Breast Pathology

Front 1

Clinical Presentation of Breast Pathology

Back 1

1. Palpable Mass
2. Inflammatory Lesions
3. Nipple Secretion
4. Mammographic Changes
5. Nipple Inversion

Hint 1

**With any of these clinical presentations, it is difficult to distinguish between what is benign and what is malignant.

Front 2

Inflammatory Breast Conditions

Back 2

1. Acute Mastitis and Breast Abscess
2. Mammary Duct Ectasia (Dilation)
3. Fat Necrosis

Front 3

Acute Mastitis

Back 3

Inflammation of the nipple or skin due to cracks or fissures in the nipple that allow bacteria to enter. S. Aureus is the most common bacteria and can lead to abscess formation.

Hint 3

**Risk factors include lactation, eczema, skin conditions
**Presents with scale-like redness
**Treated with incision, drainage, and antibiotics

Front 4

Mammary Duct Ectasia

Back 4

Dilation of the mammary duct due to the breast ducts becoming blocked resulting in a backup of secretions and resulting in inflammation and dilation. The body will respond by granulomatous inflammation which will present as "cheesy" material in the ducts.

Hint 4

Granulomatous inflammation can mimic a tumor.

Front 5

Breast Fat Necrosis

Back 5

A hemorrhage resulting from trauma causes acute inflammation. The inflammation causes fat necrosis leading to chronic inflammation in which macrophages will be present.

Hint 5

**Presents as a mass lesion mimicking a carcinoma.
**Very rare.

Front 6

Fibrocystic Breast Changes

Back 6

1. Cyst Formation/Fibrosis
2. Epithelial Hyperplasia
3. Sclerosing Adenosis

Hint 6

**Wide spectrum of benign to a great increase in risk for tumor
**Typically Bilateral
**Calcification can be present

Front 7

Epithelial Hyperplasia

Back 7

A proliferation of benign epithelial cells in breasts causing an increase in number of layers of cells beyond the double layer found in ducts. It will maintain it's "tree-like" structure but after prolonged stimulation, become full of cells or solid.

Hint 7

**Usually associated with a 1.5-2x risk for cancer

Front 8

Atypical Ductal Hyperplasia

Back 8

An excessive proliferation of benign epithelial cells in which you have more layers of cells with nuclei no longer arranged in rows that are atypically shaped. They will start to look like glands within the glands.

Hint 8

**This is just short of malignancy.
**Associated with a 5x increased chance of cancer!!

Front 9

Sclerosing Adenosis

Back 9

Although the lobular arrangement is maintained, the ducts are squeezed together causing the small ducts to proliferate and become surrounded by fibrous stroma. Can appear like malignancy because everything is squeezed together - it is not.

Hint 9

**1.5-2x chance of cancer

Front 10

Breast Fibrosis

Back 10

An increased in breast stroma and dilated ducts that appears blue grossly "Blue Dome Cysts"

Hint 10

**Due to the result of hormone stimulation, typically presents bilaterally.
**Will result is Apocrine Metaplasia

Front 11

Apocrine Metaplasia

Back 11

A thickening in the epithelium of breast tissue that appears very foamy.

Hint 11

**Almost always a sign of benign process and thus no increased risk of cancer.

Front 12

Types of Benign Breast Cancer

Back 12

1. Fibroadenoma (Stromal)
2. Phyllodes Tumor (Stromal)
3. Intraductal Papilloma (Epi)

Front 13

Fibroadenomas

Back 13

A benign stromal breast cancer in which the fibrous AND glandular tissue has new growth, but only the fibrous part is clonal expansion. It causes the duct system to squeeze into tiny channels.

Hint 13

**Most Common benign breast growth.
**Women younger than 30
**Well circumscribed palpable mass with nice edges that is moveable.
**Microscopically presents with stromal proliferation with slit-like edges.

Front 14

Phyllodes Tumors

Back 14

More aggressive (but still usually benign) proliferation of stromal tissue. Compared to fibroadenomas, has more cellularity, more mitoses, more nuclear changes.

Hint 14

**Low Grade - More common, surgically removable, rarely metastasize but can recur locally.
**High Grade - Rare and can spread like a sarcoma and cause malignancy.

Front 15

Intraductal Papilloma

Back 15

Benign epithelium tumors that usually grow in the large lactiferous ducts sitting right below the nipple. WIll present with serous of bloody nipple discharge.

Hint 15

**Rarely presents with nipple retraction or small subareolar mass.
**Microscopically present as dpi projections with vascular CT core.

Front 16

Types of Breast In-Situ Carcinomas

Back 16

1. Ductal Carcinoma In Situ
2. Lobular Carcinoma In Situ

Front 17

Types of Invasive Breast Carcinomas

Back 17

1. Invasive Ductal Carcinoma
2. Invasive Lobular Carcinoma
3. Medullary Carcinoma
4. Colloid/Mucinous Carcinoma
5. Tubular Carcinomas
6. Adenoid Cystic Carcinoma
7. Apocrine Carcinoma
8. Invasive Papillary Carcinoma

Hint 17

**All invasive breast carcinomas involve EPITHELIAL tissue

Front 18

Ductal Carcinoma In-Situ (DCIS)

Back 18

Malignant breast cancers that fill the ducts but do not breach the basement membrane. Accounts for 20-30% of all cancers. Microscopically you will see coarse calcifications in which epithelial cells are 5-6 layers thick, and presence of glandular structures within glands.

Hint 18

**Calcification of breast tissue can be fibrotic changes as well, so not a good indicator of malignancy.
**Responsive to hormones

Front 19

Comedo Carcinoma

Back 19

A DCIS with a central necrosis. Because the malignant cells grow so quickly, the middle of the tissue does not receive enough blood supply and thus dies.

Front 20

Lobular Carcinoma In-Situ (LCIS)

Back 20

Uniform cells fill the lobules sitting at the end of the ducts but do not breach the basement membrane. The malignancy can extend into the ducts as well so LCIS can involve both ducts and lobules. Frequently multifocal and bilateral compare to DCIS

Hint 20

**LCIS is a greater indicator of risk for invasive carcinoma than DCIS.
**No necrosis
**It is always an incidental finding during a biopsy because it is not detectable by normal screening techniques.

Front 21

Invasive Ductal Carcinoma

Back 21

Malignant tumor of the breast epithelium that presents as rock hard, painless masses that is white and fibrous and occasionally become fixed to the underlying muscle or overlying skin causing retraction of the tissue giving it a gritty "unripe pear" look.

Hint 21

**The most common type of breast cancer. If not specified, this is the type talked about!!!
**Looks like LARGE, raised stars that are dense and may show calcifications, but do NOT have clearly defined edges.
**Can be well or poorly differentiated. You will still have tubules but can no longer see tree-like structures.

Front 22

Invasive Lobular Carcinoma

Back 22

Malignant tumor of the breast lobular epithelium that has no tubules at all and infiltrates the stroma in single file lines. More well differentiated than ductal carcinomas and estrogen receptor positive.

Hint 22

**Less common than Ductal Carcinomas but more often bilateral and multi centered.

Front 23

Medullary Carcinoma

Back 23

A malignant tumor of the breast epithelium that has benign behavior. Is a big network of cells with well defined rounded edges that is infiltrated with lymphocytes, but does not invade aggressively.

Front 24

Colloid/Mucinous Carcinomas

Back 24

Malignant tumor of the breast epithelium that is made up of ductal cells with atypical nuclei that are swimming in mucous.

Hint 24

**Have benign behavior

Front 25

Tubular Carcinoma

Back 25

Malignant tumor of breast epithelium that has VERY well differentiated cells which may be mistaken for benign growths. Ducts are still present but no normal tree-like structure.

Hint 25

**Have benign behavior and infiltrates as a sheet.

Front 26

Adenoid Cystic Carcinoma

Back 26

A malignant tumor of breast epithelium involving salivary glandular tissue.

Front 27

T4 Breast Cancer Staging

Back 27

Size does not matter. You look for:
1. Extension into the chest wall
2. Peau D'Orange
3. Ulceration
4. Inflammatory Carcinoma

Front 28

Paget's Disease

Back 28

Malignant breast cancer in which the dermis has been infiltrated with cancerous cells.

Front 29

Gynecomastia

Back 29

Most common pathology of the male breast in which enlargement of the breast tissue can result from increased hormone levels, increased estrogen, certain medications.

Front 30

Breast Ductal Carcinoma in Men

Back 30

Men can get malignant breast cancers but since the do not have lobules, the cannot get lobular carcinomas.

Hint 30

**Because there is so little tissue for it to grow into, it infiltrates the chest wall quickly and thus tends to have more advanced presentation upon diagnosis.

Front 31

Fine Needle Aspirate

Back 31

You stick a needle into the lesion, remove, spray onto a slide, and look at specimen.

Hint 31

**Infrequently used because it is hard to differentiate and you can not do HER2 testing.

Front 32

Needle Core Biopsy

Back 32

A biopsy of a malignant tumor in which a bigger needle takes out a visible core of tissue.

Hint 32

**The larger cross sectional area allows you to see the relationship between glandular tissue and stroma.

Front 33

Excisional Biopsy

Back 33

A process following a positive needle core biopsy in which a mammogram is performed to place a wire directly through the breast lesion and then sent to the surgeon who removes all the tissue surrounding the inserted wire.