Breast Pathology (Cancerous)

Question 1

What are the risk factors for developing breast cancer?

Answer 1

Female, older age, early menarchy/late menopause, obesity, atypical hyperplasia, first degree relative with breast cancer (genetic). Generally associated with estrogen exposure.

Question 2

What is Ductal Carcinoma In Situ?

Answer 2

Malignant proliferation of cells in the ducts, it will be bounded by the basement membrane and will not invade it.

Question 3

What is “Paget’s disease of the nipple?”

Answer 3

DCIS that has walked its way up the duct and presents into the nipple.

Question 4

What is IDC?

Answer 4

Invasive ductal carcinoma, meaning that as opposed to DCIS where it is bounded by the basement membrane (hence “in situ”) IDC breached the basement membrane.

Question 5

What is Lobular Carcinoma In Situ LCIS and Invasive Lobular Carcinoma ILC?

Answer 5

Basically the malignant proliferation of the lobules, and if the proliferation is bounded by the basement membrane it is in situ (assuming full thickness of the entire cell from basement membrane to basement membrane) and if basement membrane is breached it is invasive LC.

Question 6

Malignant proliferation of cells in ducts, no mass detected, no invasion of basement membrane, but calcification seen in mammogram, what is the diagnosis? Why the calcification?

Answer 6

Ductal Carcinoma In Situ DCIS. Blood supply becomes inefficient to supply all the proliferating cells so cells in the center die and calcification occur on top of that (dystrophic calcification). This is detected in the mammogram.

Question 7

What kind of DCIS has high grade cells with necrosis and dystrophic calcification in the center of the ducts?

Answer 7

It’s called the “Camedo type” variant of DCIS.

Question 8

A woman presents with nipple ulcerations and erethema, what is the diagnosis and what should be feared?

Answer 8

Diagnosis is Paget’s disease of the nipple, this is always associated with an underlying carcinoma, because generally it is DCIS that progressed its way up the duct all the way up to the nipple.

Question 9

This disease classically forms duct-like structures, presents as mass detected in physical exam or mammography, and in late stages may present as dimpling of skin or retraction of the nipple. What’s the diagnosis?

Answer 9

Invasive Ductal carcinoma, which is the most common type of invasive carcinoma.

Question 10

What would a biopsy of invasive ductal carcinoma reveal?

Answer 10

Duct like structures and desmoplastic stroma (connective tumor that grows with and supports the tumor).

Question 11

What are the 4 subtypes of Invasive Ductal carcinoma?

Answer 11

Tubular, mucinous, medullary and inflammatory carcinoma.

Question 12

How would a tuburous invasive ductal carcinoma differ from normal breast tissue biopsy? Prognosis?

Answer 12

The tubules will look similar however they will not have the myoepithelial cells (thus will have only one layer) as well as the desmoplastic stroma. Very good prognosis.

Question 13

What is the key feature of the mucinous invasive carcinoma of the breast? Prognosis? Age distribution?

Answer 13

Malignant cells floating in a sea of mucous. Good prognosis and seen in elderly women.

Question 14

What is the key histologic feature of Inflammatory carcinoma? Prognosis?

Answer 14

Acute mastitis like presentation (very swollen and erethamatous breast) but wont resolve with ABX, biopsy will show the tumor within the dermal lymphatics. Blocks the lymphatics, messes with draining and causes the characteristic inflammation. Very poor prognosis.

Question 15

What is characteristic of Medullary carcinoma?

Answer 15

High grade malignant tumor cells with inflammatory cells in the background, (lymphocytes and plasma cells).

Question 16

What subtype of breast cancer is associated with BRCA 1 mutation?

Answer 16

Medullary carcinoma of the breasts.

Question 17

Can you find masses in LCIS?

Answer 17

No this is diagnosed incidentally. No mass or calcifications.

Question 18

What is the job of E-cadherin?

Answer 18

It’s somewhat of a glue that helps cells stick together.

Question 19

If biospy reveals dyscohesive lobular cells lacking E-cadherin that is often multifocal and bilateral, what should we suspect?

Answer 19

LCIS.

Question 20

What is our current understanding of LCIS? (In terms of Tx).

Answer 20

Not exactly a malignant proliferation but is a risk factor for it, tx-ed with tamoxifen (anti-estrogen) and close follow-up.

Question 21

How does ILC grow and how does this compare with compare with LCIS?

Answer 21

LCIS grows in a ductal pattern but ICS grows in a single file pattern, due to lack of E-cadherin.

Question 22

What is the most important staging tool for cancer and which is the most useful in terms of breast cancer?

Answer 22

Metastasis is most important in terms of determining prognosis, however axillary lymph node involvement is most useful because most do not present with metastasis.

Question 23

What is the idea of the “Sentinal lymph node biopsy?”

Answer 23

Radioactive dye is injected into the breast so that only the first tier of axillary lymph nodes light up and is removed, examined. If positive for cancer, the rest are also removed, but if negative the rest are left alone.

Question 24

What are the 3 most important factors in determining response to treatment?

Answer 24

ER, PR, and HER2 Neu mutations.

Question 25

What is the idea behind ER’s and PR’s?

Answer 25

Do the tumor have estrongen and progesterone receptors (and thus be responsive to anti progesterone and estrogen tx like Tamoxifen).

Question 26

What is the problem with the HER2 Neu gene mutation?

Answer 26

It is an gene amplification mutation where the cell expresses more HER2 Neu receptors, and this is a cell surface growth factor receptor. More HER2 Neu means more cell growth means increased chances of malignancy.

Question 27

How would we tx a patient who is HER2 Neu mutation positive for breast cancer?

Answer 27

Antibodies against the HER2 Neu receptors. I.E. Trastuzamab

Question 28

What is “Tripple Negative” carcinoma and who have this?

Answer 28

Negative for ER PR and HER2 Neu, very bad prognosis and african american women have this.

Question 29

What are three predictor of hereditary breast cancer, which accounts for 10% of all breast cancers?

Answer 29

First line family members with breast cancer, pre menopausal breast cancer, and multiple tumors.

Question 30

What are the two dominant gene mutations for hereditary breast cancers?

Answer 30

BRCA 1 and 2, single gene mutations.

Question 31

What is BRCA 1 associated with?

Answer 31

Breast carcinoma and ovarian carcinoma.

Question 32

What is BRCA 2 associated with?

Answer 32

Breast carcinoma in males.

Question 33

What are the features of male breast cancer?

Answer 33

Presents in the subaerolar region, in older males, very rare, usually IDC. Might produce nipple discharge.

Question 34

What are 2 genetic associations with male breast cancer?

Answer 34

BRCA 2 gene mutation and Klinefelter’s syndrome.