Breast Pathology Dobson LO's Flashcards
1
Q
What is poland syndrome a result of?
A
Loss of pectoralis muscles
2
Q
What arteries supply breast and what lymph nodes drain it?
A
- Lateral thoracic and internal thoracic which give off mammary arteries
- Drains mostly to the axillary lymph nodes and some to internal mammary lymph nodes
3
Q
Clinical significance of milk line remnants, accessory breast tissue and inverted nipples?
A
- Milk line remnants can result in supranumery nipples
- accessory breast tissue is usually in axilla and can pose a risk for breast cancer
- Congenital inverted nipples are benign and can evert on own, but acquired inverted nipples are omnious as it is usually caused by cancer or inflammatory disesase
4
Q
Common presenting symptoms of breast disease and clinical correlations to benign and malignant conditions.
A
- Increased bumpiness, pain, nipple discharge, and inflammed breast are common complaints
- Majority of symptomatic breast lesions are benign
- soft round rubbery moveable mass, cysts & fibroadenomas are common palpable masses
- Malignant: hard irregular immobile, most common palpable is invasive ductal carcinoma, 10% of breast cancers present with pain, 45% with sx
- upper outer quadrant
- bloody discharge suspect cancer
5
Q
Describe malignant mammogram features.
A
- Irregularly shaped densities
- Small irregular numerous and clustered calcifications
6
Q
Benign mammogram findings and what can cause the calcifications?
A
- Round densities
- Calcifications can form on secretions, fibroadenomas, and sclerosing adenomas
7
Q
What happens when the BI-RADS score goes from 3 to 4?
A
- Requires a biopsy now
- 3 is most likely benign follow up in 3 mo
- 4 is suspicious and most likely should be biopsied
- 5 is highly suggestive of malignancy and needs biopsy
8
Q
What are the inflammatory disorders fo the breast? (6)
A
- Acute mastitis
- SMOLD
- Duct ectasia
- Fat necrosis
- Lymphocytic mastopathy
- Granulomatous mastitis
9
Q
When does Acute mastitis occur and how does it present? What is in differential?
A
- Red swollen breast usually occurs within first month of breast feeding can lead to S. aureus infection
- Inflammatory breast cancer mimics acute mastitis by blocking vessels with tumor emboli, need to differentiate these two bc this cancer is very deadly and presents with red swollen breast
10
Q
How does Squamous metaplasia of lactiferous ducts (SMOLD) present, association, at risk for? (extra info from robbins)
A
- Painful red subareolar mass mimicing a bacterial abscess
- nipple inverts
- 90% associated with smokers also vitamin A deficiency
- at risk for SCC
- nipple ducts undergo keratinizing squamous metaplasia and keratin sheds blocking the ducts causing eventual rupture
- chronic granulomatous inflammatory response occurs and recurrence is common
11
Q
Duct ectasia clinical presentation, who does it occur in, histology, what does it mimic?
A
- Periareolar mass with thick white secretions ,+/- skin retractions
- occurs in 50-60’s in multiparous women
- lipid laden macrophages in dilated ducts
- Mimics invasive carcinoma clinically and radiographically- need to perform ductography
12
Q
Fat necrosis association, how does it present, histo and gross appearance?
A
- mass of fat necrosis due to breast trauma or surgery
- mimics cancer as a painless mass with skin retraction/thickening
- acute lesion is hemorrhagic with liquafactive necrosis in center and neutrophils and macrophages eventually get replacedb y scar tissue
- ill defined firm grey white nodules with chalky foci
13
Q
Lymphocytic mastopathy presentation, association,?
A
- single or multiple hard palpable masses or mammorgram densities
- common in those with DM type I, AI thyroid disease
- Needs to be distinguished from cancer
14
Q
Granulomatous mastitis association and who does it occur in?
A
- Associated with GPA, polyangiitis, sarcoidosis, TB or localized infection to breast
- only in parous women due to a hypersensitivity reaction to antigen’s during lactation
15
Q
What are the Nonproliferative benign epithelial lesions? Explain them. Is there an increased risk for cancer?
A
- Cystic change:
- granular eosinophilic cytoplasm resembling normal sweat apocrine glands
- calcificatiosn common from secretions resulting in fibrosis
- concern when solitary, but cysts dissapear with FNA
- Fibrosis:
- Adenosis:
- individual mass occurs with breast feeding due to the increased number of acini per lobule
NOT associated with cancer risk
16
Q
Proliferative lesions without atypia? Explain. Cancer risk?
A
- small risk for cancer but not a direct precursor, more of a predictor of risk
- Epithelial hyperplasia:
- incr. in # of luminal and myoepithelial cells that distend ducts
-
Sclerosing adenosis:
- incr. # acini that are compressed and distended in central part of lesion histologically mimics invasive carcinoma, but dense stroma is in swirling pattern with a circumscribed border
-
Complex Sclerosing:
- looks bad but has benign histology
-
Papilloma:
- bloody nipple discharge
-
Gynecomastia:
- imbalance btw estrogen and androgens
- DISCOS
- digoxin, isoniazid, spironolactone, cimetidine, (o)estrogen, Stilbestol
- DISCOS
- imbalance btw estrogen and androgens
17
Q
Proliferative lesions with Atypia?
A
-
Atypical ductal hyperplasia:
- resembles DCIS, monomorphoic proliferation of cells and can distinguish fromDCIS becasue only partly fills the ducts involved
-
Atypical lobular hyperplasia:
- cells identical to lobular carcinoma in situe, but cells don’t fill more than 50% lobe and there is loss of E-cadherin
- Moderate increased risk for arcinoma but still a predictor of risk NOT a direct precursor
18
Q
What are the two intralobular stromal tumors of the breast?
A
- Fibroadenoma and phylloydes tumor
- driven by MED12 mutations
19
Q
What is the most common benign tumor of breast? how does it present, who is it assoc. with, and risk for carcinoma?
A
- Fibroadenoma
- multiple and b/l masses
- associated with 50% of women receiving cyclosporin A after renal transplant, but after treatment with this stops the fibroadenomas regress
- Slight incresed risk for carcinoma
20
Q
What is a phylloydes tumor? How is it different from fibroadenomas?
A
- palpable mass can be massive
- peak age is 10-20 years older than fibroadenoma
- distinguished from fibroadenoma by higher cellularity, higher mitotic rate, nuclear pleomprphism, infiltrative borders and stromal overgrowth
21
Q
Angiosarcoma? Where does it occur, genetics, and risk factors?
A
- most common stromal malignant tumor of breast
- sporadic in women <35
- Prior radiation or Stweard Treves syndrome
22
Q
incidence of breast cancer, difference on ethnicity and geography, risk factors for developing breast cancer?
A
- most common non skin malignancy in women, 2nd leading COD to lung cancer
- 1 in 8 women develop breast cancer
- Higher incidence in developed countries and those with european descent
- women >63 yo, African american diagnosed ~59 yo, Hispanic women ~56 yo
- African American women are more likely to die and more likely to have biologically aggressive cancers
- Risks:
- woman, age, fhx first degree, personal history, increased breast density, early menarch and late menopause, no pregnancies, no breast feeding, obesity, excess estrogen
23
Q
Most common genes involved in hereditary breast cancer, age risk, associations with other cancers/syndromes
A
- BRCA1 and BRCA2 also TP53
- rare younger than 25, incidence increases after 30 yo
- BRCA’s associated with increased risk of ovarian carcinoma also
- Li Fraumani with p53 mutation
- HER2 type cancer
24
Q
ER positive pathway leads to what type of cancer, precursor lesion, what percentage of BC’s, and what gene is associated?
A
- Leads to Luminal invasive cancer ER positive HER2 negative and this makes up 50-65% of breast cancers
- associated with germline BRCA2 mutations
25
ER negative pathway leading to HER2 positive cancer makes up what percentage of BC's, precursor lesion and what mutation?
* ER negative pathway with TP53 mutations leads to HER2 positive cancers making up 20% of breast cancers
* there is no identifiable precursor lesion before DCIS occurs
26
What gene is is triple negative breast cancer associated with, what is the precursor lesion what percentage does it make iup?
* Germline BRCA1 mutation, also TP53 mutation leading to DCIS leading to ER negative, HER2 negative cancer
* makes up 15%
27
Prognosis and recurrence of Triple negative breast cancer?
* nearly all recurrences occur within first 8 years, recurrences after this are rare, but its sadly because most patients have died by then
* very aggressive cancer
28
Luminal (ER positive) cancer recurrence?
* has lowest recurrence rate at recurrence occuring in first 10 years but they occur at a steady rate over long period of time after
29
Describe "everything you know about" the Low proliferation Luminal A cancer. (ER+, HER2-)
* makes up 40-55% of luminal cancers (total luminal makes up 50-65% of breast cancer)
* major type in older women and in men
* detected at early stage
* usually low grade with low recurrence rate and cured surgically
* mets after long period of time to the bone
* responds well to antiestrogenic drugs
30
Describe "everything you know about" the High proliferation Luminal B cancer. (ER+, HER2-)
* makes up 10% of luminal cancers
* increased staining for Ki67
* **most commonly associated with BRCA2**
* higher epressionb of genes related to cellular proliferation
* only 10% have complete response to chemo
31
What is the major risk factor for luminal breast cancers? How?
* Excess estrogen exposure
* stimulates breast growth normally during puberty menstrual cycle and pregnancy, but repeated cycles of proliferation of breast epithelium leads to increased risk of cancer and damage can become fixed
* once premalignant changes are present hormones stimulate growth of cells and stromal cells aiding in tumor development
32
Describe “everything you know” about HER2+ cancers
* 10-20% of cancers
* most of these carcinomas are poorly diffrentiated with no specific morphologic pattern assoc.
* Most common subtype in patients with TP53 germline mutations (Li-Fraumeni Syndrome)
* amplification of HER2 is found in 95% of these cancers and can be treated with Herceptin
33
Describe “everything you know” about triple negative cancers (ER- HER2-, aka basal like)
* 15% of cancers
* young premenopausal women, African Americans, Hispanics
* likely to present as palpable mass btw mammograms bc it grows rapidly
* almost all are poorly differentiated
* chemo in tumors assoc. with BRCA1 result in complete or almost complete response in ⅓ of cases
34
Are myoepithelial cells preserved or not in CIS?
Preserved
35
Paget disease of the nipple
* rare form of ductal carcinoma in situe under the nipple, the cells go out to surface of nipple (w/o breaking basement mem.) and present as red eruption of skin
* mimics inflammatory process and itches
* palpable mass is in 50-60% of cases and almost all of these masses are invasive ductal adenocarcinoma usually ER - and HER2 +
36
Describe Lobular Carcinoma in Situ?
* cells grow in discohesive fasion due to mutation of CDH1 leading to loss of E cadherin
* always incidnetal **NO mammographic findings,** most patients do b/l mastectomies
* doesn't present as mass
* higher incidence of being b/l than ductal CIS
* LCIS almost always luminal type express ER and PR, and HER2 -
37
What are the cancers that make up ⅓ of breast cancers that are classified morphologically into special histologic types?
* lobular carcinoma
* carcinoma with medullary pattern
* Mucinous (colloid) carcinoma
* Inflammatory
38
Features of Malignancy?
* anaplasia
* pleomorphism
* abnormal nuclear morphology
* mitoses
* vascular changes
39
Lobular carcinoma?
* Discohesive tumor cells due to biallelic loss of CDH1 so E-cadherin
* most common type of breast cancer to present as occult primary
* characteristic pattern of metastasis
* peritoneum and retroperitoneum
* leptomeninges
* GI tract
* ovaries
40
Carcinoma with medullary pattern?
* Half of BRCA1 associated carcinomas have this appearance
* circumcribed yellow mass looks like benign and radiologically benign but not and microscope shows malignancy
* most carcinomas with medullary pattern are not assoc. with BRCA1 germline mutations, but hypermethylation of BRCA1 promoter leading to down regulation of BRCA1
* most are triple negative but behave better bc they are associated with inflammatory reaction of T cells
41
Mucinous colloid tumor
* soft rubbery and has pale grey blue gelatin appearance
* microscopy shows small islands of cells in clusters with large mucin lakes
* can have good prognosis
42
Inflammatory carcinoma?
* only 3% of cancers with very poor prognosis 3-10% survival in 3 years
* High incidence in african americans
* Peau d'dorange due to plugging of lymphovascular spaces of dermis with carcinoma
* **mimics acute mastitis**
