Breast Disorders Flashcards
Structure of a terminal ductule-lobular unit
TDLU histology
Breast cysts
- Non-proliferative breast mass
- Common in women ages 30-50
- Round or ovoid in shape
Fibrocystic change
- Nonproliferative breast mass
- VERY common
- Cycic pain and nodularity with menstrual cycle
- Histology shown below
- Dilation of ducts and acini
- Dense stroma
Benign proliferative breast lesions without atypia
- Intraductal papilloma
- Fibroadenoma
- Usual ductal hyperplasia
Intraductal papilloma
- Benign proliferative breast lesion w/o atypia
- Usually found ~2 cm from nipple
- Assocaited with bloody or serous nipple discharge
- Histology shown below
- Proliferation of epithelial cells w/in the duct
- Fibrous stalk usually present
- Surgical excision recommended
Fibroadenoma
- Benign proliferative breast lesion w/o atypia
- Common in ages 15-35
- Well-defined, mobile mass
- Histology shown below
- VERY dense stroma
- Compressed ducts
- Well circumscribed by normal breast tissue
- May be observed or surgically excised
Usual ductal hyperplasia
- Benign prolfierative breast lesion without atypia
- Retain usual cytologic features of benign cells
- No treatment needed
Benign proliferative breast lesions with atypia
- Atypical ductal hyperplasia
- Atypical lobular hyperplasia
- Lobular carcinoma-in-situ
Atypical ductal hyperplasia
- Beingn proliferative breast lesion w/ atypia
- < 0.2 cm in size
- Takes up part of, but not the entirety, of the duct (unlike DCIS)
- Surgical excission recommended to prevent progression to DCIS (10% of cases)
Atypical lobular hyperplasia
- Benign proliferative breast lesion w/ atypia
- <50% of acini involved
- Slight breast distension
- Can be treated w/ observation since rate of progression is fairly low
Lobular carcinoma-in-situ
- Benign proliferative breast lesion w/ atypia
- Greater extent of disease than ALH w/ higher risk of progression
- Nuclear grade usually low
- Homogenous cells that are “discohesive” (loosely arranged)
Ductal carcinoma-in-situ
- Malignant breast lesion
- Cells fill the ducts without invading through the basement membrane
- May be low nuclear grade and homogeneous, or high nuclear grade and heterogeneous
- Cohesive, unlike the discohesive lobular carcinoma-in-situ
-
Comedo necrosis (shown below) is when there is a central necrotic core within the DCIS
- This increases risk of invasion and of recurrence
DCIS vs LCIS histology
A is DCIS, B is LCIS
DCIS is sometimes referred to as. . .
. . . “stage 0” breast cancer
Clinical diagnosis and management of DCIS
- Microcalcifications on mammogram are suggestive of DCIS
- Treatment is with surgical excision (lumpectomy)
- Frequent followup due to high risk of progression to invasive breast cancer
Major prognostication and treatment factors for invasive breast cancer
- Hormone receptor status
- Nuclear grade
- Her2/neu expression
HER2/neu and Estrogen receptor positive cancers have a ___ prognosis
HER2/neu and Estrogen receptor positive cancers have a good prognosis
We can treat them with targeted agents!
Lymphatics of the breast
Invasive ductal carcinoma
- Invasive malignancy
- 80% of breast cancers
- Often found with co-existing DCIS
- Presents as a solitary, firm mass with poorly defined margins
- Is often painless
Invasive ductal carcinoma susceptibility
75% of ductal carcinoma is ER+
Invasive lobular carcinoma
- Invasive breast cancer
- 15% of invasive breast cancers
- Forms “single file cords” on histology
Invasive lobular carcinoma susceptibility
>90% ER+
Types of invasive breast cancer
- Invasive ductal carcinoma
- Invasive lobular carcinoma
- Inflammatory breast cancer
- Paget disease of the nipple
Paget disease of the nipple
- Eczematous patch on the nipple
- Associated with underlying DCIS or invasive ductal carcinoma
- Intraepidermal proliferation of mammary-type epithelial cancer cells
Distinctive cell morphology in Paget disease of the nipple
Treatment of invasive breast cancer
-
Surgery:
- Lumpectomy vs Mastectomy
-
Adjuvant therapy:
- Radiation (for all, to reduce recurrence)
- Hormonal therapy for 5 years (all ER+ tumors)
- Chemotherapy (if high risk characteristics of tumor)
When is the best time to perform a breast exam?
The follicular phase of the menstrual cycle
This is because there will be less secretory tissue or fibrocystic change at this time
Sequence of evaluations of breast mass
- Breast exam and mammogram
- Ultrasound (if mammogram inconclusive)
- MRI (for women at extremely high risk of breast cancer, for example BRCA1 or 2 carriers)
Cyclic mastalgia
- Often involves luteal phase of the menstrual cycle
- Pain often in outer quadrants of the breast
Non-cyclic mastalgia
- May be associated with antihypertensives, antidepressants, or hormone use
- Potential causes:
- Iatrogenic
- Tumors
- Cysts
- Hx breast surgery
- Mastitis
- Idiopathic
Approach to mastalgia should first start by differentiating. . .
- Cyclic mastalgia
- Non-cyclic mastalgia
- Chest wall pain (extra-mammary)
Treatments for mastalgia
- Behavioral:
- Type fitting bra
- Weight reduction
- Regular exercise
- Pharmacologic
- Danazol (Androgen approved by FDA for treating cyclic mastalgia from fibrocystic change, but has significant side effects and should be second-line after behavioral therapy)
Approach to nipple discharge
- Spontaneous or expressed?
- Unilateral or bilateral?
- Uniductal or multiductal?
- Color?
- Associated mass?
Characteristics of benign nipple discharge
- Non-spontaneous
- Non-bloody
- Green, yellow, or brown
- Bilateral
Characteristics of malignant nipple discharge
- Bloody, unilateral discharge
- With associated mass
Patient presents with bloody, unilateral, uniductal breast discharge. No mass is palpable on exam. What is the next step in workup?
Ductography
Characteristics of a breast mass that suggest malignancy
- Size > 2 cm
- Immobility
- Poorly defined margins
- Firmness
- Overlying skin changes
- Retraction or changes in nipple
- Bloody nipple discharge
- Ipsilateral axillary lymphadenopathy
What do you do with a suspicious breast mass?
Core needle biopsy!!!
Overview of breast masses
Once you have your core needle biopsy of a breast mass, the next step is. . .
-
For nonproliferative and proliferative without atypia:
- Monitoring, no treatment
-
For proliferative with atypia (aka ADH, ALH, or LCIS):
- Surgical excision
- If confirmed non-invasive by surgery, close surveillence, lifestyle and diet change, and possibly chemoprevention w/ SERM
- If found to be invasive, chemotherapy and radiation
In a young patient, ___ is usually peferred to ___ as an imaging modality
In a young patient, ultrasound is usually peferred to mammography as an imaging modality
Since breast tissue tends to be firm and dense on mammography
Mammography in a breastfeeding woman
All of the breast milk can make imaging poorer quality!
Have them pump just prior to your imaging.
“Rubbery” breast mass
Buzzword for texture associated with fibroadenoma
Usually firm, nontender, rubbery masses, < 1 cm, that does not change with the menstrual cycle
A breast mass with benign features in a woman below age 25 is HIGHLY likely to be a fibroadenoma.
Confirm with FNA.
___ is preferred to ___ as a biopsy modality for breast masses in patients with a low risk of breast cancer
Fine needle aspirate is preferred to core needle biopsy as a biopsy modality for breast masses in patients with a low risk of breast cancer
Mammography schedule
Breast exams annually starting at age 40
Mammography annually starting at age 50 for no risk factors
Mammography annually starting at age 35 for FHx breast cancer
