Breast

Front 1

Fibrocystic change of the breast*

Back 1

Cystic changes of either the glands or duct. This stretches the connective tissue and causes fibrosis.

Most common change in premenopausal woman.

Hormone-mediated, normal variation as a consequence of the estrogen and progesterone levels.

Vague irregularity to breast tissue

"Lumpy breast" in upper outer quadrant

Blue domed cysts

1) Cysts: dilation of lobules. Filled with semi-translucent blue-brown fluid.

2) Fibrosis: cysts rupture release secretory material into stroma and inflame

3) Adenosis: Increased acini per lobule. Normally occurs during pregnancy

Front 2

Fibrocystic change risk for cancer?*

Back 2

Classically it's benign.

Fibrosis, cysts, apocrine metaplasia means BENIGN

Front 3

What breast changes carry increased risk for invasive carcinoma?*

Back 3

Ductal hyperplasia and sclerosing adenosis (too many glands that are fibrosed) = 2x risk

Atypical hyperplasia = 5x risk

The risk applies to BOTH breasts

Front 4

Intraductal papilloma pathophysiology*

Back 4

Within the large duct that goes to the nipple, you can grow a fibrovascular fingerlike projection covered by epithelium.

This papillary lesion often bleeds and produces bloody nipple discharge.

Epithelial cells AND MYOEPITHELIAL CELLS line the papillary projection (myo are absent in papillary carcinoma)

Usually premenopausal women.

Front 5

Fibroadenoma pathophysiology*

Back 5

Tumor of fibrous tissue + glands

MC benign neoplasm of breast

MC tumor in premenopausal

Well-circumscribed, mobile, marble-like

Estrogen sensitive (can shrink as menopause occurs)

Benign; no risk for carcinoma

Front 6

Phyllodes tumor*

Back 6

Fibroadenoma-like with overgrowth of fibrous component, increased cellularity

Leaf-like projections

Most commonly seen in postmenopausal women

CAN be malignant

Front 7

Acute Mastitis

Back 7

First month of breastfeeding.

Local bacterial infenction due to crack and fissures in the nipples.

Breast erythematous, painful, fever often present.

Treat with abx and continued expression of milk from the breast

Front 8

Squamous Metaplasia of Lactiferous Ducts (Zuska disease, periductal mastitis)

Back 8

Painful erythematous subareolar mass.

90% are smokers, maybe from a Vitamin A deficiency

Keratizing squamous metaplasia of nipple ducts.

Keratin sheds and plugs ductal, dilation and rupture eventually.

En bloc surgical removal of the involved duct and tract. Plus abx.

Front 9

Duct Ectasia

Back 9

Palpable periarolar mass with thick white or green nipple secretions.

50-60yo multiparous women.

Fibrosis scar shows nipple retraction

Not associated with smoking.

Ducts filled with lipid laden macrophages.

Front 10

Sclerosing adenosis morphology and risk

Back 10

Increased number of acini compressed and distorted in the central portion.

Stromal fibrosis may completely compress lumens to look like cords of cells (mimicking carcinoma)

2x risk of carcinoma

Front 11

Complex Sclerosing Lesion morphology

Back 11

Components of sclerosing adenosis, papillomas, and epithelial hyperplasia.

Radial scar : irregular, looks like invasive carcinoma (central glands surrounded by radiating projections into stroma)

Front 12

Gynecomastia

Back 12

Only benign lesion in male breast.

Button-like subareolar enlargement.

Imbalance between estrogens and androgens

Seen a lot in cirrhosis (since estrogen isn't as metabolized)

Also seen in puberty, hyperestrenism, Klinefelter Syndrome (XXY)

Front 13

Ductal Carcinoma in situ

Back 13

Malignant proliferation of cells in the duct, hasn't broken through the basement membrane.

Detected as calcification on mammography

Comedo type: high grade cells with necrosis and dystrophic calcification in center of ducts. (kind of looks like a bullseye)

Front 14

Paget disease of the breast, treatment

Back 14

DCIS that extends (walks up the duct) up to the skin of the nipple

Nipple ulceration and erythema

Almost always associated with an underlying carcinoma, poorly differentiated

ER- HER2+

Mastectomy is curative in >95% of women

Front 15

Invasive Ductal Carcinoma, NST

Back 15

Malignant cells have invaded past the basement membrane

Forms duct-like structures in desmoplastic stroma (connective tissue hooked onto the tumor)

"poorly-defined margins and cuts with gritty sensation. The cut surface is gray, opaque, and slightly depressed. Streaks of gray extend into the surrounding fibroadipose tissue."

Detected by physical exam or mammography

Advanced tumors may result in dimpling of skin or retraction of nipple

Front 16

Subtypes of Invasive ductal carcinoma

Back 16

Tubular carcinoma

Mucinous carcinoma

Medullary carcinoma

Inflammatory carcinoma

Front 17

Tubular carcinoma

Back 17

Well-differentiated tubules that lack myoepithelial cells

Good prognosis

Front 18

Inflammatory carcinoma

Back 18

Inflammed, swollen breast

Carcinoma in dermal lymphatics blocks drainage of the breast

Like mastitis, but much worse.Poor prognosis

Front 19

Medullary carcinoma

Back 19

Large, high-grade cells growing in sheets with associated lymphocytes and plasma cells

Most common in 6th decade

Increased in BRCA1 carriers

Usually no hormone receptors

Prognosis slightly better than NST

Front 20

Lobular carcinoma in situ and treatment

Back 20

Malignant proliferation of cells in lobules (no invasion of BM)

Discovered incidentally, does not produce mass or calcification.

Dyscohesive cells lack E-cadherin

Mucin positive signet ring positive cells common

Almost always ER/PR +, HER2 -

Often multifocal and bilateral

Treat with tamoxifen

Front 21

Invasive lobular carcinoma

Back 21

Tumor of cells that grow along lobules, but invade BM

Invade in a single-file pattern due to lack of E-cadherin

Often involves spread to peritoneum, retroperitoneum, and leptomeninges

Front 22

TNM staging and prognosis of breast cancer

Back 22

TNM staging = Tumor size, Node metastases, Metastasis for distant

Metastasis is most important factor

Spread to axillary lymph nodes is most useful factor

Sentinel node biopsy is used to assess those axillary lymph nodes

Front 23

Predictive factors and treatment of breast cancer

Back 23

Most important factors are Estrogen receptor, Progesterone Receptor and HER2/neu gene amplification status.

ER and PR (nucleus) are associated with response to tamoxifen (anti estrogen)

HER2/neu (surface receptor) amplification is associated with response to trastuzumab

If they're triple negative (no ER, no PR, no HER2/neu) then they have a very poor prognosis. Won't respond to tamoxifen or trastuzumab.

Front 24

Hereditary Breast Cancer

Back 24

10% of breast cancer cases

Multiple first-degree relatives with breast cancer, tumor at an early age, or multiple tumors are signifiers

BRCA1 and BRCA2 are the most important single gene mutations

BRCA1 = breast + ovarian cancer

BRCA2 = breast carcinoma in males

Front 25

Male Breast Cacner

Back 25

Subareoloar mass in older male

Highest density underneath the nipple

Usually invasive ductal carcinoma (lobular is rare)

BRCA2 associated

Klinefelter syndrome associated

Front 26

Most common form of invasive breast cancer?

Back 26

ER + HER2- (like lobular carcinoma)

Front 27

Second most common form of invasive breast cancer?

Back 27

ER ± HER2+

Front 28

Major type of invasive carcinomas in BRCA1 carriers

Back 28

ER- HER2-

Front 29

Nottingham Histologic Grading

Back 29

Grade I: tubular, uniform nuclei low proliferation

Grade II: tubules + cords, mitotic + moderate pleiomorphism + moderate mitoses

Grade III: ragged nests or solid sheets of cells + enlarged irregular nuclei + high proliferative rate of necrosis

Front 30

Fat Necrosis

Back 30

Usually prior history of surgery or trauma

Mass, thickening with retraction or mammographic density or calcification

Acute = hemorrhagic with liquefactive

Few days = proliferating fibroblasts + chronic inflammatory cells

Eventually = scar

Front 31

Mucinous carcinoma

Back 31

Subtype of invasive ductal carcinoma

Older women, grows slowly

Tumor is rubbery or soft with pale gray-blue gelatinous cut surface

Tumor cells arranged in clusters and small islands floating in lakes of mucin (colloid)

Prognosis slightly better than NST

Front 32

Tubular carcinoma

Back 32

Women in their late 40's

Consists exclusively of well-formed tubules

No myoepithelial cells

Sometimes cribiform pattern

Front 33

Definition of Sojourn time

Back 33

Duration between when a lesion can be detected on mammography and when it presents clinically (2 years premenopausal, 1 year postmenopausal)

Front 34

BIRADS Grade 0

Back 34

Need Additional Imaging or prior mammograms for comparison

Front 35

BIRADS Grade 1

Back 35

Negative - nothing to comment on

Front 36

BIRADS Grade 2

Back 36

Benign

Front 37

BIRADS Grade 3

Back 37

Probably benign (<2% malignant)

Initial short follow-up suggested

Front 38

BIRADS Grade 4

Back 38

Suspicious (2-95% malignant)

Biopsy suggested

Front 39

BIRADS Grade 5

Back 39

Highly suggestive of malignancy (>95%)Appropriate action should be taken

Front 40

BIRADS Grade 6

Back 40

Known Biopsy - Proven Malignancy

Front 41

Medication causes of gynecomastia

Back 41

Spironolactone

Hormones

CimetidineKetoconazole

(Some Hormones Create Knockers)

Digoxin

Front 42

Intraductal papilloma presentation

Back 42

Bloody discharge, excessive call growth

Front 43

Duct ectasia presentation

Back 43

Blockage of lactiferous ducts

Greenish, sebaceous, or bloody discharge

Front 44

Galactorrhea presentation

Back 44

bilateral, milky or clear/white substance

Front 45

Causes of galactorrhea

Back 45

Pituitary lesions (microadenoma/macroadenoma)

Antipsychotics that suppress dopamine

Hypothyroidism

Estrogens

Front 46

Work-up and treatment of galactorrhea

Back 46

Take history of meds, check breast discharge

Get TSH levels and PRL (fasting)

MRI of sella turcica if PRL > 100

Remove offending agent

Front 47

Microadenoma vs Macroadenoma and treatment

Back 47

Microadenoma (<1cm) = bromocriptine or cabergoline, dopamine agonistsMacroadenoma (>1cm) = surgery

Front 48

Treatment of mastitis

Back 48

Dicloxacillin

Front 49

peau d'orange

Back 49

Inflammatory breast cancer