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Breast-Gao > Breast-Gao > Flashcards

Breast-Gao Flashcards

1
Q

Good prognosis subtypes of breast ca

A 
Colloid/mucinous
Papilary
Tubular
Medullary
Cribiform
Adenoid cystic
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2
Q

Lesions with similar relative risk of developing invasive carcinoma

A

Papilloma
Radial scar
Florid hyperplasia
Sclerosing adenosis

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3
Q

PASH is produced by what cell type?

A

myofibrofblasts

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4
Q

PASH cells lining slit like spaces IHC …

A 
vimentin
actin
ER
CD34
negative for CD31
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5
Q

Independent prognostic factors for breast cancer

A

grade
lymph node status
LVI
tumor size

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6
Q

Molecular phenotype classification of breast cancer

A

Luminal A
Luminal B
ERBB2
Basal like

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7
Q

After excision, adjuvant treatment decisions for breast cancer are based on…

A

tumor size
MBR grade
ERBB2
LVI

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8
Q

pN1 definition

A
  1. 1 node positive for macromets, 2 nodes positive for miromets, 1 node positive for ITC
  2. 2 nodes positive for micromets, 1 node positive for ITC
  3. 1 node positive for macromets, 1 node positive for micromets, 1 node positive for ITC
  4. 1 internal mammary sentinel lymph node with a micromet and negative axillary lymph nodes
  5. 3 nodes positive for macromets, 1 node positive for ITC
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9
Q

myoepithelial markers of breast, list 4

A

SMMHC
Calponin
p63
actin

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10
Q

most helpful IHC to distinguish between florid ductal hyperplasia of the usual type and atypical ductal hyperplasia (ADH)

A

CK5/6

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11
Q

excisional biopsy suggested for florid ductal hyperplasia?

A

NO

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12
Q

excisional biopsy suggested for….

A

intraductal papilloma
mucocele like lesion
lobular carcinoma in situ
flat epithelial atypia with ADH

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13
Q

which feature does NOT help distinguish between benign from malignant phyllodes

A

leaflike structures

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14
Q

benign vs malignant phyllodes features

A

heterologous elements
mitoses
margins
cellularity

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15
Q

breast fibromatosis

A

proliferation of myofibroblastic cells
positive for beta catenin
a/w trauma
a/w gardner syndrome

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16
Q

does fibromatosis consistently respond to hormonal therapy

A

NO

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17
Q

IHC for granular cell tumors

A 
neuron specific enolase
vimentin
S100
CEA
negative for ER
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18
Q

paget disease cells positive for…

A 
EMA
CEA
CK
CAM5.2
HER2
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19
Q

FEA is independently most a/w increased incidence of which lesion

A

ADH

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20
Q

low grade dcis is more positive for ____ than high grade dcis

A

ER
PR
Cyclin D1
near diploidy

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21
Q

which clinical presentation is most a/w breast carcinoma

A

palpable mass

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22
Q

which breast lesions have NO increased relative risk of developing breast carcinoma

A

apocrine cysts
duct ectasis
mild hyperplasia
adenosis

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23
Q

risk factors for breast carcinoma

A

breast density
ethnicity
hormone replacement therapy
alcohol consumption

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24
Q

are breast implants a/w breast carcinoma

A

NO

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25
Q

name of postmastectomy angiosarcomas

A

Stewart-Treves

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26
Q

biomarker profile for BRCA1 associated breast cancers

A

ER neg, PR neg, Her2 neg, CK5/6 pos

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27
Q

Histologic features of diabetic mastopathy

A

keloidal like stromal fibrosis
lymphocytic ductitis
lymphocytic lobulitis
lymphocytic vasculitis

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28
Q

what favours dx of ADH over DCIS

A

Overlapping nuclei= ADH

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29
Q

the most concern in interpreting ER/PR IHC

A

no staining in an invasive lobular carcinoma

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30
Q

Extensive Intraductal Carcinoma positive (EIC+) is defined as:

A

DCIS present involving at least 25% of the area of the invasive carcinoma AND extending outside the invasive carcinoma mass

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31
Q

Toker cell IHC

A

CK7 positive
Her2 positive
CD138 negative

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32
Q

better prognosis for patients with IDC NOS

A

high percentage of tubule formation (>75%)

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33
Q

Definition of isolated tumor cells

A

single cluster of tumor cells - 0.2 mm or - 200 cells

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34
Q

clinical response to herceptin has been shown in trials with cutoff ERBB2/CEP17 ratios as low as:

A

2.0

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35
Q

Classify stromal tumors of the breast

A

Biphasic tumors:

  • fibroadenoma
  • phyllodes
  • periductal stromal tumor

Pure stromal tumors: according to tissue of origin

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36
Q

Benign stromal tumors of breast

A
  • benign stromal spinde cell tumors (BSCT)
  • PASH
  • nodular fasciitis
  • fibromatosis
  • lipoma, spindle cell lipoma
- leiomyoma
neural:
- granular cell tumor
- neurofibroma
- schwannoma

vascular:
- angioma, angiomatosis

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37
Q

Benign stromal spindle cell tumors subtypes

A

BSCT with predominant myofibroblastic differentiation: myofibroblastoma

BSCT with predominant fibroblastic differentiation: solitary fibrous tumor/ hemangiopericytoma

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38
Q

Malignant stromal tumors of breast

A
  • malignant stromal cell tumor with predominant myofibroblastic differentiation
  • malignant stromal cell tumor with predominant fibroblastic differentiation
  • liposarcoma
  • leiomyosarcoma
  • angiosarcomas: primary, postrads, post radical mastectomy
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39
Q

5 features of sclerosing adenosis that distinguish it from tubular carcinoma

A
  1. lobulated clustered arrangement- retention of the lobular architecture vs. haphazard distribution of tubules
  2. compressed and distorted tubular lumens- vs. open angulated tubules
  3. fibrous stroma compressing tubules- vs. desmoplastic stroma
  4. tubules lined by 2 layers of cells (luminal epithelial and outer myoepithelial)
  5. tubules invested by basement membrane - PAS highlights
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40
Q

Features of microglandular adenosis

A
  • haphazard proliferation of small round tubules
  • tubules have open lumens
  • tubules lined by single layer of epithelial cells- absent myoepithelial cell layer
  • lumen contains colloid-like secretory material
  • dense fibrous stroma
  • multilayered basement membrane on EM
  • epithelial cells are positive for S100 and cytokeratins
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41
Q

Classify benign prolfierative lesions of the breast

A
  1. Proliferative disease without atypia

2. Proliferative disease with atypia

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42
Q

Classify proliferative disease without atypia

A
  1. Moderate to florid hyperplasia
  2. Sclerosing adenosis
  3. Papilloma
  4. Complex sclerosing lesion
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43
Q

Relative risk of developing carcinoma in proliferative disease without atypia

A

1.5- 2 % (5-7% lifetime risk)

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44
Q

Classify proliferative disease with atypia

A
  1. atypical ductal hyperplasia

2. atypical lobular hyperplasia

45
Q

Relative risk of developing carcinoma in proliferative disease with atypia

A

4 - 5 (13-17% lifetime risk)

46
Q

What malignant lesions can mimic collagenous/mucinous spherulosis?

A
  1. Adenoid cystic carcinoma

2. Signet ring cell carcinoma

47
Q

2 clinical features of nipple adenoma

A
  1. nippe discharge

2. swelling of the nipple +/- erosion

48
Q

4 histologic features of nipple adenoma

A
  1. well circumscribed
  2. haphazardly arranged, proliferating tubular structures
  3. 2 cell types lining these tubules
  4. varying degrees of epithelial hyperplasia
  5. fibrous stroma
49
Q

Risk factors of breast cancer

A
  • female
  • age- peak 75-80yo
  • age at first live birth (nulliparous or >35 at first birth)
  • age at menarche/menopause- younger than 11 and later menopause
  • breast feeding DECREASES RISK
  • carcinoma of the contralateral breast
  • estrogen exposure
  • FDR with breast cancer
  • alcohol
  • history of atypical hyperplasia in previous biopsies
  • race/ ethnicity: nonhispanic whites > african americans > asian/pacific islanders > hispanics
  • radiation exposure
50
Q

GENETIC risk factors

A 
BRCA1
BRCA2
CHEK2
Li Fraumeni
Cowden syndrome- PTEN
51
Q

QA/QC: a mammotome biopsy for calcifications does not show any calcifications in the sections. What are your next steps…

A
  1. check the accompanying specimen radiographs for calcifications
  2. use polarized light to detect calcium oxalate crystals
  3. cut deeper levels X3
  4. if calcifications are still not seen, take XRs of the block
  5. if the XRs show calcs, cut the block at the level of the calcifications
    - the Xrays do not show calcifications, have the specimen radiographs and block XRs reviewed by radiology to confirm the presence or absence of calcifications in the respective images
    - if the specimen radiograph has confirmed calcifications, but the slide sections and block Xrs do not, then report as calcifications not seen in slide sections or block XRs. Calcifications may have fallen out during block trimming
52
Q

a breast lumpectomy specimen suspicious for malignancy is received in the lab. you cannot feel the mass. how do you handle the specimen?

A
  • check if patient identification is correct (at least 2 identifiers should match)
  • check if the correct side of the breast was operated on
  • look up the pertinent imaging modality for the size and location of the mass
  • if you still cannot identify the mass, have a specimen radiograph done to localize any abnormalities for sectioning
  • if you still cannot identify the lesion, take random samples of the 4 quadrants and map them. focus sections on the area in the breast where the abnormality was initially suspected
  • if any of the samples are positive histologically, go back and take more samples from that specific quadrant
  • if none of the samples are positive, submit the entire specimen serially, or after mapping it
53
Q

gross characteristics of phyllodes

A
  • well circumscribed and firm

- cut surface: gray-white, solid with cystic areas, with fleshy leaflike processes that protrude into the cystic spaces

54
Q

histo features of phyllodes

A
  • stromal hypercellularity - pronounced in the periductal areas
  • benign glandular/epithelial elements, projecting into cystic spaces as leaflike processes
55
Q

list 5 histo features that help differentiate benign and malignant phyllodes

A
  1. increased mitotic activity- seen in an area away from the ductts, 5/10 hpf indicates borderline malignancy (in the absence of any worrisome features listen below, 10/10 hpf is significant)
    - marked atypia of the stromal cells
    - stromal overgrowth– absence of epithelial elements at least 1 low power (X4) field
    - an infiltrating margin- versus a pushing margin
    - tumor necrosis (and hemorrhage)
    - malignant heterologous elements present even in the absence of other criteria
56
Q

how to differentiate phyllodes tumor from a fibroadenoma

A

most helpful feature= cellular hyperplastic spindle cell stroma

leaf like processes– note that these alone in the absence of a hypercellular stroma DO NOT qualify the lesion as a phyllodes tumor

57
Q

recommended treatment for phyllodes

A

local excision with a wide margin (at least 1 cm) of normal tissue (presence of tumor at the resection margin is a major determinant of local recurrence)

58
Q

how would you word your diagnosis in a core needle biopsy/FNA cytology where you cannot differentiate a cellular fibroadenoma from a benign phyllodes tumor

A

Wording: biphasic tumor, with stromal and epithelial elements.
- as the stromal cellularity can be variable within a tumor and the margins cannot be assessed, the differential between a fibroadenoma and a benign phyllodes tumor would be deffered to the resection specimen (a malignant phyllodes tumor can be diagnosed on a core needle biopsy)

OR

Wording: fibroepithelial lesion with increased stromal cellularity. Recommend excision for further evaluation of the lesion.

59
Q

how would you differentiate a malignant phyllodes tumor from a sarcomatoid (metaplastic) carcinoma?

A

IHC: stromal cells are negative for epithelial markers like AE1/AE3 and CAM 5.2, and positive for CD 34 and Bcl2 in a phyllodes

60
Q

What other mesenchymal elements/metaplasias can be found in a phyllodes?

A

adipose, osseous, chondroid, smooth muscle, rhabdomyoblastic. Any of these can show a malignant component (presence of stromal elements other than fibromyxoid indicate a worse prognosis)

61
Q

histologic features of a radial scar

A
  • stellate configuration (flower head)
  • central elastosis and fibrosis
  • entrapped distorted ductules in the central scar
  • dilated ductules at the periphery with various patterns of epithelial hyperplasia
  • tubules lined by 2 layers of cells (luminal epithelial and outer myoepithelial)
62
Q

clinical significance of radical scar

A
  • benign mimic of cancer
  • some authors believe most tubular carcinomas arise from radial scars, particularly if the radial scar is > 1 cm
  • the RR of subsequent breast carcinoma is twice that of normal
  • for most clinicians, the finding of a radical scar on a core biopsy is an indication for excision
63
Q

Usual ductal hyperplasia features

A

Architectural:

  • peripheral elongated clefts
  • intratubular lumina, irregular in size, shape and location
  • streaming (cells arranged in parallel bundles)
  • tufts and mounds projecting into the lumen
  • irregularly shaped/twisted bridges (long axis of nuclei are parallel to the long axis of the bridge)

Cellular:

  • 2 cell types (epithelial and myoepithelial)
  • nuclei oval, monochromatic, overlapping with indistinct nucleoli
  • indistinct cell borders, nuclei seem to lie in a syncytial mass
  • apocrine metaplasia, foamy macrophages common
  • absence of necrosis
64
Q

epithelial hyperplasia features

A

intratubular lumens: irregular, slit like, mainly peripheral
streaming: present
bridges: long axis of nuclei parallel to the bridge
cell types: polymorphous (epithelial and myoepithelial)
cell margin: indistinct
nucleus: overlapping monochromatic nuclei with indistinct nucleoli
apocrine metaplasia: can be focally present
necrosis: absent

65
Q

low grade DCIS features

A

intratubular lumens: regular, rounded, rigid
streaming: absent
bridges: roman arches - long axis of nuclei perpendicular to the bridge
cell types: monotonous (only epithelial cells)
cell margin: well defined
nucleus: evenly spaced nuclei with or without obviously malignant features (atypia, hyperchromasia, prominent nucleoli)
apocrine metaplasia: absent
necrosis: present/absent

66
Q

UDH vs. ADH immunostains

A

HMWCK: positive in UDH, negative in ADH
ER: patchy in UDH, diffuse in ADH

67
Q

3 benign breast conditions whose histology is commonly confused with that of invasive breast carcinoma

A
  • complex sclerosing lesion- radial scar
  • sclerosing adenosis
  • microglandular adenosis
68
Q

list 6 histologic subtypes of DCIS

A 
solid 
cribiform
papillary
micropapillary
comedo
clinging
69
Q

what histologic features should be included in a report of DCIS

A

nuclear grade: I, II, III
necrosis: absent-I, punctate-II, comedo-III
pattern: cribiform, solid, micropapillary, papillary, comedo
size of largest focus (cm)
microinvasion: present/absent
distance to resection margins or involvement of resection margin(s) and extent of involvement
calcification: intraluminal, stromal, in benign breast tissue

70
Q

low grade DCIS

A

well defined cell membranes
uniform nuclear and cell size and shape
rare mitosis
punched out appearance of lumen with polarization of cells around
aracdes and bridges uniform in thickness with rigid contours
necrosis unusual but possible
calcifications frequent

71
Q

intermediate grade DCIS

A

cells do not fulfill criteria of either low grade or high grade
some intermediate grade lesions grow in patterns mimicking UDH (irregular architecture, streaming)

72
Q

high grade DCIS

A

cells with large pleomorphic nuclei
coarse chromatin
prominent nucleoli
frequent mitosis
frequent central comedo necrosis (necrosis can be so extensive that only 1 layer of atypical cells is left at periphery of duct: clinging DCIS)
demosplasia and angiogenesis can be seen in stroma

73
Q

reporting elements for DCIS in CAP

A
  • procedure
  • lymph node sampling
  • specimen laterality
  • tumor site (optional)
  • size (extent) of DCIS
  • histologic type
  • architectural patterns- optional
  • nuclear grade
  • necrosis
  • margins
  • treatment effect– response to presurgical therapy
  • lymph nodes– required only if lymph nodes are present in the specimen
  • pathologic staging, pTNM
  • additional pathologic findings- optional
  • ancillary studies- optional
  • microcalcifications- optional
  • clinical history- optional
  • comment- optional
74
Q

goals of specimen sampling in DCIS

A
  • clinical or radiologic lesion for which the surgery was performed must be examined microscopically
  • if DCIS, LCIS or atypical hyperplasia is identified, all fibrous tissue should be examined
  • all other gross lesions noted in the specimen must be sampled
75
Q

how should resection margins be reported in DCIS?

A

if margins are samples with perpendicular sections, the pathologist should report the distance from the DCIS to the closest margin, when possible
The color of ink of any margin that is positive should be documented
If DCIS present at the margin, the extent of margin involvement should be reported:
- Focal (DCIS at margin in a <1mm area in 1 block)
- minimal/moderate (between focal and extensive)
- extensive (DCIS at the margin in an area >/- 15mm or in 5 or more low power fields and/or in 8 or more blocks)

76
Q

clinical importance of finding ITC’s in lymph node in patients with DCIS

A

NO prognostic importance, since almost all tumor cells present in lymph nodes of patients with DCIS are isolated tumor cells or the cells may be artifactually displaced from a previous procedure

77
Q

Lymph node met found in a patient with DCIS… now what….?

A

if a larger met is found, additional tissue sampling and review of slides is helpful to determine if an area of invasion is present

78
Q

how should axillary nodes be examined…

A
  • grossly involved nodes, which may have 1 or more sections submitted for microscopic evaluation
  • all other nodes (should be thinly sectioned and entirely submitted for microscopic evaluation)
  • a single H&E from each lymph node block is considered sufficient for routine evaluation
79
Q

how to report axillary nodes

A
  • total number of lymph nodes examined, including sentinel lymph nodes
  • the number of nodes with mets– only nodes with micro and macromets are included for the total number of involved nodes for N classification. NOT ITC’s
  • greatest dimension of largest metastatic focus
  • presence of ENE, because it may be a/w higher frequency of axillary recurrence
80
Q

list six types of invasive ductal carcinoma

A 
tubular
mucinous
medullary
invasive papillary
apocrine
metaplastic
81
Q

prognostic factors that assess outcome at time of diagnosis….

A 
distant mets
axillary node mets
size of primary tumor
skin invasion/inflammatory carcinoma
tumor grade
LVI
histo subtype
82
Q

prognostic factors that assess likelihood to respond to a given therapy

A

ER/PR/ERBB2

83
Q

subtypes of invasive breast carcinoma that indicate a better prognosis than IDC NOS

A 
colloid/mucinous
papillary
tubular
medullary
cribiform
adenoid cystic
84
Q

sentinel node negative on FS and positive on permanent section…. what to do….

A
  • document in final report that the sentinel LN is positive on permanent section, and comment on whether it was a sampling issue (not present in frozen) or an interpretive issue (ITCs, or difficult to identify subtype) as the reason for reporting the frozen section as negative.
    Make sure the pathologist who has reported the frozen section is aware of the discrepancy
85
Q

if a sentinel node is reported as positive, what is the expected treatment….

A

ALND for macromets (>2mm) historically
Currently– axillary radiation = acceptable alternative, with no role for further treatment.
Treatment varies by institution, surgeon and patient factors.
For micromets treatment varies with institution policy, surgeon decision and patient factors.
ITCs in sentinel node= NODE NEGATIVE= no need for ALND

86
Q

what to report in a positive lymph node…

A

number of nodes / TOTAL
size of deposit
extracapsular extension
histologic subtype of met and whether it resembles the identified primary tumor

87
Q

Luminal type

A

ER positive, HER2 negative

88
Q

Luminal A

A

low proliferation

89
Q

Luminal B

A

high proliferation

90
Q

some luminal B

A

ERBB2 positive

91
Q

Basal like

A

ER negative, ERBB2 negative

92
Q

prognosis of luminal A

A

good

93
Q

prognosis of luminal B

A

not as good

94
Q

prognosis of ERBB2 positive

A

poor

95
Q

prognosis of basal like

A

poor (except medullary carcinoma)

96
Q

features of BRCA1 breast carcinomas

A 
poorly differentiated
syncytial growth pattern
pushing margins
prominent stromal lymphocytic response
ER/PR negative
ERBB2 negative
high Ki67
high mitotic count
CK 5/6 positive
EGFR positive
97
Q

what % of tumors with BRCA1 are medullary….

A

13%

98
Q

ALH

A

acini: not distended or distorted
lumen: present
pagetoid spread: absent
lobular involvement: partial involvement of the acini within a TDLU
cell composition: variable cell types

99
Q

LCIS

A

acini: distended and distorted
lumen: absent
pagetoid spread: along terminal ducts
lobular involvement:
- more than half of the acini within a TDLU
- more than 1 TDLU involved
- enlarged acini may show confluence, with little intervening stroma (macroacini)
cell composition: monotonous cells

100
Q

histologic types/patterns of LCIS

A 
classic
pleomorphic
necrotic
signet ring cell type
macroacinar (forms a mass)
101
Q

implications of LCIS

A

some 20-30% patients develop invasive carcinoma (diagnosis on core needle biopsy), after long term follow up of 30 years

  • this increased risk applies to both breasts (slightly larger on the side of the biopsy)
  • the invasive carcinoma can be either ductal or lobular type
  • the RR increases from 4.9 after 1 biopsy to 16.1 after a second biopsy shows LCIS
102
Q

WHO implications of LCIS

A

if classical on core:

  • close, long term follow up
  • excision when pathologic-radiologic discordance

if pleomorphic LCIS of classical LCIS with comedo necrosis or bulky mass forming LCIS
- excision with negative margin or mastectomy

103
Q

clinical mgmt of LCIS

A
  • LCIS at margins is not reported nor an indication for reexcision (WHO). patient requires lifelong follow up with or without tamoxifen
  • reexcision is recommended for LCIS of the following subtypes or with following features: pleomorphic, necrotic, pure signet-ring cell, solid duct involvement, presence of comedo necrosis, and macroacinar variant
  • reexcision can be considered in cases of strong family history, patient apprehension and where prolonged follow up cannot be ensured
  • reexcision is recommended if LCIS does not account for mammographic abnormality or if something else was found that is usually excised (ADH)
104
Q

2 architectural features of classic ILC

A
  • single file pattern

- targetoid pattern– neoplastic cells invade the stroma of residual ducts in concentric fashion

105
Q

3 cytological features of classic ILC

A
  • small uniform cells with bland nuclei
  • lack of cohesiveness
  • presence of intracellular mucin
106
Q

what are the histological variants of ILC

A
  • classic
  • alveolar
  • tubulolobular
  • mixed
  • solid
107
Q

what are the cytologic variants of ILC

A 
pleomorphic
signet ring
histiocytoid
apocrine
myoepithelial
mixed
108
Q

name 2 associated genetic abnormalities of ILC

A

LOH on 16q- site of E-cadherin and beta-catenin genes

LOH at 11q13

Breast-Gao (1 decks)

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