaly mets (lung, breast and pancreatic cancer) Types Invasive ductal carcinoma > invasive lobular carcinoma > others (medullary, colloid, tubular, papillary) |
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Infiltrating ductal carcinoma Presentation, Gross Path, Histology, Grading, Mammogram, External Changes
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Histology - firm nodule with gritty cut surfaces, cords, nests or tubules of malignant cells. Irregular, spiculated, stellate infiltration, dense fibrosis
Grading - based on tubule formation, nuclear pleomorphism and mitotic activity Mammogram - not well circumscribed, irregular calcification External changes - Nipple retraction, "puckering" or peau d'orange (blocked lymphatics), inflammatory signs rarely (sign of metastatic) |
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Breast mets locations
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Go to liver, lung, bone, brain
via lymphatic invasion |
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Invasive lobular carcinoma, Histology
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Multicentric, OFTEN BILATERAL, increases chance of cancer in contralateral breast
Diffusely invasive but doesn't incite fibrosis so doesn't make scirrhous nodules Histology: Rubbery, poorly circumscribed, single-file strands of poorly cohesive cells and targetoid arrangement of cells around ducts |
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Cell types ductal vs lobular types
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Ductal - bigger groups of cells
Lobular - small groups in a single file |
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Medullary Carcinoma, RF and Presentation
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Associated with BRCA1, better prognosis if tumor is all medullary carcinoma.
LOTS of lymphatic involvement |
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Colloid (mucinous) carcinoma, Presentation
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Occurs in older women
Associated with lots of extracellular mucin with tumor cells in "lakes" of mucin Better prognosis and lower grade than usual types |
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Tubular carcinoma, Presentation
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May be hard to differentiate from SA, simple tubules pointed on one end may go away from stroma into fat. Low-grade with good prognosis
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Prognostic factors for breast cancer
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Stage is most important: LN involvement and mets raise a lot.
Locally advanced disease worsens prognosis Tumor size - bigger is worse Tumor grade, histologic subtypes play a role Hormonal receptor and gene marker a) ER/PR positive tumors tend to be low grade/better prognosis. nuclear stain b) C-erb-B2 (Her2/neu) - tends to be high grade/worse prognosis. membrane antibody |
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Treatment for breast cancer
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Mastectomy
Lumpectomy Almost always add one adjuvant (radiation, chemotherapy, hormone therapy) |
