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ENRP II > Breast Pathology Robbins/Lecture Part 1 > Flashcards

Breast Pathology Robbins/Lecture Part 1 Flashcards

1
Q

Screening by palpation has _ (little/no effect) on reducing breast cancer mortality

A

little effect

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2
Q

what are the three sources of blood to the breast and what locations do they supply

A
  1. axillary artery gives rise to branches that supply the lateral breast: lateral thoracic artery, superior thoracic artery, thoracoacromial artery, and subscapular artery
  2. Internal thoracic artery supplies the medial breast
  3. Posterior intercostal arteries supply the whole breast
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3
Q

breast carcinomas tend to spread via ?

A

lymphatics

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4
Q

lymph from the breast lobules, nipple, and areolar region collect where?

A

into the subareolar lymphatic plexus

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5
Q

75% of lymph in the subareolar lymphatic plexus drains where?

A

into the pectoral lymph nodes and eventually the AXILLARY LYMPH NODES

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6
Q

25% of lymph from the subareolar lymphatic plexus drains where

A

internal mammary/parasternal lymph nodes

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7
Q

axillary lymph nodes drain where?

A

subclavian lymph nodes (also drains upper limbs)

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8
Q

parasternal lymph nodes drain into?

A

bronchomediatinal nodes (which also drains thoracic organs)

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9
Q

Poland Syndrome

A

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)

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10
Q

Poland syndrome affects _ (men/women) more

A

men

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11
Q

what are the disorders of development involving the breasts

A
  1. milk line remnants
  2. nipple eversion
  3. acessory axillary breast tissue
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12
Q

supernumaerary nipples of breast result from persistence of _ along the milk line.

A

epidermal thickenings

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13
Q

the milk line extends from?

A

axilla to perienum

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14
Q

milk line remnants typically come to attention due to ?

A

painful swelling prior to menstruation

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15
Q

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.

A

ductal system

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16
Q

congenital nipple inversion is the failure of the nipple to _ during development. It is usually of elivcal insignifigance because they?

A

evert

correct spontaneously during pregnancy of traction

acquired nipple retraction is indicative of an inflammatory or neoplastic process

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17
Q

the breast undergo expansion of the lobular system after _

A

menarche

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18
Q

following puberty the duct system expands and proliferates giving rise to?

A

terminal duct lobular units (TDLU)

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19
Q

changes in the female breast are most dynamic and profoud during ?

A

reproductive years

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20
Q

only with _ does the breast completely mature and become fully functional

A

pregnancy

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21
Q

by the end of full term pregnancy the breast is composed mostly of?

A

lobulues seperated by scant stroma

lobules proliferate and increase in size and number during pregnancy

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22
Q

after the third decade long before menopause _ and _ start to involute. The interlobular stroma is converted from _ to _

A

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

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23
Q

what are the two types of stroma in breasts?

A

interlobular and intralobular

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24
Q

what are the two types of epithelial cells in the breasts?

A

luminal and myoepithelial cells

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25
Q

what are the two major epithelial structures in the breast

A

ducts and lobules which form the TDLU

TDLU= terminal duct lobular unit

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26
Q

mastodynia

A

pain

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27
Q

cyclic/diffuse pain of the breast is related to?

A

menstrual cycle

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28
Q

noncyclic/localized pain of the breast is related to?

A

a ruptured cyst, trauma, infection

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29
Q

nipple discharge associated with malignancy is most commnly due to?

A

ductal carcinoma insitu

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30
Q

discharge in older women that is spontaneous, unilateral, and bloody is likely to have a ____ origin

A

malignant

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31
Q

milky glacatorrhea can be caused by?

A

increased prolactin, stimulation, hypothyroidism, drugs

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32
Q

lumpiness of the breast/nodulatirty of the breast usually is a manifestation of _ glandular tissue

A

normal

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33
Q

what is the greatest presentation of breast cancer?

A

an abnormal mammogram

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34
Q

palpable breast masses can arise from proliferations of _ cells or _ cells

A

epithelial or stromal cells

these proliferative masses are usually detected when they reach 2 to 3 cm

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35
Q

benign palpable masses tend to look/feel like what

A

round/oval in shape, rubbery, mobile, and circumscribed borders

95% of palpable masses are benign

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36
Q

the most common palpable benign masses in the breast are _ and _

A

cysts and fibroadenomas

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37
Q

the likelyhood that a palpable breast mass is malignant increases with _

A

age

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38
Q

what does a malignant palbable breast mass usually feel/look like

A

hard, irregular borders, invade tissue planes

20% in the central/subareolar region

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39
Q

50% of carcinomas in the breast are loacted?

A

on the upper outer quadrant close to the axillary tail

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40
Q

the most common palpable malignant mass in the breast is?

A

invasive ductal carcinomas

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41
Q

mammographic screening allows you to detect _ asymptomatic breast cancers before they metastasive

A

nonpalpable

<1cm

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42
Q

the sensitivity and specificity of mammography increases with?

A

age

as we age our stroma is replaced with fat and makes it easier to see masses on mammography

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43
Q

mammography looks for?

A

calcification and density changes (fat, fibrous tissue)

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44
Q

widespread ductal carcinoma insitu shows what on mammography

A

calcifications

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45
Q

10% of invasive carcinomas arent detected on mammography, why could these cancer potentially escape detection

A
  1. they are surrounded by radiodense tissue (like in a younger breast)
  2. they are small infilatrates
  3. diffuse infiltrates with no desmoplastic response
  4. they are located close to the chest wall/periphery of the breast, in a place that mammography doesn’t visualize
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46
Q

all palpable masses require further _

A

investigation

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47
Q

what are some other imaging modalities other than mammography to detect breast cancer?

A

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)

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48
Q

what is the bi-rads score

A

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

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49
Q

inflammatory diseases of the breast are rare and usually caused by?

A

infections, autoimmune diseases, foreign body infiltration, extravasted keratin or secretions

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50
Q

what is acute mastitis ?

A

this is when a breastfeeding women develops an infection in the breast through fissures/cracks allowing bacteria to enter

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51
Q

what is the most common orgnaism of acute mastitis

A

Staph Aureus

less commonly can be caused by streptocci

Gram positive, catalase +, Coagulase + bacteria
golden colonies on agar

52
Q

clinical presentation of acute mastitis

A

erythematous and painful breasts with fever

53
Q

what are the outcomes of acute mastitis

A

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

54
Q

treatment of acute mastitis?

A

antibiotics, and continued expression of milk from the breasts

55
Q

squamous metaplasia of lactiferous ducts other names

A

subareolar abcess, periductal mastitis, Zuska Disease

56
Q

clinical presentation of squamous metaplasia of lactierous ducts

A

painful erythematous subareolar mass that mimics a bacterial abcess

57
Q

risk factor for squamous metaplasia of lactiferous ducts?

A

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

58
Q

recurrent cases of squamous metaplasia of lacteriferious ducts can cause?

A

a fistula tract under the smooth muscle of the nipple that opens onto the skin at the edge of the areola

59
Q

in many women affected by squamous metaplasia of the lactiferous ducts presents with?

A

nipple inversion due to traction

60
Q

key histological feature of squamous metaplasia of lactiferous ducts

A

keratinizing squamous metaplasia

61
Q

describe the pathology behing squamous metaplasia of the lactiferous duct

A

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

62
Q

how do we treat squamous metaplasia of lacteiferous ducts

A

drainage of cyst
keratinized squamous metaplasia remains in the ducts- unless you remove the duct and the fistula tract

63
Q

duct actasia presents with?

A

periareolar mass, thick white secretions from the nipple, and skin retraction

may present very similarly to invasive carcinoma need to determine this.

64
Q

in duct ectasia pain and erythema are _ (common/uncommon)

A

uncommon

65
Q

ectatic dilated ducts are filled with?

A

inspissated secretions and lipid laden macrophages

66
Q

with rupture of the ectatic duct what happens?

A

inflammatory reaction with lymphocytes, macrophages, and plasma cells around the duct

fibrosis/ granulomas can form- giving the periareolar mass that is found

67
Q

presentation of fat necrosis in the breast is _ (variable/constant)

A

variable (protean)

68
Q

risk factor for fat necrosis of the breast

A

trauma/surgery

also seen in the pancreas

69
Q

how can fat necrosis present?

A

painless palpable masses, skin thickening/retraction, mammographic densities or calcifications

70
Q

pathology of fat necrosis in the breast

A

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

71
Q

grossly how does fat necrosis of the breast look?

A

ill defined- firm- white gray nodules that contain small chalky white excerences

72
Q

what are the risk factors for lymphocytic mastopathy aka sclerosing lymphocytic lobulitis?

A

autoimmune conditions like type 1 diabetes, autoimmune thyroid disease

73
Q

how does lymphocytic mastopathy present

A

with single or multiple hard palpable masses or densities on mammography

74
Q

palpable masses in lymphocytic mastopathy are associated with?

A

dense collagenized stroma

this makes it hard to get a needle biopsy

75
Q

within the collagnized stroma of lymphocytic mastopathy there is what?

referring to how the TDLU looks

A

atrophic ducts and lobules with a thickened basement membrane and lymphocytic infilatrate

76
Q

granulomatous lobular mastitis only occurs in what population

A

women who have given birt

**parous

common in the immunocompromised, nipple piercings

77
Q

what is granulomatous lobular mastitis and what does it resemble (what other disease process in the breast)

A

granulomas around the lobules of the breast that contain lipids and neutrophils

similar presentation to : cystic neutrophilic granulomatous masitis (corynebacterium cause)

78
Q

treatment of granulomatous mastitis

A

antibiotics and steroids

79
Q

benign epithelial lesions of the breast are classified into what 3 groups?

A
  1. nonproliferative breast changes
  2. proliferative breast changes with or without atypia
  3. atypical hyperplasia
80
Q

benign epithelial lesions usually do not cause symptoms but are frequently detected as?

A

calcifications or densities on mammography

birad score of 0-3

81
Q

what is a non-proliferative breast change

A

fibrocystic changes which are common morphologic changes in the breast

lumpy bumpy breasts: dense breasts with cysts, benign histological finding

82
Q

do nonproliferative breast changes have an increased risk of breast cancer?

A

no

83
Q

what are the three principal nonproliferative morphologic changes?

A

Cysts, FIbrosis, and Adenosis

aka fibrocystic change

84
Q

how do the cysts look in fibrocystic change

A

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

85
Q

cysts in fibrocystic change are lined by ?

A

metaplastic apocrine cells (these cells have granular and esosinophilic cytoplasm that resembles epithelium of a sweat gland)

flattened atrophic epithelim

86
Q

cysts in fibrocystic change can rupture and cause?

A

fibrosis through chronic inflammation

87
Q

how do we confirm the presence of a cyst in fibrocystic change?

A

if the mass dissapears after fine needle aspiration of its contents (fluid filled)

88
Q

what is adenosis?

A

an increase in the number of acini per lobule (cavities in glands)

acini (cavities in a gland)

89
Q

adenosis is a normal feature of _

A

pregnancy

90
Q

in non-pregnant women adenosis can occur as?

A

focal change

91
Q

acini are lined by _ epithelium and _ are typically present in the lumens

A

columnar

calcifications

92
Q

what is a lactational adenoma

A

palbable mass present during breast feeding due to adenosis occuring in the glands of the lobule

regress after cessation of breast feeding

93
Q

what are proliferative breast changes without atypia?

A

these are lesions in the breast that cause proliferation of epithelial cells but no cytologic atypic

94
Q

is there an increase risk of susequent carcinoma in either breast with proliferative breast changes without atypica

A

a very small increase risk

considered predictor of risk and not direct precursor

95
Q

what morphological changes are seen in proliferative breast disease without atypia?

A
  1. Epithelial Hyperplasia
  2. Sclerosing Adenosis
  3. Complex Sclerosing lesion
  4. papilloma
  5. gynecomastia in males (increase in breast tissue)
96
Q

a complex sclerosing lesion looks like?

A

a stellate scar

need a biopsy

97
Q

more than 80% of duct papillomas produce _

A

nipple discharge which can be bloody if the papilloma undergoes torsion causing infarction

98
Q

what is proliferative breast disease with atypia

A

proliferations of either ductal or lobular epithelial cells with some histological features of carcinoma insitu in either breast

moderate predictor of risk for carcinoma

99
Q

what are the two morphologic patterns of proliferative breast disease

A

atypical duct hyperplasia (ADH)
atypical lobular hyperplasia (ALH)

100
Q

benign breast hitological changes have associated risk for developing breast cancer in _ (both breasts, one breast)

A

both breasts

101
Q

risk reduction of breast cancer can be given by?

A

prohylactic mastectomy or estrogen antagonsits like tamoxifen

102
Q

pathogenesis of gynecomastia in males

A

estrogen /androgen imbalance that leads to the stimulation of breast tissue

103
Q

how does gynecomastia present on histology?

A

collagenous connective tissue with ductal epithelial hyperplasia and no lobule formation

more fat, more glandsular tissue

button like subareolar enlargement

104
Q

what can cause gynecomastia?

A
  1. liver disease
  2. drugs
  3. XXY karyotype
105
Q

what drugs cause gynecomastia ?

A

DISCOS
digoxin
isoniazid
spironolactone
cimetidine
oestrogens
stilboestrol

106
Q

stromal tumors of the breast are termed _ becuase they also include a non-neoplastic epithelial component

A

biphasic

non neoplastic component is caused by stromal cells secreting growth factors

107
Q

what are the two intralobular stromal tumors

A

firboadenoma and phyllodes tumors

108
Q

both a fibroadenoma and a phyllodes tumor are drivedn by somatic mutation in?

A

MED12

109
Q

what is the most common benign tumor of the female breast?

A

fibroadenoma

hormonally sensitive: occur ages 20-30

110
Q

what medication can cause fibroedemonas that regress when taken off the medication

A

cyclosporine A (given after renal rtansplantation)

111
Q

how do fibroadenomas present?

A

circumscribed lesion that is grossly white and rubbery surrounded by yello adipose tissue

radiodense

112
Q

in a fibroadenoma proliferation of the intralobular stroma distorts the associated _

A

epithelium

113
Q

peak age for a phyllodes tumor vs. fibroadenoma

A

PT: 40-50
fibrodenoma- 20-30

114
Q

phyllodes tumor is distinguied from fibroadenoma on the basis of higher?

A

cellularity, mitotic rate, nuclear pleomorphism, stromal overgrowth, and infiltrative borders

leaf like apperance on histology

115
Q

low grade phyllodes tumors resemble:

high grade phyllodes tumors resemble:

A

low grade: fibroadenoma

high grade: sarcomas

low grade is most common MED12- benign

high grade can reoccur and can metastisize TERT

116
Q

what are the interlobular stromal lesions?

4 of them

A
  1. myofibroblastoma
  2. lipomas
  3. fibromatosis
  4. angiosarcoma (malignant)
117
Q

what is a myofirboblastoma?

A

this is a interlobular stroma tumor comprised of myofibroblasts

fun fact: men equally affected

benign and has same incidence in men!

118
Q

what is a lipoma

A

an interlobular stroma lesion made up of fat cells

119
Q

what is a fibromatosis?

A

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

120
Q

what is the most common stromal malignancy?

A

angiosarcoma

121
Q

most angiosarcomas of the breast involve the breast perenchyma (stroma) and occur in women of what age

A

young women (35)

poor prognosis

122
Q

risk factors for angiosarcomas

A

prior radiation or stewart treves syndrome

123
Q

what is stewart- treves syndrome

A

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

124
Q

metastasis to the breast are rare and most commonly arise from _ or _ cancers

A

melanomas or ovarian cancers

125
Q

lymphomas of the breast are primary _ cell type

A

B

non-hodgkins lymphoma

126
Q

T-cell lymphomas of the breast may arise in associated with breast implants why?

A

chronic inflammation is known to stimulate lymphoma development

127
Q

young women with burkitt lymphoma may present with massive bilateral breast involvment often while _ or _

starry sky, high Ki index

A

pregnant or lactating

ENRP II (25 decks)

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