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95 Cards in this Set

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What are the causes of breast masses?
inflammatory conditions, response to fluctuating hormones, benign neoplasms, malignant neoplasms
How do the breasts change from prepuberty to menarche? During menstrual cycle?
-prepuberty: breast tissue has a few ducts;
-menarche: ducts further develop-->terminal buds proliferate to give rise to lobules (sites of milk formation)
-During secretory phase of menstrual cycle: stroma surrounding lobules gets edematous-->breast fullness
@ what age, are you more likely to find a malignant mass?
50
What is acute mastitis? What causes it? When does it occur? Sx's?
In first few wks post delivery; Principal organism: Staphylococcus (Streptococcus); Portal of entry: nipple crack;
-Infection confined to 1 segment of breast leading to pain, localized swelling, & inflammation.
How does mammary duct ectasia present? At what age?
palpable mass, often w/ bloody nipple discharge & necrotic debris thru nipple; Get enlarged ducts filled w/ debris & surrounded by fibrous tissue, lots of chronic inflammatory cells; Age: late reproductive life & post menopause;
What is often in a post-menopasual obese patient & presents as a palpable mass that you think may be breast CA until further study?
fat necrosis; since breast has lots of fatty tissue, subject to trauma or radiotherapy. Macro: well defined area <2cm, micro: anucleate fat cells surrounded by foamy histiocytes w/ Ca deposition & fibrosis (late)-->b/c fat is a lipid, so saponification of fat is a byproduct of calcium.
What breast change is in 50% of women & thought to be due to hormonal stimulation? 10% get clinically apparent dz manifest by periodic discomfort & palpable masses like Breast CA. Age?
fibrocystic change; 30-60 y/o age group;
In fibrocystic change, describe the microscopic lesions of a 30-45 y/o vs someone 40-menopause. What is thought to cause this?
30-45: fibroadenosis & epithelial hyperplasia;
40-menopause: fibrocystic change & cystic hyperplasia. b/c of imbalance b/w hyperplasia of ductule & lobular epithelium w/ each menstrual cycle.
On palpation, describe the differences w/ fibrocystic change in younger vs older age group.
younger: diffuse granularity & nodularity; tender esp during secretory phase or premenstrual period of cycle;
older: ill-defined rubbery mass;
-areas of discrete swelling representing cyst presence-->making it hard to distinguish from localized CA
What is 'blue domed cyst disease'?
what breast surgeons call fibrocystic change; grossly on younger women: multiple nodules og gray tissue, in older women you have large cysts
When does fibrocystic change tend to begin to appear?
premenopausal women when breast CA incidence is starting to inc;
Do benign proliferative breast lesions inc the chance of subsequently getting breast CA?
w/ atypical hyperplasia (disorderly cell growth & nuclear pleomorphism) are inc risk for breast CA (5x higher risk!)
Do women w/ cystic change tend to have atypical hyerplasia?
no, majority (70%) do not-->so not @ inc risk of getting CA.
What has a hobnail appearance?
Microscopy of apocrine metaplasia of fibrocystic change.
@ what age does gynecomastia tend to occur? What are the causes? Unilateral or bilateral?
-adolescence or older males;
-from hormonal effect; assoc w/ Klinefelter's syndrome, liver dz, certain drugs like digitalis;
-often unilateral; variable amt of ductule proliferation & prominent edematous & cellular stroma
Describe juvenile hypertrophy. When does it occur?
Excessive & persistent enlargement of 1 or both breasts in 11-14 y/o females.
-usually coincides w/ menarche, but may precede it
What does juvenile hypertrophy look like micro & macro?
micro: proliferation of all elements of breast (epithelium, ductules, stroma)
macro: identical to adjacent breast tissue;
What is metaplastic change?
replacement of 1 cell type w/ another type
What are the characteristics of apocrine metaplasia?
-cells w/ granular eosinophilic cytoplasm, round nuclei;
-sometimes have decapitation secretions or coarse hyaline globules;
-frequently in fibrocystic change;
-papillary morphology common in cysts;
-NO NECROSIS SEEN (ddx apocrine intraductal CA)
What is clear cell metaplasia?
clear of vacuolated cytoplasm rather than granular & eosinophilic
What is squamous metaplasia associated w/?
infarcted papilloma which may follow FNA biopsy, Phyllodes tumor, syringomatous adenoma, ducts w/ perareolar abscess, lining of biopsy cavity (squamous metaplasia can be confused w/ CA!)
Describe the characteristics of mucinous metaplasia.
-rare, typically affects nl isolated lobule, may occur in papilloma, no known pre-neoplastic potential;
Who gets lactational change and how does it present?
-Repro age females w/ recurrent hx of pregnancy; rarely, postmenopausal females (digitalis, neuroleptics); males on stilbestrol;
-May present as mass during pregnancy or post-partum.
Describe the micro & macro changes of lactational change?
macro: sharply circumscribed, may involve a pre-existing tubular adenoma (=lactating adenoma) <5cm.
micro: expanded lobules, secretory or regressive patterns seen. Foamy (milk thats being produced) background differentiates it from CA.
describe the characteristics of scerlosis adenosis. Bilateral or unilateral?
-common lesion, often bilateral!
-may form mass (<2cm), but usually microscopic finding;
What do you seen w/ micro of sclerosing adenosis?
micro: lobular architecture preserved-->this is key to diagnosis; fibrosis may distort lumina & make myoepithelial cells prominent. (preservation of epithelium & myoepithelium=bening. If you lose myoepithelial cells, then its an invasive CA).
What is in the differential diagnosis of someone w/ sclerosing adenosis?
-atypical apocrine adenosis: atypical lobular cells w/ apocrine cells;
-invasive CA: no myoepithelial cells (loses this layer!)
Who is affected by complex sclerosing lesion/radial scar and how does it appear? Bilateral or unilateral?
-middle age to older women.
-frequently multiple & bilateral
-radiology: stellate mass is suspicious
-macro: may form palpable mass;
-micro: central scar w/ stellate arrangement of ducts; pattern may be obscrued by only pt of lesion being sampled w/ core biopsy; 30% have atypia & CA.
How does someone w/ duct ectasia/periductal mastitis present?
majority are subclinical; pts present w/ nipple pain & tenderness or chronic nipple discharge.
Describe the lesion of duct ectasia/periductal mastitis.
-Lesion shows lymphoplasma infiltrate & pigmented histiocytes w/ foam cells in epithelium & lumen which obliterate lumen rather than cause ectasia. Acute form w/ PMNs is rarely seen.
What is collagenous spherulosis & what should be considered in its differential diagnosis?
-incidental microscopic finding consisting of spheres of eosinophilic material surrounded by myoepithelial cells Epithelial cells around lesion may be benign, atypical or malignant.
-DDx: DCIS, Adenoid cystic CA, lobular neoplasia
What population is more likely to get acute mastitis? They have an increased chance of getting what?
often cracks in nipple in nursing women-->allows bacterial entry (staph or anaerobes);
-inc risk for inversion of nipple or congenital anomaly;
-Micro: squamous metaplasia of lg ducts or thick walled abscess cavity from chronic infection.
What is the cause of granulomatous mastitis? what should be in the differential?
-idiopathic in US;
-DDx: TB, fungi, protozoa, duct rupture, rxn to CA, sarcoid, Wegener's.
Leakage/rupture of silicome implants can cause what? Whats in micro?
Mastitis-->from additives and/or silicone. Micro: histiocytes w/ FBG w/ fibrosis & empty spaces w/ refractile material. Changes in regional lymph nodes
Besides gynecomastia, what other breast pathology can occur in males? It feels like painless dense rubbery fibrous tissue. Its also in women 24-72 age range.
Lymphocytic mastitisu (DM or fibrous mastopathy is the idiopathic form)
A pt w/ systemic dz like RA or amyloidosis can get what in the breast? What does it look like w/ macro/micro?
amyloid tumor in breast; Macro: nodule w/ granular or waxy cut surface. Micro: amorphous eosinophilic material w/ FBG rxn. (Congo red-->apple green birefringence)
what is the most common benign breast neoplasm in women 25-35 y/o? who is more likely to get them?
fibroadenoma; african americans
do fibroadenomas predispose to breast CA?
No
What does fibroadenoma feel like on palpation and on cut section?
usually solitary, freely movable & not fixed to chest wall; don't infiltrate surrounding tissue; cut section: soft gray; micro: biphasic appearance of proliferation of ductules & mensenchyme
The myxoid change of a fibroadenoma is associate w/ Carney's complex. What is Carney's complex?
myxoma of heart, skin, hyperpigmentation of skin & endocrine changes.
What benign neoplasm is in women >50 y/o & is the most common cause of bloody breast discharge from torsion/hemorrhage? Its found as single lesion w/ large duct, usually close to nipple
Intraductal papilloma (no myoepithelail cells, have atypical intraductal proliferation; arborizing growth pattern projecting into lg duct; can get CA in papilloma)
Are intraductal and intralobular CA invasive?
No, they're non-invasive in situ and early dz, but they can be assoc w/ fibrosis, may present as mass, & detect w/ mammography.
What is it called when there is ductal (DIN) and lobular neoplasia (LIN)?
Intraductal neoplasia (these are preneoplastic processes for malignnacy)
What are the characteristics of DIN?
distinct cell borders, secondary lumens-rosettes, larger nuclei than LIN, variants: stratified, spindle cell, apocrine;
What are the characteristics of LIN?
indistinct cell borders, solid or loosely cohesive, intracytoplasmic lumens, small uniform nuclei, variants: pleomorphic;
Which stage of DIN has cribriform proliferation of uniform cells?
DIN 1: low risk
Which stage of DIN has comedo necrosis (completely occludes duct?
DIN 3
What is microinvasive CA? If you detect this, how is it managed?
cluster of tumors cells break thru basement membrane, area <2mm; managed as DCIS;
What % of DCIS has been found to have metastasized?
3%
What does microinvasive CA look like on micro?
tongue-like invasion from duct; stroma frequently fibroblastic & myxoid.
What condition will cause an inc risk for invasive lobular & ductal bilaterally, is not detectable macroscopically, and on micro is in a clover like pattern?
LIN
How are LIN 1, 2, & 3 lesions differentiated?
based on inc distention of acini to confluence of acini.
At 50 years old, what is your risk of developing breast CA?
50%
What is the risk of developing breast CA in American women?
1 in 8
Breast cancer is the _____ cancer in women, and ______in cancer deaths in women.
top, 2nd in most
How have the incidence and mortality of breast CA changes in the past half century?
1% annual inc in incidence (lung cancer has had a much larger change inc in incidence), constant mortality (thus more cures & found @ much earlier stages-->more in situ & stage 1 b/c of inc emphasis of breast CA diagnosis & more mammograms)
What is the 5 yr survival in someone w/ stage 1 vs stage 4 breast ca?
stage 1: 84%, Stage 4: 48%
What % of breast CA's now are node negative at diagnosis?
85%
What % of breast CA are small, noninvasive lesions picked up my mammograms?
65%
Is the incidence of breast CA higher in white or black women? Prognosis?
incidence higher in whites, prognosis worse in blacks
Which countries have inc risk of breast ca: those in N America & N. Europe or those in Africa or Asia?
N. America/N. Europe
How do you define regional spread of breast cancer/
to lymph nodes, chest wall, or skin
What are the risk factors for breast ca?
age, country, fam hx, previous hx of CA or breast dz, estrogen: early menarche & late menopause & obesity, estrogenic drugs but OCPs seem ok, inc income or SES, previous fibrocytsic dz if atypical hyperplasia is detected in lesion
should a woman w/ breast cancer diagnosis take OCPS?
no b/c breast CA growth is promoted by estrogen
Is a patient w/ benign breast dz at inc risk of getting breast CA?
depends on type of dz; low risk w/ proliferative dz w/ no atypia; Significantly inc risk w/ proliferative dz w/ atypia.
Pts w/ which gene mutation have 85% chance of developing CA by 70?
BRCA1 mutation
Pts w/ which gene have a worse breast CA prognosis?
Her2/neu
Which Breast CA gene is assoc w/ inc risk of ovarian CA?
BRCA1
Which 2 gene mutations are responsible for 80% of familial early onset causes of IDC, NOS?
BRCA1 (chromosome 17q21) & BRCA2 (chrom 13q12-13)
What is the most common type of infiltrating ductal CA?
IDC, NOS
What is the tx for infiltrating ductal CA?
lumpectomy or simple mastectomy
What is IDC w/ dermal lymphatic plugging by tumor emboli w/ LN mets?
'inflammatory' CA
When does infiltrating ductal CA have a nipple discharge?
if its assoc w/ larger ducts
What 3 things does the Scarff-Bloom-Richardson system measure?
tubule formation, mitotic activity, nuclear pleomorphism
What are the three grades of infiltrating ductal carcinoma accoding to the S-B-R system?
3-5: well differentiated, grade 1; 6-7: moderately differtiated, grade 2; 8-9: poorly differentiated, grade 3.
What age group gets infiltrative ductal CA vs intralobular CA?
infiltrative: pre and post menopausal women;
intralobular: premenopausal women
How does intralobular ca present?
NOT as mass--usually incidental finding; Usually bilateral and multifocal!
What % of intralobular CA develops into invasive cancer?
25%. Controversy about amt of surgery, sometimes bilateral mastectomy for invasive
Is invasive breast CA usually w/ pre or post menopausal women?
Usually post
Invasive breast cancer is usually of what type?
infiltrative
is premenopausal ca and those found in 20s and 30s usually aggressive?
YES! usually aggressive, bilateral, assoc w/ fam hx of breast cancer
Which types of breast CA have a better prognosis?
mucinous, tubular, medullary are better compared to infiltrating lobular and ductal which have a similar tx & prognosis.
What is Paget's dz?
type of breast CA where overlying epidermis is infiltrated by individual Cancer cells arising in underlying adjacent breast CA; Sx: eczema centered primarily around nipple & areolar region;.
What are the characteristics of male breast cancer/
1% of all breast cancer; older men; Sx: asymtpomatic, nipple discharge or Paget's dz.
-inc risk w/ Klinefelter's
-same prognosis as female breast CA
-higher incidence of mets (55%)
-ER+. +/- PR +, +/-RSA
What is a phyloddes utmor (aka giant fibroadenomas or cystosarcoma phyloddes)?
-tend to occur in 40 y/0, presents as painless discrete mass, often longstanding w/ sudden enlargement;
-consists of epithelium and assoc neoplastic stroma (biphasic tumor like fibroadenoma) & heterologous elements more often seen (chondroid, osseous, lipioud) than in fibroadenoma.
-tend to recur but don't metastasize, good prognosis;
-Image: leaf like processes protrude into cystic spaces lined by epithelial & myoepithelial cells;
What is peau d'orange?
as skin lymphaics are invaded, skin taken on characteristics dimpling similar to orange skin in appearance.
What happens as the breast malignancy grows?
can palpate mass, infiltrates into surrounding breast tissue, attaches to underlying muscle, peau d'orange, nipple retraction w/ growth into surrounding muscle; malignancy can ulcerate thru skin, bleed, discharge necrotic material
Which lymph nodes does breast CA drain into?
axillary
What are the most common places of breast CA mets?
brain, bone marrow (but can go anywhere; painful to bone as its osteoblastic)
Post mastectomy, where does breast CA commonly occur?
scar site, can recur as much as 20 yrs post initial tx
What are the 4 stages of breast CA?
Stage I: node negative;
Stage II: breast mass w/ LN mets or involvement of overlying skin
Stage III: more extensive, involves extensive adherence to skin, muscle, fixed lymph nodes
Stage IV: widely metastatic dz
Which breast CA pt has the best prognosis?
if their axillary LN's are negative (or one w/ less than 4 positive ones); if pt has hormone receptors (ER or PR)b/c can remove estrogen influence or anti-estrogens like tamoxifen
Which monoclonal Ab drug has been shown to slow growth of HER-2 positive tumors. It blocks HER-2 receptors and controls growth.
Herceptin
Does chemo inc breast CA pt survivial?
yes, but if LN negative, reluctance to tx them w/ aggressive chemo-->should look at different prognostic factors
Pts w/ which gene amplification (aka erbB2/neu) have inc numbers of growth factor receptors, have more aggressive malignancies, and this is overexpressed in 25-35% of primary breast CA's and is assoc w/ inc risk of recurrent dz or shorter overall survivial?
HER-2 gene