Breast Pathology Robbins/Lecture Part 1 Flashcards
Screening by palpation has _ (little/no effect) on reducing breast cancer mortality
little effect
what are the three sources of blood to the breast and what locations do they supply
- axillary artery gives rise to branches that supply the lateral breast: lateral thoracic artery, superior thoracic artery, thoracoacromial artery, and subscapular artery
- Internal thoracic artery supplies the medial breast
- Posterior intercostal arteries supply the whole breast
breast carcinomas tend to spread via ?
lymphatics
lymph from the breast lobules, nipple, and areolar region collect where?
into the subareolar lymphatic plexus
75% of lymph in the subareolar lymphatic plexus drains where?
into the pectoral lymph nodes and eventually the AXILLARY LYMPH NODES
25% of lymph from the subareolar lymphatic plexus drains where
internal mammary/parasternal lymph nodes
axillary lymph nodes drain where?
subclavian lymph nodes (also drains upper limbs)
parasternal lymph nodes drain into?
bronchomediatinal nodes (which also drains thoracic organs)
Poland Syndrome
a disorder when affected individuals are missing or have underdeveloped muscles on one side of their body
**usually have UE muscle abnormalities and can have organ problems as well
in dobson lecture he included a picture of a women who had one breast bigger than the other (breast tissue failed to develop)
Poland syndrome affects _ (men/women) more
men
what are the disorders of development involving the breasts
- milk line remnants
- nipple eversion
- acessory axillary breast tissue
supernumaerary nipples of breast result from persistence of _ along the milk line.
epidermal thickenings
the milk line extends from?
axilla to perienum
milk line remnants typically come to attention due to ?
painful swelling prior to menstruation
in some women the normal _ extends into the subcutaneous tissue of the chest wall or the axillary fossa giving rise to acessory axillary breast tissue. Prophylatic breast tissue removal does not include this axillary tissue and cancer can still arise in these areas.
ductal system
congenital nipple inversion is the failure of the nipple to _ during development. It is usually of elivcal insignifigance because they?
evert
correct spontaneously during pregnancy of traction
acquired nipple retraction is indicative of an inflammatory or neoplastic process
the breast undergo expansion of the lobular system after _
menarche
following puberty the duct system expands and proliferates giving rise to?
terminal duct lobular units (TDLU)
changes in the female breast are most dynamic and profoud during ?
reproductive years
only with _ does the breast completely mature and become fully functional
pregnancy
by the end of full term pregnancy the breast is composed mostly of?
lobulues seperated by scant stroma
lobules proliferate and increase in size and number during pregnancy
after the third decade long before menopause _ and _ start to involute. The interlobular stroma is converted from _ to _
lobules and their specialized stroma
the interlobular stroma is converted from radiodense fibrous stroma to radiolucent adipose tissue
radiolucent- on x-ray they appear dark because the light penetrates through it
what are the two types of stroma in breasts?
interlobular and intralobular
what are the two types of epithelial cells in the breasts?
luminal and myoepithelial cells
what are the two major epithelial structures in the breast
ducts and lobules which form the TDLU
TDLU= terminal duct lobular unit
mastodynia
pain
cyclic/diffuse pain of the breast is related to?
menstrual cycle
noncyclic/localized pain of the breast is related to?
a ruptured cyst, trauma, infection
nipple discharge associated with malignancy is most commnly due to?
ductal carcinoma insitu
discharge in older women that is spontaneous, unilateral, and bloody is likely to have a ____ origin
malignant
milky glacatorrhea can be caused by?
increased prolactin, stimulation, hypothyroidism, drugs
lumpiness of the breast/nodulatirty of the breast usually is a manifestation of _ glandular tissue
normal
what is the greatest presentation of breast cancer?
an abnormal mammogram
palpable breast masses can arise from proliferations of _ cells or _ cells
epithelial or stromal cells
these proliferative masses are usually detected when they reach 2 to 3 cm
benign palpable masses tend to look/feel like what
round/oval in shape, rubbery, mobile, and circumscribed borders
95% of palpable masses are benign
the most common palpable benign masses in the breast are _ and _
cysts and fibroadenomas
the likelyhood that a palpable breast mass is malignant increases with _
age
what does a malignant palbable breast mass usually feel/look like
hard, irregular borders, invade tissue planes
20% in the central/subareolar region
50% of carcinomas in the breast are loacted?
on the upper outer quadrant close to the axillary tail
the most common palpable malignant mass in the breast is?
invasive ductal carcinomas
mammographic screening allows you to detect _ asymptomatic breast cancers before they metastasive
nonpalpable
<1cm
the sensitivity and specificity of mammography increases with?
age
as we age our stroma is replaced with fat and makes it easier to see masses on mammography
mammography looks for?
calcification and density changes (fat, fibrous tissue)
widespread ductal carcinoma insitu shows what on mammography
calcifications
10% of invasive carcinomas arent detected on mammography, why could these cancer potentially escape detection
- they are surrounded by radiodense tissue (like in a younger breast)
- they are small infilatrates
- diffuse infiltrates with no desmoplastic response
- they are located close to the chest wall/periphery of the breast, in a place that mammography doesn’t visualize
all palpable masses require further _
investigation
what are some other imaging modalities other than mammography to detect breast cancer?
Digital breast tomosynthesis - detects changes in breast parchemymal tissue
ultrasonography- cystic vs solid lesions
MRI- tumor vasculatiry and blood flow, good in evaluation of high density breasts (younger breasts)
what is the bi-rads score
this is a scoring system that determines what to do now after a mammogram
birads 0-3 state that the lesion is probably benign
birads 4-6 state that they are either suspcious for malignancy and need tissue biopsy or that it is malignant and it needs to be removed/treated
inflammatory diseases of the breast are rare and usually caused by?
infections, autoimmune diseases, foreign body infiltration, extravasted keratin or secretions
what is acute mastitis ?
this is when a breastfeeding women develops an infection in the breast through fissures/cracks allowing bacteria to enter
what is the most common orgnaism of acute mastitis
Staph Aureus
less commonly can be caused by streptocci
Gram positive, catalase +, Coagulase + bacteria
golden colonies on agar
clinical presentation of acute mastitis
erythematous and painful breasts with fever
what are the outcomes of acute mastitis
typically the infection is localised to one duct system but can spread
in the case of staph aures: an abcess can form
in the case of streptococci: cellulitis can occur
treatment of acute mastitis?
antibiotics, and continued expression of milk from the breasts
squamous metaplasia of lactiferous ducts other names
subareolar abcess, periductal mastitis, Zuska Disease
clinical presentation of squamous metaplasia of lactierous ducts
painful erythematous subareolar mass that mimics a bacterial abcess
risk factor for squamous metaplasia of lactiferous ducts?
smoking this is because with smoking there is a relative vitamin A def and with antioxidant def there is a differentiation in ductal epithelium
90% of people with this disease smoke
recurrent cases of squamous metaplasia of lacteriferious ducts can cause?
a fistula tract under the smooth muscle of the nipple that opens onto the skin at the edge of the areola
in many women affected by squamous metaplasia of the lactiferous ducts presents with?
nipple inversion due to traction
key histological feature of squamous metaplasia of lactiferous ducts
keratinizing squamous metaplasia
describe the pathology behing squamous metaplasia of the lactiferous duct
epithelial differentiation causes keratinizing metaplasia to line the ducts of the breast, this metaplasia (change in cell type) will extend deep into the nipple duct and keratin will become trapped and form an abcess which dilates the duct and can cause it to rupture. Once the keratin is ruptured from the duct this illicits a granulomatous response around the duct tissue
prone to bacterial infections
how do we treat squamous metaplasia of lacteiferous ducts
drainage of cyst
keratinized squamous metaplasia remains in the ducts- unless you remove the duct and the fistula tract
duct actasia presents with?
periareolar mass, thick white secretions from the nipple, and skin retraction
may present very similarly to invasive carcinoma need to determine this.
in duct ectasia pain and erythema are _ (common/uncommon)
uncommon
ectatic dilated ducts are filled with?
inspissated secretions and lipid laden macrophages
with rupture of the ectatic duct what happens?
inflammatory reaction with lymphocytes, macrophages, and plasma cells around the duct
fibrosis/ granulomas can form- giving the periareolar mass that is found
presentation of fat necrosis in the breast is _ (variable/constant)
variable (protean)
risk factor for fat necrosis of the breast
trauma/surgery
also seen in the pancreas
how can fat necrosis present?
painless palpable masses, skin thickening/retraction, mammographic densities or calcifications
pathology of fat necrosis in the breast
lesion that is hemorhagic with liquafactive fat with neutrophils and macrophages
fibroblasts proliferate and inflammatory cells move in
giant cells, calcification, and hemosiderin appear and then the lesion is replaced by scar tissue
grossly how does fat necrosis of the breast look?
ill defined- firm- white gray nodules that contain small chalky white excerences
what are the risk factors for lymphocytic mastopathy aka sclerosing lymphocytic lobulitis?
autoimmune conditions like type 1 diabetes, autoimmune thyroid disease
how does lymphocytic mastopathy present
with single or multiple hard palpable masses or densities on mammography
palpable masses in lymphocytic mastopathy are associated with?
dense collagenized stroma
this makes it hard to get a needle biopsy
within the collagnized stroma of lymphocytic mastopathy there is what?
referring to how the TDLU looks
atrophic ducts and lobules with a thickened basement membrane and lymphocytic infilatrate
granulomatous lobular mastitis only occurs in what population
women who have given birt
**parous
common in the immunocompromised, nipple piercings
what is granulomatous lobular mastitis and what does it resemble (what other disease process in the breast)
granulomas around the lobules of the breast that contain lipids and neutrophils
similar presentation to : cystic neutrophilic granulomatous masitis (corynebacterium cause)
treatment of granulomatous mastitis
antibiotics and steroids
benign epithelial lesions of the breast are classified into what 3 groups?
- nonproliferative breast changes
- proliferative breast changes with or without atypia
- atypical hyperplasia
benign epithelial lesions usually do not cause symptoms but are frequently detected as?
calcifications or densities on mammography
birad score of 0-3
what is a non-proliferative breast change
fibrocystic changes which are common morphologic changes in the breast
lumpy bumpy breasts: dense breasts with cysts, benign histological finding
do nonproliferative breast changes have an increased risk of breast cancer?
no
what are the three principal nonproliferative morphologic changes?
Cysts, FIbrosis, and Adenosis
aka fibrocystic change
how do the cysts look in fibrocystic change
small cysts form from dilation of lobules and can coaleace with other cysts to form a larger cyst, they are blue in color and are lined by flattened atrophic epithelium or metaplastic apocrine cells
cysts in fibrocystic change are lined by ?
metaplastic apocrine cells (these cells have granular and esosinophilic cytoplasm that resembles epithelium of a sweat gland)
flattened atrophic epithelim
cysts in fibrocystic change can rupture and cause?
fibrosis through chronic inflammation
how do we confirm the presence of a cyst in fibrocystic change?
if the mass dissapears after fine needle aspiration of its contents (fluid filled)
what is adenosis?
an increase in the number of acini per lobule (cavities in glands)
acini (cavities in a gland)
adenosis is a normal feature of _
pregnancy
in non-pregnant women adenosis can occur as?
focal change
acini are lined by _ epithelium and _ are typically present in the lumens
columnar
calcifications
what is a lactational adenoma
palbable mass present during breast feeding due to adenosis occuring in the glands of the lobule
regress after cessation of breast feeding
what are proliferative breast changes without atypia?
these are lesions in the breast that cause proliferation of epithelial cells but no cytologic atypic
is there an increase risk of susequent carcinoma in either breast with proliferative breast changes without atypica
a very small increase risk
considered predictor of risk and not direct precursor
what morphological changes are seen in proliferative breast disease without atypia?
- Epithelial Hyperplasia
- Sclerosing Adenosis
- Complex Sclerosing lesion
- papilloma
- gynecomastia in males (increase in breast tissue)
a complex sclerosing lesion looks like?
a stellate scar
need a biopsy
more than 80% of duct papillomas produce _
nipple discharge which can be bloody if the papilloma undergoes torsion causing infarction
what is proliferative breast disease with atypia
proliferations of either ductal or lobular epithelial cells with some histological features of carcinoma insitu in either breast
moderate predictor of risk for carcinoma
what are the two morphologic patterns of proliferative breast disease
atypical duct hyperplasia (ADH)
atypical lobular hyperplasia (ALH)
benign breast hitological changes have associated risk for developing breast cancer in _ (both breasts, one breast)
both breasts
risk reduction of breast cancer can be given by?
prohylactic mastectomy or estrogen antagonsits like tamoxifen
pathogenesis of gynecomastia in males
estrogen /androgen imbalance that leads to the stimulation of breast tissue
how does gynecomastia present on histology?
collagenous connective tissue with ductal epithelial hyperplasia and no lobule formation
more fat, more glandsular tissue
button like subareolar enlargement
what can cause gynecomastia?
- liver disease
- drugs
- XXY karyotype
what drugs cause gynecomastia ?
DISCOS
digoxin
isoniazid
spironolactone
cimetidine
oestrogens
stilboestrol
stromal tumors of the breast are termed _ becuase they also include a non-neoplastic epithelial component
biphasic
non neoplastic component is caused by stromal cells secreting growth factors
what are the two intralobular stromal tumors
firboadenoma and phyllodes tumors
both a fibroadenoma and a phyllodes tumor are drivedn by somatic mutation in?
MED12
what is the most common benign tumor of the female breast?
fibroadenoma
hormonally sensitive: occur ages 20-30
what medication can cause fibroedemonas that regress when taken off the medication
cyclosporine A (given after renal rtansplantation)
how do fibroadenomas present?
circumscribed lesion that is grossly white and rubbery surrounded by yello adipose tissue
radiodense
in a fibroadenoma proliferation of the intralobular stroma distorts the associated _
epithelium
peak age for a phyllodes tumor vs. fibroadenoma
PT: 40-50
fibrodenoma- 20-30
phyllodes tumor is distinguied from fibroadenoma on the basis of higher?
cellularity, mitotic rate, nuclear pleomorphism, stromal overgrowth, and infiltrative borders
leaf like apperance on histology
low grade phyllodes tumors resemble:
high grade phyllodes tumors resemble:
low grade: fibroadenoma
high grade: sarcomas
low grade is most common MED12- benign
high grade can reoccur and can metastisize TERT
what are the interlobular stromal lesions?
4 of them
- myofibroblastoma
- lipomas
- fibromatosis
- angiosarcoma (malignant)
what is a myofirboblastoma?
this is a interlobular stroma tumor comprised of myofibroblasts
fun fact: men equally affected
benign and has same incidence in men!
what is a lipoma
an interlobular stroma lesion made up of fat cells
what is a fibromatosis?
an interlobular stromal lesion that can involve both fibroblasts and myofibroblasts in the muscle
it is locally agressive and doesnt metastasice
can be caused by trauma or genetic predilection
what is the most common stromal malignancy?
angiosarcoma
most angiosarcomas of the breast involve the breast perenchyma (stroma) and occur in women of what age
young women (35)
poor prognosis
risk factors for angiosarcomas
prior radiation or stewart treves syndrome
what is stewart- treves syndrome
A rare disorder marked by the presence of an angiosarcoma (a malignant tumor of blood or lymph vessels) in a person with chronic (long-term) lymphedema
metastasis to the breast are rare and most commonly arise from _ or _ cancers
melanomas or ovarian cancers
lymphomas of the breast are primary _ cell type
B
non-hodgkins lymphoma
T-cell lymphomas of the breast may arise in associated with breast implants why?
chronic inflammation is known to stimulate lymphoma development
young women with burkitt lymphoma may present with massive bilateral breast involvment often while _ or _
starry sky, high Ki index
pregnant or lactating
