Breast Pathology

Front 1

benign neoplasms involving CALCIFICATIONS

Back 1

(1) fat necrosis - leads to saponification

(2) sclerosing adenosis

Front 2

What stain is useful for differentiating between ductal VS lobular breast cancer

Back 2

E. Cadherin --> lost in LOBULAR, not ductal

Front 3

Examples of inflammatory conditions of the breast

Back 3

(1) Acute Mastitis - bacterial infxn of breast commonly causes by STAPH AUREUS, w/ or w/o abscess: erythematous breast w/ nipple discharge. Associated with breast feeding: fissures develop in nipple providing route for microbe entry. Rx with dicloxacillin.

(2) Periductal mastitis - Presents as SUBAREOLAR MASS w/ nipple retraction. Commonly caused by smoking which induces relative vitamin A deficiency, specialized epithelium of duct requires vitamin A. Get squamous metaplasia of the lactiferous ducts (normally columnar?) leading to duct blockage and inflammation [see keratinization within duct].

(3) Mammary Duct ectasia - Presents as PERIOAREOLAR MASS w. green-brown nipple discharge. See chronic inflammation with plasma cells seen on biopsy. Inflammation with dilation (ectasia) of the subareolar duct. Rare, usually arising in MULTIPAROUS post-menopausal women.

(4) Fat necrosis - Necrosis of breast fat caused by trauma. Found as a mass on physical exam OR abnormal calcification in mammography. Biopsy - necrotic fat with associated calcifications and giant cells.

Front 4

Which breast condition causes green-brown nipple discharge? Is it benign or malignant?

Describe the typical patient that would present this way?

What is the cause?

Back 4

Mammary Duct Ectasia. Non-neoplastic but rather associated with inflammation.

Multiparous post-menopausal patient

Inflammation with dilatation of subareolar duct, see plasma cells on bx.

Front 5

Common pathology caused by breast feeding. How do you treat it?

Back 5

Acute mastitis - infection of breast with S.Aureus. Continue breast feeding and treat with dicloxacillin.

Front 6

What condition of the breast is associated with squamous metaplasia of the duct? What's the etiology.

Back 6

Periductal mastitis. Smoker --> Vitamin A deficiency --> squamous metaplasia of duct.

Front 7

Patient presents with hard mass in physical exam. Patient reports recent car accident. Diagnosis?

Back 7

Fat necrosis

Front 8

Benign neoplasms of the breast - list & brief description

Back 8

(1) Fibrocystic change - fibrosis and cysts in breasts. Vague irregularity of breast in pre-menopausal woman, usually in UOQ. Most common in PREMENOPAUSAL breast. Benign but certain types inc risk cancer (atypical ductal hyperplasia [5X], ductal hyperplasia [2X], and sclerosing adenosis [2X]. This is occurring in the MAJOR DUCT. NO INC RISK FOR FIBROSIS+CYSTS+APOCRINE METAPLASIA)

(2) fibroadenoma - tumor of fibrous tissue & glands located in the STROMA. Presents as small, mobile, firm mass with sharp edges. It is the most common tumor in women <35 (PREMENOPAUSAL). ESTROGEN DEPENDENT: bigger size and tenderness with estrogen. NO MALIGNNANT POTENTIAL.

(3) intraductal papilloma - Presents as serous/bloody nipple discharge. Papillary growth into a LARGE DUCT. Fibrovascular projections lines by EPITHELIAL + MYOEPITHELIAL cells. [vs. PAPILLARY CARCINOMA - no ME cells] Small tumor growing in lactiferous ducts. Typically grows beneath areola. Slight INC RISK CARCINOMA (1.5-2X)

(4) Phyllodes tumor - fibroadenoma-like tumor with OVERGROWTH of fibrous component. Histo - Leaf-like projections. It is a large bulky mass of CT and cysts. Most commonly 6th decade post-menopausal woman. Has malignant potential.

Front 9

25 y/o woman presents with "marble-like", firm, mobile breast mass. Most likely diagnosis? Potential for cancer?

Back 9

Fibroadenoma - no malignant potential.

Front 10

"Leaf-like projections on histology ."

Potential for malignancy?

Premenopause or post menopause?

how would these feel?

Back 10

Phyllodes tumor.

YES, some may become malignant.

POST

large bulky mass

Front 11

Three most commonly tested receptors for malignant breast tumors.

Back 11

(1) Estrogen Receptor

(2) Progesterone receptor

(3) HER2 receptor

Front 12

What is DCIS?

Back 12

Ductal carcinoma in situ - an malignant proliferation of cells in ducts WITHOUT INVASION OF BASEMENT MEMBRANE. This arises from ductal atypia.

Front 13

Mammographic results for DCIS?

Back 13

Microcalcifications

Front 14

Subtype of DCIS involving ductal caseous necrosis. See high grade cells with necrosis and dystrophic calcification at the center of the ducts.

Back 14

Comedocarcinoma

Front 15

Distinct disease resulting as a complication of DCIS.

Back 15

Paget Disease

Front 16

Results when ductal cells migrate from a site of DCIS up to the nipple.

Back 16

Paget disease

Front 17

Causes nipple ulceration and erythema.

Back 17

Paget disease

Front 18

Malignant proliferation of cells in lobules with no invasion of BM

Back 18

LCIS - lobular carcinoma in situ

Front 19

Dis-cohesive cells that lack E-Cadherin is the hallmark of this pathology.

Back 19

Lobular carcinoma (LCIS or invasive lobular carcinoma)

Front 20

Patient's breast mass tested negative for E-Cadherin and she was treated with TAMOXIFEN.

(a) what was her most likely diagnosis?

(b) what is the mechanism of action of tamoxifen. Risks?

Back 20

(a) LCIS - lobular carcinoma in situ

(b) Tamoxifen is a estrogen receptor antagonist in breast tissue. However, it is an estrogen receptor AGONIST on the uterus and bone and thus increases risk for endometrial cancer and thromboembolic events.

Front 21

The worst and most invasive form of breast cancer.

Back 21

Invasive ductal carcinoma

Front 22

The most common form of breast cancer

Back 22

Invasive ductal carcinoma

Front 23

60 y/o patient presents w/ non-painful, non-tender, 3x4cm rock hard mass in UOQ. Most likely diagnosis?

Back 23

Invasive ductal carcinoma

Front 24

"rock-hard mass" w/ sharp margins

classic "stellate" infiltration.

advanced tumors cause skin dimpling and retraction of nipple.

Back 24

invasive ductal carcinoma

Front 25

this carcinoma grows in a "single-file pattern" and cells may have signet ring morphology.

Back 25

invasive lobular carcinoma

Front 26

This form of invasive breast carcinoma is often bilateral.

Back 26

Invasive Lobular carcinoma

Front 27

This breast malignancy is triple negative, but has a good prognosis.

Back 27

MEdullary carcinoma.

Front 28

breast malignancy involving a fleshy, cellular, lymphocytic infiltrate.

Back 28

medullary carcinoma

Front 29

"Peau d'orange --> breast skin resembles orange-peel. 50% survival @ 5 yrs.

Back 29

Inflammatory breast cancer

Front 30

Get an inflamed, swollen breast. caused when neoplastic cells block lymphatic drainage.

Back 30

Inflammatory breast cancer

Front 31

Patient experiences nipple retraction.

(1) If this were non-neoplastic what could be the cause?

(b) which cancer is associated with nipple retraction?

Back 31

(a) periductal mastitis

(b) invasive ductal carcinoma

Front 32

Patient receives treatment for acute mastitis but it does not resolve. Blood tests for pathogens come back negative. What is another likely etiology?

How would you confirm this?

Back 32

Inflammatory carcinoma of breast

--> clinical signs of inflammation + finding of tumor cells in DERMAL LYMPHATICS

Front 33

This type of breast cancer is common in patients with BRCA1 mutations

Back 33

Medullary carcinoma

Front 34

Patient has a well-circumscribed mass. On histology you see high-grade tumor cells growing in sheets with lymphocytes and plasma cells. Most likely diagnosis?

Back 34

Medullary carcinoma!

Front 35

3 cancers associated with desmoplasia?

Back 35

invasive ductal carcinoma and pancreatic adenocarcinoma + diffuse gastric adenocarcinoma

Front 36

What about invasive ductal carcinoma makes it feel "rock hard."

Back 36

Desmoplastic reaction to invasion of stroma. Stroma proliferates and feels "rock hard."

Front 37

Important risk factors for invasive ductal carcinoma?

Back 37

Gender is the most important risk factor although breast cancer can alsodevelop in men. Other risk factorsinclude inherited genetic mutations, personal history of breast cancer, age(higher risk > 65 years-old, but average age 46-61), age at menarche(<11), age at first live birth (younger better), first-degree relatives withbreast cancer – especially two or more first degree relatives diagnosed youngerthan 55 years old, atypical hyperplasia, non-Hispanic white women,postmenopausal hormone replacement therapy, high breast density, radiationexposure, and carcinoma of the contralateral breast or endometrium. Fibrocysticdisease does not increase risk (relative risk = 1.0). Either DCIS or lobular carcinoma in situleads to a relative risk of developing invasive carcinoma of 8.0-10.0 (25%-30%lifetime risk). Although family historyis important, over 87% of women with a family history will not develop breastcancer.

Front 38

For women with BRCA1 mutations, what is the relative risk of developing breast cancer?

Back 38

For women with BRCA1 mutations, the risk of developing breast cancerrisk by age 70 is 40-90%

Front 39

BRCA1 increases risk of developing which types of cancer?

Back 39

Breast

Ovarian (serous cystadenocarcinoma)

Prostate

Pancreatic

Front 40

Li Fraumeni increases risk for which main types of cancer?

Back 40

Sarcoma, breast, leukaemia and adrenal gland (SBLA) syndrome.