Breast Benign Epithelial Lesions

Question 1

A wide variety of benign alterations in ducts and lobules are observed in the breast.

Most come
to clinical attention when detected by mammography or as incidental findings in surgical
specimens.

These lesions have been divided into three groups, according to the subsequent
risk of developing breast cancer:

Answer 1

(1) nonproliferative breast changes,

(2) proliferative breast
disease, and

(3) atypical hyperplasia.

Question 2

• This group includes a number of very common morphologic alterations that are often grouped under the term fibrocystic changes.
• To the clinician the term might mean “lumpy bumpy” breasts on palpation;
• to the radiologist, a dense breast with cysts;
• and to the pathologist, benign
• histologic findings.
• These lesions are termed nonproliferative to distinguish them from “proliferative” changes, which are associated with an increased risk of breast cancer.

Answer 2

NONPROLIFERATIVE BREAST CHANGES (FIBROCYSTIC CHANGES)

Question 3

There are three principal morphologic changes:

Answer 3

(1) cystic change, often with
apocrine metaplasia;

(2) fibrosis;
(3) adenosis.

Question 4

Small cysts form by the dilation and unfolding of lobules, and in turn may coalesce to form larger cysts.

Question 5

Unopened cysts contain_____________________

Answer 5

• turbid,
• semi-translucent fluid that produces a brown or blue color (blue-dome cysts)

Question 6

Cysts are lined
either by a _______________

Answer 6

a flattened atrophic epithelium or by metaplastic apocrine cells

Question 7

The cyst lined by metaplastic apocrine cells, which have an _________________ ( Fig. 23-7C ).

Answer 7

abundant granular, eosinophilic cytoplasm and round nuclei,
closely resemble the normal apocrine epithelium of sweat glands

Question 8

Calcifications are common and may be detected by mammography (see Fig. 23-7A ).
_______________ is a term mammographers use to describe calcifications that line the
bottom of a rounded cyst.

Answer 8

“Milk of calcium”

Question 9

Cysts are alarming when they are ______________to
palpation. The diagnosis is confirmed by the disappearance of the cyst after fineneedle
aspiration of its contents.

Answer 9

solitary and firm

Question 10

rCysts frequently rupture, releasing secretory material into the adjacent

stroma.

The resulting chronic inflammation and fibrosis contribute to the palpable
firmness of the breast

Answer 10

Fibrosis.

Question 11

_____________is defined as an increase in the number of acini per lobule.

Answer 11

Adenosis

Question 12

A normal physiologic adenosis occurs during_________.

Answer 12

pregnancy.

Question 13

In nonpregnant women,
adenosis can occur as a__________.

The **acini are often enlarged (blunt-duct

adenosis) , but are not distorted as is seen in sclerosing adenosis, described later.
* *Calcifications are occasionally present within the lumens.

The acini are lined by
columnar cells,whichmay appear benign or show atypical features (“flat epithelial
atypia”).

These lesions may be the earliest recognizable precursor of epithelial neoplasia.

Answer 13

focal change

Question 14

Lactational adenomas present as palpable masses in pregnant or lactating women.

They
are formed by normal-appearing breast tissue with physiologic adenosis and lactational
changes.

These lesions are probably not true neoplasms but an exaggerated focal response
to hormonal influences.

Question 15

_____________includes atypical ductal hyperplasia and atypical lobular
hyperplasia.

Atypical ductal hyperplasia is present in 5% to 17% of specimens from biopsies
performed for calcifications and is found less frequently in specimens from biopsies for
mammographic densities or palpable masses.

Occasionally, atypical ductal hyperplasia is
associated with radiologic calcifications; more commonly it is adjacent to another calcifying
lesion.

Atypical lobular hyperplasia is an incidental finding and is found in fewer than 5% of
specimens from biopsies performed for any reason.

Answer 15

Proliferative disease with atypia

Question 16

Morphology. _______________ is a cellular proliferation resembling carcinoma in situ but
lacking sufficient qualitative or quantitative features for diagnosis as carcinoma.

Unlike other
benign changes, atypical hyperplasias harbor some of the same acquired genetic losses and
gains that are present in carcinoma in situ.

Question 17

_________________ is recognized by its histologic resemblance to ductal carcinoma
in situ (DCIS)

. It consists of a relatively monomorphic proliferation of regularly spaced cells,
sometimes with cribriform spaces.

Answer 17

Atypical ductal hyperplasia

Question 18

How to distinguish DCIS from atypical hyperplasia?

Answer 18

It is distinguished from DCIS by being limited in extent and
only partially filling ducts ( Fig. 23-12A ).

Question 19

___________a is defined as a proliferation of cells identical to those of lobular
carcinoma in situ (LCIS,described later), but thecells do not fill or distend more than 50% of
the acini within a lobule ( Fig. 23-12B ).

Answer 19

Atypical lobular hyperplasia

Note : Atypical lobular hyperplasia can also involve
contiguous ducts through pagetoid spread, in which atypical lobular cells lie between the
ductal basement membrane and overlying normal ductal epithelial cells.

Question 20

CLINICAL SIGNIFICANCE OF BENIGN EPITHELIAL CHANGES

Answer 20

Multiple epidemiologic studies have classified benign histologic changes in the breast and
determined their association with the later development of invasive cancer [11] [12] [13] ( Table
23-1 ).

Question 21

_____________changes do not increase the risk of cancer.

Answer 21

Nonproliferative

Question 22

___________________ is associated with a mild increase in risk,

Answer 22

Proliferative disease

Question 23

while_________________ confers a
moderate increase in risk. Both breasts are at increased risk, although a few more subsequent
carcinomas occur in the same breast. [14]

Risk reduction can be achieved by bilateral
prophylactic mastectomy or treatment with estrogen antagonists, such as tamoxifen. [15]
However, more than 80% of women with atypical hyperplasia will not develop breast cancer, and
many choose careful clinical and radiologic surveillance over intervention.

Answer 23

proliferative disease with atypia

Question 24

Benign Epithelial Lesions

NONPROLIFERATIVE BREAST CHANGES (Fibrocystic
changes)

Answer 24

• Duct ectasia
• Cysts
• Apocrine change
• Mild hyperplasia
• Adenosis
• Fibroadenoma w/o complex features

Question 25

PROLIFERATIVE DISEASE WITHOUT ATYPIA 1.5 to 2.0 (5% to 7%)

Answer 25

• Moderate or florid hyperplasia
• Sclerosing adenosis
• Papilloma
• Complex sclerosing lesion (radial scar)
• Fibroadenoma with complex features

Question 26

PROLIFERATIVE DISEASE WITH ATYPIA 4.0 to 5.0 (13% to 17%)

Answer 26

Atypical ductal hyperplasia (ADH)
Atypical lobular hyperplasia (ALH)

Question 27

CARCINOMA IN SITU 8.0 to 10.0 (25% to 30%)

Answer 27

Lobular carcinoma in situ (LCIS)
Ductal carcinoma in situ (DCIS)