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pathology f2014 > Breast pathology > Flashcards

Breast pathology Flashcards

1
Q

Galactocoele

A

Cystic dilatation of obstructed duct (during lactation)

  • Painful lump
  • May get infected-persistent induration
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2
Q

Common lesions/nodules

A
    1. Fibrocystic changes (FCC)
    1. Carcinoma
    1. Fibroadenoma
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3
Q

Fibrocystic change (FCC)

A
  • OCP protective against FCC

Pathogenesis

  • Exaggerated,distorted cyclical changes associated with hormonal changes of menstrual cycle
  • Pathology in both epithelium (proliferation) and stroma (fibrosis)

Types of FCC

  • Nonproliferative- Simple FCC: no epithelial hyperplasia:
  • Proliferative disease without atypia
    • – Sclerosing adenosis
    • – Florid benign hyperplasia – Radial scar
    • – Papilloma
  • Proliferative disease with atypia
    • Atypical Ductal hyperplasia (ADH)
    • Atypical Lobular hyperplasia (ALH)

Nonproliferative (simple FCC):

  • Gross: dilated cysts (blue domed); serous or turbid fluid
  • histo: large nuclei
  • Sx: lumpy breast -> no defined mass in premenopausal
  • Cysts and fibrosis; multifocal, bilateral
  • Apocrine metaplasia
  • Fibrosis of stroma
  • ± Lymphomononuclear infiltration
  • Duct Ectasia, adenosis, mild apocrine hyperplasia

Proliferative FCC

  • histo: epithelial hyperplasia
  • slits on periphery

Epithelial hyperplasia - ducts and ductules

  • Mild to severe, typical or atypical
  • Cribriform pattern
  • Duct papillomatosis - mild, moderate severe-may produce nipple discharge
  • presence of > 2 layers of myoepithelial cells can mimic ductal carcinoma in situe (DCIS) clinically and on imaging
  • Risk of Ca correlates with degree of
  • atypical hyperplasia
  • CLINICAL: like simple FCC + nipple discharge ± microcalcification on mammography.

Sclerosing adenosis (Proliferative)

  • lots of gland w fibrosis
  • Clinically and histologically mimics carcinoma -> proliferation of acini which are in swirly pattern (different from breast cancer)
  • back to back glands
  • Hard, rubbery mass
  • Dense fibrous stroma, mammography
  • may be positive for calcification
  • Masses of proliferated ducts and ductules, back to back arrangement
  • Look for double layer of cells (myoepithelial cells)
  • Very low risk of carcinoma
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4
Q

Duct Ectasia

aka Plasma cell mastitis, granulomatous mastitis

A
  • inspissated secretion, dilatation, rupture
  • inflammation, granular debris, leucocytes
  • foamy histocytes, lymphomononuclear cells
  • plasma cells and granulomas
  • produces induration, nipple retraction
  • mimics carcinoma clinically
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5
Q

Traumatic fat necrosis

A
  • Uncommon , may have history of trauma
  • Large pendulous breasts
  • Mimic carcinoma clinically
  • Fat necrosis, cholesterol clefts, neutrophils, lipid laden
  • macrophages
  • Later - lymphocytes, fibrosis, cysts ± **calcification **
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6
Q

Breast cancers

A
  • Fibroadenoma
  • Phylloides tumor
  • Intraduct papilloma and papillary Carcinoma
  • Carcinoma
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7
Q
A

Fibroadenoma

Microscopic image:

  • Left: Intracanicular showing elongated, compressed, distorted ducts
  • Right: Pericanicular showing oval ducts surrounded by stroma
  • Commonest benign tumor of breast (female); Tumor of stromal cells
  • ? Relation to excess estrogen, prepubertal and young women
  • If associated with FCC then called Fibroadenosis

Gross image: Loose edematous myxoid fibroblastic stroma +ductlike epithelial lined spaces

Clinically:

  • Single, discrete, mobile encapsulated nodule 1-10 cm, marble-like mass
  • Grow and painful during later part of menstrual cycle, pregnancy -> estrogen sensitive
  • most common benign tumour of breast - no malignant potential,
  • Regress: menopause
  • Risk of carcinoma is very low
  • Increased risk associated with cysts larger than 0.3cm, sclerosing adenosis, epithelial calcification and papillary apocrine change
  • Large lobulated popcorn calcification;still mobile and soft lesion (“mouse in the breast”)
  • Small clustered calcification on mammogram-require Bx to exclude CA
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8
Q
A

Phylloides tumour

aka Cystosarcoma Phylloides

  • *Gross image**
  • giant lobules (10 to 15 cm) cut surface slits and clefts-leaf like
  • *Histo:**
  • proliferation of stroma
  • hypercellular
  • leaf-like structures
  • *3 types:**
  • benign: zonal hypercellularity,mild atypia stromal cells, no stromal overgrowth, mitosis <5/HPF, pushing borders
  • borderline: zonal hypercellularity, moderate atypia stromal cells, no stromal overgrowth, mitosis 5-10/HPF, pushing borders
  • malignant: zonal hypercellularity, mod-marked atypia stromal cells, stromal overgrowth, mitosis >10/HPF, inflitrative borders
  • *Etiology**
  • 6 to 7th decade

Pathogenesis

If malignant (rare)

  • stroma
  • mitosis & anaplasia (sarcoma)
  • may recur
  • Metastasis (very rare) is through hematogenous, (not LN)
  • Infiltrate surrounding breast
  • Wide local excision without LN dissection 40
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9
Q
A

Intraductal papilloma

  • Arise in the lumen of a large duct, single, less than 1 cm
  • If multiple - recurrence, risk of cancer (Papillary Ca)

Microscopic

  • arrowheads: cuboidal epithelium
  • Delicate branching papillae in lumen
  • Fibrovascular core
  • Double layer of epithelial cells
  • No atypia or mitosis

Etiology:

  • premenopausal women

Sx:

  • torsion results in bleeding
  • bloody Nipple discharge, retraction (classic of papillary lesion)
  • Large Duct Papilloma: solitary, situated in lactiferous sinuses of nipple, bloody discharge
  • Small Duct Papillomas: multiple and located deeper within the ductal system
  • Clinical: small palpable masses, density or calcification on mammogram for both papillomas
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10
Q

Types of carcinoma

A
  • Duct (90%), lobular (10%) • Noninfiltrating (insitu)
    • Intraduct Carcinoma: (Comedo, Papillary,Paget’s)
    • Lobular Carcinoma In situ (LCIS)
  • Infiltrating Carcinoma
    • – Duct :(Scirrhous,Medullary, Colloid)
    • – Lobular
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11
Q

Breast carcinoma: general features

A

Breast carcinoma: general features

  • Mass w poorly defined borders
  • invasion of underlying muscular layer
  • absence of myoepithelium
  • Second most common malignancy in females (lung is commonest)
  • Accounts for 20% cancer deaths in females
  • Over 40 years
  • 25% postmenopausal

Risk factors

  • Genetic
    • familial, some autosomal
    • dominant,
    • ovarian Ca at early age
  • Early menarche, late menopause
  • More in nulliparous, if first child after 30 years age
  • Obesity, high fat diet (excess estrogens)
  • Estrogen therapy in postmenopausal?
  • P53-tumour suppressor gene- Li Fraumeni syndome
  • BRCA-1 gene–chr 17q21,1:800 females
  • BRCA-2 gene–chr 13q12,less common, early onset
  • FCC with atypical epithelial hyperplasia

Sx

  • Mass, induration, fixation to pectoralis, skin (nipple retraction and dimpling)
  • Lymphedema - skin thick around hairfollicles
  • Peaud’orange

Dx

  • FNAC, Needle biopsy, Lumpectomy
  • Recent trials- nipple aspiration, ductal lavage, random periareolar FNA
  • Core needle biopsy- vacuum assisted- stereotactic, advanced breast biopsy instrument(ABBI)
  • Site: Upper outer quadrant 50%

C&C

  • Metastasis: Lungs, bone, liver, adrenals
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12
Q

LCIS & DCIS

A

LCIS (10%):

  • no calcifications, no mass
  • no lumps due to lack/loss of caderins so more diffuse & dyscohesive

Ductal (90%): distended ducts

  • no breach of BM
  • calcifications present
  • more necrosis -> pain
  • B/L10-20%
  • Develop ca rate of 1% per year (low grade, untreated, small)
  • Death <2%

Types

  • comedo type
  • non-comedo types: cribiform (present image), solid, papillary, Micropapillary

Etiopath:
- HER2, Myc, BRCA1 & 2

Comedo carcinoma

  • Intraduct tumor (High grade DCIS)
  • Necrotic center: Cells inspissated material (squeeze out like toothpaste)
  • Less often ER, PR positive, Her2Neu positive
  • Higher recurrence rate
  • How many become invasive? Upto 60%
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13
Q

Infiltrating duct Ca NOS (not otherwise stated)

A
  • Commonest ( 75%)
  • Scirrhous - hard, dense
  • desmoplasia
  • Cords and nests of cells
  • 3-4 cm mass detected -> advanced tumours may result in dimpling of skin or retraction of nipple
  • Infiltrative edges
  • Necrosis, calcification
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14
Q

Colloid Carcinoma

A
  • Mucinous (>90% special type)
  • Rare (1-6%)
  • Intracellular and extracellular mucin: Nests of cells in seeds of Extracell mucin
  • Associated with solid/non- invasive papillary carcinoma
  • Very good prognosis
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15
Q

Medullary Carcinoma

A
  • Fleshy, soft: fish flesh apperance
  • Large sheets of large oval cells, little stroma
  • high grade carcinoma w Lymphocytic immune response
  • assoc w BRCA1 mutation
  • Better prognosis
  • Structure similar to dysgerminoma ovary, seminoma testis
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16
Q

Lobular carcinoma

A
  • Arise from terminal ductules (acini) -> presence of glands
  • Multicentric 20% bilateral (LCIS-20-40% B/L)
  • Two types- In situ, infiltrating
  • In situ: No mass, detected incidentally in FCC or mammography
  • Micro: Entire lobule distended - oval, noncohesive cells
  • No pleomorphism or mitosis
  • 30% cases exhibit invasive lobular or duct Ca, same side or opposite side.
17
Q

Infiltrating lobular carcinoma

A
  • Poorly outlined, induration, no distinct mass
  • Indian file( foot prints of Indians on the sand in a linear fashion) - single file of tumor cells, round, uniform
  • Bull’s eye pattern - tumor cells around normal acini and ducts
  • ± duct carcinoma (mixed pattern)
  • *Sx**
  • no calcifications
  • no lumping due to lack of E-cadherin

C&C:

  • ER/PR/Her2 triple -ve is worst prognosis
18
Q

Inflammatory carcinoma

A
  • Occasionally a carcinoma in pregnancy behaves very aggressively and clinically mimics an abscess
  • hot, tender, swollen- called inflammatory carcinoma; mimics acute mastitis clincally
  • bad prognosis -> presence of cancer in dermal lymphatics
19
Q
A

Paget’s disease of breast nipple

  • *Histo:**
  • hyperchromatic nuclei
  • clear cytoplasm
  • halos similar to Toker cells
  • underlying Intraduct carcinoma in large duct with spread to skin, areola, nipple
  • Eczema even without a palpable mass
  • Hyperemia, edema, fissuring, ulcer, oozing ± infection
  • *Etiology:**
  • ductal carcinoma in situ mechanisms
  • assoc w 50% underlying malignancy
  • 100% related to invasive carcinoma or ductal carcinoma
  • *Pathogenesis:**
  • ER/PR -ve

Sx

  • Palpable mass 50-60% cases- underlying invasive carcinoma- poorly diff, ER negative, overexpress Her2Neu
  • Prognosis of Paget’s disease – features of underlying carcinoma
  • Paget’s cells (? Toker cells in epithelium)- extend from DCIS via ductal system via lactiferous sinuses into nipple skin

pathology f2014 (17 decks)

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