Repro; Zaman - Breast Pathology; Kct

Front 1

What are the causes of breast masses?

Back 1

inflammatory conditions, response to fluctuating hormones, benign neoplasms, malignant neoplasms

Front 2

How do the breasts change from prepuberty to menarche? During menstrual cycle?

Back 2

-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

Front 3

@ what age, are you more likely to find a malignant mass?

Back 3

50

Front 4

What is acute mastitis? What causes it? When does it occur? Sx's?

Back 4

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.

Front 5

How does mammary duct ectasia present? At what age?

Back 5

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;

Front 6

What is often in a post-menopasual obese patient & presents as a palpable mass that you think may be breast CA until further study?

Back 6

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.

Front 7

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?

Back 7

fibrocystic change; 30-60 y/o age group;

Front 8

In fibrocystic change, describe the microscopic lesions of a 30-45 y/o vs someone 40-menopause. What is thought to cause this?

Back 8

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.

Front 9

On palpation, describe the differences w/ fibrocystic change in younger vs older age group.

Back 9

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

Front 10

What is 'blue domed cyst disease'?

Back 10

what breast surgeons call fibrocystic change; grossly on younger women: multiple nodules og gray tissue, in older women you have large cysts

Front 11

When does fibrocystic change tend to begin to appear?

Back 11

premenopausal women when breast CA incidence is starting to inc;

Front 12

Do benign proliferative breast lesions inc the chance of subsequently getting breast CA?

Back 12

w/ atypical hyperplasia (disorderly cell growth & nuclear pleomorphism) are inc risk for breast CA (5x higher risk!)

Front 13

Do women w/ cystic change tend to have atypical hyerplasia?

Back 13

no, majority (70%) do not-->so not @ inc risk of getting CA.

Front 14

What has a hobnail appearance?

Back 14

Microscopy of apocrine metaplasia of fibrocystic change.

Front 15

@ what age does gynecomastia tend to occur? What are the causes? Unilateral or bilateral?

Back 15

-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

Front 16

Describe juvenile hypertrophy. When does it occur?

Back 16

Excessive & persistent enlargement of 1 or both breasts in 11-14 y/o females.
-usually coincides w/ menarche, but may precede it

Front 17

What does juvenile hypertrophy look like micro & macro?

Back 17

micro: proliferation of all elements of breast (epithelium, ductules, stroma)
macro: identical to adjacent breast tissue;

Front 18

What is metaplastic change?

Back 18

replacement of 1 cell type w/ another type

Front 19

What are the characteristics of apocrine metaplasia?

Back 19

-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)

Front 20

What is clear cell metaplasia?

Back 20

clear of vacuolated cytoplasm rather than granular & eosinophilic

Front 21

What is squamous metaplasia associated w/?

Back 21

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!)

Front 22

Describe the characteristics of mucinous metaplasia.

Back 22

-rare, typically affects nl isolated lobule, may occur in papilloma, no known pre-neoplastic potential;

Front 23

Who gets lactational change and how does it present?

Back 23

-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.

Front 24

Describe the micro & macro changes of lactational change?

Back 24

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.

Front 25

describe the characteristics of scerlosis adenosis. Bilateral or unilateral?

Back 25

-common lesion, often bilateral!
-may form mass (<2cm), but usually microscopic finding;

Front 26

What do you seen w/ micro of sclerosing adenosis?

Back 26

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).

Front 27

What is in the differential diagnosis of someone w/ sclerosing adenosis?

Back 27

-atypical apocrine adenosis: atypical lobular cells w/ apocrine cells;
-invasive CA: no myoepithelial cells (loses this layer!)

Front 28

Who is affected by complex sclerosing lesion/radial scar and how does it appear? Bilateral or unilateral?

Back 28

-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.

Front 29

How does someone w/ duct ectasia/periductal mastitis present?

Back 29

majority are subclinical; pts present w/ nipple pain & tenderness or chronic nipple discharge.

Front 30

Describe the lesion of duct ectasia/periductal mastitis.

Back 30

-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.

Front 31

What is collagenous spherulosis & what should be considered in its differential diagnosis?

Back 31

-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

Front 32

What population is more likely to get acute mastitis? They have an increased chance of getting what?

Back 32

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.

Front 33

What is the cause of granulomatous mastitis? what should be in the differential?

Back 33

-idiopathic in US;
-DDx: TB, fungi, protozoa, duct rupture, rxn to CA, sarcoid, Wegener's.

Front 34

Leakage/rupture of silicome implants can cause what? Whats in micro?

Back 34

Mastitis-->from additives and/or silicone. Micro: histiocytes w/ FBG w/ fibrosis & empty spaces w/ refractile material. Changes in regional lymph nodes

Front 35

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.

Back 35

Lymphocytic mastitisu (DM or fibrous mastopathy is the idiopathic form)

Front 36

A pt w/ systemic dz like RA or amyloidosis can get what in the breast? What does it look like w/ macro/micro?

Back 36

amyloid tumor in breast; Macro: nodule w/ granular or waxy cut surface. Micro: amorphous eosinophilic material w/ FBG rxn. (Congo red-->apple green birefringence)

Front 37

what is the most common benign breast neoplasm in women 25-35 y/o? who is more likely to get them?

Back 37

fibroadenoma; african americans

Front 38

do fibroadenomas predispose to breast CA?

Back 38

No

Front 39

What does fibroadenoma feel like on palpation and on cut section?

Back 39

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

Front 40

The myxoid change of a fibroadenoma is associate w/ Carney's complex. What is Carney's complex?

Back 40

myxoma of heart, skin, hyperpigmentation of skin & endocrine changes.

Front 41

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

Back 41

Intraductal papilloma (no myoepithelail cells, have atypical intraductal proliferation; arborizing growth pattern projecting into lg duct; can get CA in papilloma)

Front 42

Are intraductal and intralobular CA invasive?

Back 42

No, they're non-invasive in situ and early dz, but they can be assoc w/ fibrosis, may present as mass, & detect w/ mammography.

Front 43

What is it called when there is ductal (DIN) and lobular neoplasia (LIN)?

Back 43

Intraductal neoplasia (these are preneoplastic processes for malignnacy)

Front 44

What are the characteristics of DIN?

Back 44

distinct cell borders, secondary lumens-rosettes, larger nuclei than LIN, variants: stratified, spindle cell, apocrine;

Front 45

What are the characteristics of LIN?

Back 45

indistinct cell borders, solid or loosely cohesive, intracytoplasmic lumens, small uniform nuclei, variants: pleomorphic;

Front 46

Which stage of DIN has cribriform proliferation of uniform cells?

Back 46

DIN 1: low risk

Front 47

Which stage of DIN has comedo necrosis (completely occludes duct?

Back 47

DIN 3

Front 48

What is microinvasive CA? If you detect this, how is it managed?

Back 48

cluster of tumors cells break thru basement membrane, area <2mm; managed as DCIS;

Front 49

What % of DCIS has been found to have metastasized?

Back 49

3%

Front 50

What does microinvasive CA look like on micro?

Back 50

tongue-like invasion from duct; stroma frequently fibroblastic & myxoid.

Front 51

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?

Back 51

LIN

Front 52

How are LIN 1, 2, & 3 lesions differentiated?

Back 52

based on inc distention of acini to confluence of acini.

Front 53

At 50 years old, what is your risk of developing breast CA?

Back 53

50%

Front 54

What is the risk of developing breast CA in American women?

Back 54

1 in 8

Front 55

Breast cancer is the _____ cancer in women, and ______in cancer deaths in women.

Back 55

top, 2nd in most

Front 56

How have the incidence and mortality of breast CA changes in the past half century?

Back 56

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)

Front 57

What is the 5 yr survival in someone w/ stage 1 vs stage 4 breast ca?

Back 57

stage 1: 84%, Stage 4: 48%

Front 58

What % of breast CA's now are node negative at diagnosis?

Back 58

85%

Front 59

What % of breast CA are small, noninvasive lesions picked up my mammograms?

Back 59

65%

Front 60

Is the incidence of breast CA higher in white or black women? Prognosis?

Back 60

incidence higher in whites, prognosis worse in blacks

Front 61

Which countries have inc risk of breast ca: those in N America & N. Europe or those in Africa or Asia?

Back 61

N. America/N. Europe

Front 62

How do you define regional spread of breast cancer/

Back 62

to lymph nodes, chest wall, or skin

Front 63

What are the risk factors for breast ca?

Back 63

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

Front 64

should a woman w/ breast cancer diagnosis take OCPS?

Back 64

no b/c breast CA growth is promoted by estrogen

Front 65

Is a patient w/ benign breast dz at inc risk of getting breast CA?

Back 65

depends on type of dz; low risk w/ proliferative dz w/ no atypia; Significantly inc risk w/ proliferative dz w/ atypia.

Front 66

Pts w/ which gene mutation have 85% chance of developing CA by 70?

Back 66

BRCA1 mutation

Front 67

Pts w/ which gene have a worse breast CA prognosis?

Back 67

Her2/neu

Front 68

Which Breast CA gene is assoc w/ inc risk of ovarian CA?

Back 68

BRCA1

Front 69

Which 2 gene mutations are responsible for 80% of familial early onset causes of IDC, NOS?

Back 69

BRCA1 (chromosome 17q21) & BRCA2 (chrom 13q12-13)

Front 70

What is the most common type of infiltrating ductal CA?

Back 70

IDC, NOS

Front 71

What is the tx for infiltrating ductal CA?

Back 71

lumpectomy or simple mastectomy

Front 72

What is IDC w/ dermal lymphatic plugging by tumor emboli w/ LN mets?

Back 72

'inflammatory' CA

Front 73

When does infiltrating ductal CA have a nipple discharge?

Back 73

if its assoc w/ larger ducts

Front 74

What 3 things does the Scarff-Bloom-Richardson system measure?

Back 74

tubule formation, mitotic activity, nuclear pleomorphism

Front 75

What are the three grades of infiltrating ductal carcinoma accoding to the S-B-R system?

Back 75

3-5: well differentiated, grade 1; 6-7: moderately differtiated, grade 2; 8-9: poorly differentiated, grade 3.

Front 76

What age group gets infiltrative ductal CA vs intralobular CA?

Back 76

infiltrative: pre and post menopausal women;
intralobular: premenopausal women

Front 77

How does intralobular ca present?

Back 77

NOT as mass--usually incidental finding; Usually bilateral and multifocal!

Front 78

What % of intralobular CA develops into invasive cancer?

Back 78

25%. Controversy about amt of surgery, sometimes bilateral mastectomy for invasive

Front 79

Is invasive breast CA usually w/ pre or post menopausal women?

Back 79

Usually post

Front 80

Invasive breast cancer is usually of what type?

Back 80

infiltrative

Front 81

is premenopausal ca and those found in 20s and 30s usually aggressive?

Back 81

YES! usually aggressive, bilateral, assoc w/ fam hx of breast cancer

Front 82

Which types of breast CA have a better prognosis?

Back 82

mucinous, tubular, medullary are better compared to infiltrating lobular and ductal which have a similar tx & prognosis.

Front 83

What is Paget's dz?

Back 83

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;.

Front 84

What are the characteristics of male breast cancer/

Back 84

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

Front 85

What is a phyloddes utmor (aka giant fibroadenomas or cystosarcoma phyloddes)?

Back 85

-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;

Front 86

What is peau d'orange?

Back 86

as skin lymphaics are invaded, skin taken on characteristics dimpling similar to orange skin in appearance.

Front 87

What happens as the breast malignancy grows?

Back 87

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

Front 88

Which lymph nodes does breast CA drain into?

Back 88

axillary

Front 89

What are the most common places of breast CA mets?

Back 89

brain, bone marrow (but can go anywhere; painful to bone as its osteoblastic)

Front 90

Post mastectomy, where does breast CA commonly occur?

Back 90

scar site, can recur as much as 20 yrs post initial tx

Front 91

What are the 4 stages of breast CA?

Back 91

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

Front 92

Which breast CA pt has the best prognosis?

Back 92

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

Front 93

Which monoclonal Ab drug has been shown to slow growth of HER-2 positive tumors. It blocks HER-2 receptors and controls growth.

Back 93

Herceptin

Front 94

Does chemo inc breast CA pt survivial?

Back 94

yes, but if LN negative, reluctance to tx them w/ aggressive chemo-->should look at different prognostic factors

Front 95

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?

Back 95

HER-2 gene