Breast Pathology Dr. Dobson Flashcards
- How to tell another physician where you felt a mass
2. 25% mass in breast is where
- Quadrants or which clock hour
2. Internal mass draining into mediastinal LN can only be seen on CT or imaging
Poland Syndrome
No pectoral is muscle = one breast is very droopy, the other is normal
= also no shoulder or upper arm and hand anomalies can be present
If pt has supernumerary nipples what to do
Make sure you monitor those also due to breast tissue and ducts in those regions also
Accessory axilliary breast tissue or nipple can lead to
Risk of carcinoma even if the pt has mastectomy = so keep monitoring
Nipple Inversion is a problem when
Only when acquired and not there by birth
Acquired can be cancer or inflammation
2 cells in duct and lobules and importance in bx
- Epithelial = protection (ductal) + make milk (lobular)
- Myoepithelial = contraction
= cancer does not have myoepithelial layer in bx
= most malignancies come from epithelium layer
Malignant cells come from what **
+ most common location
TDLU, Terminal Duct Lobular Unit **
= found most in upper outer quadrant
Breast during
- Not in pregnancy
- During pregnancy
- Post menopausal
- More stroma (dense)
- More glands = lobules (for milk)
- More fat, lower TDLU
Pain = mastodynia SXs, % cancer
1. Cyclic (diffuse) = menstrual 2 Noncylic (localized) = ruptured cyst, trauma, infection
= 10% cancer present with mastodynia
Breast discharge 2 types and thing to think about
Usually normal if discharge from both
- Milky = elevated prolactin, repeated stimulation, hyperthyroidism, OC,TCA, methyldopa
- Bloody = large duct papilloma, pregnancy, DCIS, other malignancy
Lumpiness is usually what
+ 4 categories
Normal glandular hyperplasia
- Category A : almost all fat, 10%
- Scattered areas of fibroglandular density, 40%
- Heterogenously dense, 40%
- Extreme dense, 10%
Physical exam feeling of mass that indicates malignant mass
Solid, not circumscribed, immobile,
- Most palpable BENIGN lesions
2. Most palpable MALIGNANT lesions
- Cysts, or fibroadenomas
2. Invasive ductal carcinoma
Where does invasive carcinoma usually go
Into pectoralis muscle
What to look for on a mammogram :
- Densities = breast lesions replaced by adipose (how many, shape, size from 1cm—> 15% have already metastasized)
- Calcifications = usually apocrine cyst, hyalinized fibroadenoma, sclerosis adenosis, necrotic fat (small, irregular, numerous, clustered = malignancy SIGN of DCIS)**
Precursor lesion of breast cancer
DCIS
Palpable mass what do you do
Mammogram
If you dont see anything then you AHVE TO do a biopsy
Imaging US does what
MRI does what
- US : solid vs cystic
2. MRI : BVs seen so more helpful in dense high density breasts
Standardize a pts mammogram findings how
BI-RADS
BI-RADS categories (only know what happens from 3 to 4)
0 : need more imaging before category assignment
1 : - (annual screening continue)
2: Benign finding (annual screening continue)
3 : Probable benign (6mo redue mammogram)
4 : Suspicious abnormality (need bx)
5 : high chance malignancy (DO BX)
6 : bx proven malignancy (bx confirms cancer before tax starts)
Inflammatory disease of breast cancer can look like and what histo
- Can mimic mastitis (inflammation in breast = Staph Aureus cellulitis in breast feeding = )
- Obstructs dermal BVs with tumor emboli, always consider if you see red swollen breast = DEADLY and poor prognosis
Breast mastitis TX
During feeding of baby = staph aureus
TX with Dictoxacillin
SMOLD = Squamous Metaplasia of Lactiferous Ducts
- Is what + location
- Presents how
- Common sx
- Associated with
- Recurrent subareolar abscess or breast mastitis, Zuska disease
- Subareolar mass, painful red mass looks like bacterial abscess
- Inverted nipple (from fibrosis)
- Smokers , VIT A deficiency
SMOLD can cause and what happens in duct
- Keratin plug in duct from inflammation and squamous metaplasia in duct —-> Abscess in duct
- SCC if not corrected
Duct Ectasia
- Presents how
- Dx how (US and BX findings also)
- Is what
- Nipple secretions = white, serous, palpable mass, nipple inversion
- Put dye in in duct system = see saccular dilation OR by US, BX = fibrosis + M + lymphocytes + plasma cells
- Duct dilations, causing inflammation at times
Fat necrosis presents how + happens how + classified how
- Mass with fibrosis and calcification (coarse eggshell calcification)
- Trauma or surgery (like breast reduction)
- BI-RADS 2
Lymphocytic Mastopathy (Sclerosing Lymphocytic Lobulitis)
- Presents how (findings)
- Is what
- Associated with
- Histology
- Single or many HARD palpable masses or mammography can densities
- Fibroinflammatory condition uncommon
- T1D
- Atrophic ducts, thick BM, lymphocytes many seen
Granulomatous inflammation of breast can be what
- Polyangiitis
2.. sarcoidosis - TB
- Infection inflammatory disorder
= very uncommmon n
3 types of benign epithelial lesions of breast and what they mean
- Nonproliferation changes
- Proliferative breast disease (with atypia, with no atypia)
- Atypical hyperplasia
= no cancer precursor lesions, only increase risk of cancer at some point later
Nonproliferative Breast changes
- Other name
- What do you see 3 things
- Feels like what
- Fibcystic changes
- Cystic changes (apocrine metaplasia), fibrosis, adenosis (increase acini per lobule)
- Lumpy bumpy breast on palpating
Cysts
- Look like
- Can cause what in chronic situation
- Concerning when and how to dx
- Blue dome
- Can rupture and cause fibrosis
- Solid and firm, do fine-needle aspiration of contents
Adenosis
- Presents how
- Normal when
- Increased acini in lobule (many glands)
2. During pregnancy
5 proliferative breast disease without atypia + what risk
= risk of developing into precursor lesion
- Epithelial hyperplasia
- Sclerosing adenosis
- Complex Sclerosing lesion
- Papilloma
- Gynecomastia
Sclerosing adenoma histology
- Acini compressed by dense stroma
- Calcifications
- Acini are in swirling pattern
- Enlarged lobular unit
Complex Sclerosing lesion histo ho to know it is this
- You see myoepithelial cells
Ductal Papillomas
- Present how at times
- See what on mammogram
- Pt come in usually for what
- Bloody discharge (Stalk undergoing torsion / infarction)
- Calcification
- Palpable mass
2 types of Proliferative breast diseases with Atypia and what risk meaning
- Atypical ductal hyperplasia (TDLU hyperplasia)
- Atypical Loblar Hyperplasia (TDLU hyperplasia )
= increased risk of carcinoma precursor lesion made in future
Atypical hyperplasia pts can do what to reduce risk of developing carcinoma
- mastectomy bilateral
- E antagonist TAMOXIFEN
= only lower then 20% progress to carcinoma so most choose to monitor
Relative risk vs absolute risk
- Relative : risk change when you change something by HOW MUCH compared to others
- Absolute : risk change when you do something relative to yourself
Drugs associated with Gynecomastia
DISCOS
- Digoxin
- Isoniazid
- Spironalactone
- Cimetidine
- Oestrogens
- Stiboestrol
Diseases that can cause gynocomastia
- Liver dz
- Lowered testosterone
- XXY Kleinfelters
- Testicular neoplasm (secrete hCG)
Fibroadenoma and phyllodes tumor are driven by what
MED12 mutations
Most common benign tumors of female breast
Fibroadenoma
What drug can cause fibroadenoma and who is given this
Cyclosporine A (immunosuppressant) after renal transplant, regress after drug termination
Fibroadenoma present how and dx
Mass palpable
Core needle bx
Phyllodes tumor
- Present how
- Different from fibroadenoma how
- 3 types
- Mass palpable
- More cellularity and active mitotically, more stroma
- Low grade, intermediate, high grade
= can grow really big
Interlobular stromal lesion stromal type
- Benign you see
- Malignant you see
- Myofibroblastoma (myofibroblasts) + Lipoma + Fibromastosis (fibroblasts + myofibroblasts)
- Angiosarcoma : stromal malignant tumor, young mean 35yo
Angiosarcoma is associated with what 2 things
- Prior radiation
- Stewart Treves Syndrome (Mastectomy with lymphedema as result )
- Sporadically
Location of DCIS and LCIS
DCIS = Unilateral LCIS = bilateral treatment
Staging system used for prognosis in breast carcinoma
AJCC 8th edition
Who has the highest incident of breast cancer
European (63yo average for sporadic)
AA dx usually earlier + higher mortality (usually more aggressive types also)
Risk of breast cancer in density + other things
Higher density (higher TDLUs)
= early menarche (before 12yo = late menopause (over 55yo) = Late 1st pregnancy (over 35yo) = no breast feeding, no pregnancies = postmenopausal obesity , inactivity
Factors that decrease risk of breast cancer the most
Prolonged breastfeeding Early pregnancy (before 20yo)
Cancer with the most driver genes
Breast adenocarcinoma
Hereditary breast carcinoma works how
You are born with BRCA1 or BRCA 2 = genetic
Then at any time in your life some epigenetic or spontaneous mutations can happen causing a second BRCA mutation = you get the cancer (breastfeeding, high estrogen are some risks)
4 genes
- BRCA
- p53
- PTEN (cowden) =
- SKT11 (Peutz Jegher) =
Luminal type Brest cancer is common in what descent
And age
60-70yo, European descent
HER2 gene breast cancer % of them and peaked at what age
60yo , 20%
- Luminal cancers express what receptors
- HER2 express what
- Triple 1 express what
- ER (BRCA)
- HER2 neu (Tyrosine kinase) (TP53)
- None including no PR (BRCA1 and TP53 and more)
Luminal , HER2, Triple - cancaer recurrence rate in 10yo
- Luminal (lowest rate
2. HER2 and Triple - have highest recurrence (HER2 has another peak after 7years)
Lobular and ductal are usually what type of cancer
Lobular = invasive carcinoma Ductal = Adenocarcioma
Carcinoma in situ lobular or ductal are
=
Noninvasive and in myoepithelial cells present
= DCIS + LCIS are precursor lesions
= when detected with mammogram 70% of DCIS have already progressed to invasion of strome
DCIS looks like what and seen how
Mammogram = small CA+2 in duct system
Comedo type DCIS
Necrosis and ca inside several ducts , high grade proliferation
Pages disease
DCIS that is not in peripheral ducts, only in larger duct under nipple (tumor cells crawl out to surface of nipple = red eruption , itchy)
- 50% have an underlying mass in breast
- Most are ER - and HER2 +
LCIS grows how , Rs it has and how to find it
In discohesive fashion due to X CDH1 (no E-Cadherin, adhesion of cells)
= not on mammogram or has a mass due to no fibrosis (bx for other reasons)
= ER + , PR + , HER2-
LCIS and DCIS risk of bilateral
Higher chance of bilateral effect in LCIS
Large carcinomas invade where
Pectoralis and chest wall and dermis
How to grade invasive carcinomas
Nottingham Histologic Score
Malignant cancer words you see
Vascular change’ Mitosis Abnormal nuclear morphology Pleomorphism Anaplasia
Most common places Lobular Carcinoma invades to
- What factors this tumor has
- How its found
GI, peritoneum, ovaries, brain (leptomeninges)
= grow in single file line
1. CDH1 mutation = no E-Cadherin
2. By accident on checking for something else, no mass
Carcinoma with medullary pattern
- Type of Rs
- Type of cancer/prognosis
- Factors it had
- Triple - type
- Better prognosis for this subtype, may Tcells (immune response to tumor)
- BRCA1 is usually associated with this type of tumor pattern
Mucinous (colloid) carcinomas
- Looks like and feel like
- Histo, type of cancer
- Prognosis
- Soft, rubbery feel like + Mucin or Gelatin look like
- Malignant cells floating in mucin
- Good prognosis for this type
Inflammatory carcinoma
- Survival after 3 years
- Ethnicity with higher risk
- Looks like
- What happens
- 3-10%
- AA
- Acute mastitis, Peau d’orange (orange peal)**,
- Extensive lymph and BV involvements on dermis
Most important prognostic indication of breast cancer
Metastasis
Carcinoma en cuirasse
Spreads of breast cancer all over breast plate if nothing is done to breast cancer
Saying in breast cancer stage 2 vs stage 3
2 = 2cm-5cm 3 = over 5cm
(Stage 0 = DCIS, Stage 1 = invasive under 0cm-2cm)
Mutations of BRCA cause defects in
HRR
