Breast

Question 1

Breast in embryologically derived from_____

Answer 1

The skin. It is a modified sweat gland

Question 2

Milk Line

Answer 2

Line from axilla to the vulva along which breast tissue can develop anywhere on that line

Question 3

2 layers of epithelium in Lobulues and Ducts

Answer 3

Luminal Cell layer - inncer cell layer, milk production in lobules
Myoepthelial Cell Layer - Outer cell layer, contractile to propel milk to nipple

Question 4

Indications that Breast tissue is hormone sensitive

Answer 4

1) After menarche see increase in estrogen and porgesterone and a corresponding increase in breast size and lobule formation
2) Breast are tender during menstrual cycle
3) During pregnancy undergo hyperplasia (E and P from corpus luteum, P from placenta, E from fetus and placenta workign together)
4) After menopasue breast tissue udnergoes atrohpy

Question 5

Breast tissue is highest in which quandrant

Answer 5

upper outer quandrant

Question 6

Galactorrhea

Answer 6

Milk production outside of lactation. Causes include nipple stimulation, prolactinoma of anterior pituitary, and drugs

Question 7

Acute Mastitis

Answer 7

Bacterial infection of breast (staphylococcus aureus). Gain entry to breast usually after breast feeding. Breast is erythematous and purulent nipple discharge (can eventually get abscess formation. Encourage to continue breast feeding to treat in addition to antibiotic (dicloxacillin)

Question 8

Periductal Mastitis

Answer 8

Inflamation of subareolar ducts. Usually seen in smokers since they get a Vitamin A deficiency that leads to squamous metaplasia of lactiferous ducts that can block and inflame the duct with their keratin.
See subareolar mass with nipple retraction

Question 9

Mammary Duct Ectasia

Answer 9

Inflammation with dilation (ectasia) of subareolar ducts. Presents as sub areolar mass with GREEN BROWN NIPPLE DISCHARGE. Plasma cells on biopsy. See in multiparous, postmenopausal women

Question 10

Fat Necrosis of Breast

Answer 10

Mass on physical exam or abnormal calcifications on mammography. Necrosis usually occurs due to trauma to the fat

Question 11

Fibrocystic Change
(Fibrosis, cysts, apocrine metaplasia)
Ductal hyperplasia
Sclerosing Adneosis
Atypical hyperplasia

Answer 11

Development of fibrosis and cysts in the breast and is hormone mediated.
Presents as vague irregularity of the breast tissue (lumpy breast)
Cysts have a blue-dome like appearance on gross exam.
Benign but some are related to increased risk for invasive carcinoma in both breasts
Fibrosis, cysts, apocrine metaplasia - no increased risk
Ductal hyperplasia, Sclerosing Adneosis - 2 x risk
Atypical hyperplasia - 5 x risk

Question 12

Intraductal Papillmoa (papilloma vs papillary carcinoma)

Answer 12

Papillary growth usually into a large duct. Characterized by by fibrovascular projection into duct. Classically presents as bloody nipple discharge.
Papilloma - fibrovascular projection lined by both epithelial and myoepthelial cells.
Papillary carcinoma - projection covered by ONLY epithelial cells, NO myoepithelial

Question 13

Fibroadenoma

Answer 13

Tumor of fibrous tissue and glands. Most common benign neoplasm seen in premenopausal women. Well circumscribed, mobile, marble like mass that is estrogen senstive. No increased risk of carcinoma

Question 14

Phyllodes Tumor

Answer 14

Fibroadenoma like tumor with overgrowth of the fibrous component, LEAF LIKE projections on biopsy. Seen in postmenopausal typically and some can be malignant

Question 15

Risks for breast cancer

Answer 15

Female
Old age
Early menarche/late menopause/lack of pregnancy
Obesity
Atypical Hyperplase (usually driven by excess estrogen)
Hereditary (1st degree relatives with breast cancer = mother, sister, daughter)

Question 16

Ductal Carcinoma in Situ (comedo type)

Answer 16

Malignant proliferation of cells in ducts with no invasion of basement membrane. Often detected as calcification in mammography (no mass). Need to biopsy since fat necrosis and fibrocystic changes can also display calcification. If it extends up the duct to involve the skin get paget disease (nipple ulceration and erythema)
Comedo type = high grade cells with necrosis and dystrophic calcification in center of ducts (since lack vasculature)

Question 17

Paget Disease

Answer 17

Sign of DCIS> See nipple ulceration and erythema

Question 18

Invasive Ductal Carcinoma

Answer 18

Invasive carcinoma that classically forms duct like structures. Most common breast cancer. Presents as 2cm mass or 1cm calcification. Advanced tumor can cause dimpling of the skin or retraction of the nipple.
includes the subtypes: tubular carcinoma, mucinous carcinoma, medullary carcinoma and inflammatroy carcinoma

Question 19

Tubular Carcinoma.

Answer 19

IDC characterized by well differentiated tubules that lack myoepithelial cells. Good prognosis

Question 20

Mucinous Carcinoma

Answer 20

IDC characterized by abundant extracellular mucin (tumor cells float in mucous pool) good prognosis and occurs in old women (70)

Question 21

Medullary Carcinoma

Answer 21

IDC characterized by large, high grade cells growing in sheets with associated lymphocytes and plasma cells. Well circumscribed mass that can mimic fibroadenoma. Higher incidence in BRCA1. Good prognosis

Question 22

Inflammatory Carcinoma

Answer 22

IDC characterized by carcinoma in dermal lymphatics. Presents as inflammed swollen breast with no discrete mass. Often mistaken for acute mastitis but doesnt improve with antibiotics or breast feeding. Poor prognosis

Question 23

Lobular Carcinoma in Situ

Answer 23

Malignant proliferation of cells in lobules with no invasion of the basement membrane. No mass or calcifications so incidentally found on biopsy. See dyscohesive cells since they lack E-cadherin to bind them together. Often multifocal and bilateral. Treat with tamoxifen to reduce risk of subsequent cancer but low chance of developing into ILC

Question 24

Invasive Lobular Carcinoma

Answer 24

Invasive carcinoma that typically grows in single-file pattern (dont form ducts because they lack e-cadherin to hold them together.

Question 25

Prognostic Factors for Breast cancer

Answer 25

TNM
Metastasis is most important prognostic. Mets mean bad prognosis but most people dont presents with mets
N= nodes = spread to axillary lymph nodes is most useful prognostic factor (do sentinel lymph node biopsy)

Question 26

Predictive Factors for Treatment

Answer 26

Estrogen Receptor (ER) and Progesterone Receptor (PR) and HER2/neu gene amplification (overexpression) status
ER and PR positive then treat with tamoxifen/antiestrogenic agents. Both receptors are located in the nucleus
HER2/neu amplification then treat with trastuzumab (antibody to HER2 receptor on cell surface)

Question 27

Triple Negative Cancers

Answer 27

Negative for ER, PR, and HER2/neu have poor prognosis. More common if African American women

Question 28

Hereditary Breast Cancer

Answer 28

BRCA1 = increased risk for breast (medullary carcinoma) and ovarian (serous carcinoma of ovary and fallopian tube) carcinomas
BRCA2 = increased risk for breast cancer for males.
Can choose to do a bilateraly mastectomy but this only decreases risk not make it zero since breast tissue can hide axilla or subcutaneous tissue of chest wall

Question 29

Male breast cancer

Answer 29

Very rare but presents as subareolar mass with nipple discharge. Most common is invasive ductal carcinoma
BRCA2 and Klinefelter (XXY) at increased risk