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Pathoma Notes > CH16 - Breast Pathology > Flashcards

CH16 - Breast Pathology Flashcards

1
Q

What is the breast?

A

modified sweat gland; embryologically derived from the skin

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2
Q

From where can breast tissue develop?

A

anywhere along the milk line, which runs from the axilla to the vulva (e.g., supernumerary nipples).

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3
Q

What is the functional unit of the breast?

A

the terminal duct lobular unit

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4
Q

What do the lobules make?

A

milk that drains via ducts to the nipple

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5
Q

What are the lobules and ducts lined by?

A

two layers of epithelium, luminal cell layer and myoepithelial layer

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6
Q

What is the luminal cell layer? Its function?

A

inner cell layer lining the ducts and lobules; responsible for milk production in the lobules

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7
Q

What is the myoepithelial cell layer? Its function?

A

outer cell layer lining ducts and lobules; contractile function propels milk towards the nipple.

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8
Q

What is the breast tissue sensitive to?

A

hormone

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9
Q

What does the male and female breast tissue primarily consist of before puberty?

A

large ducts under the nipple

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10
Q

What is the development after menarche primarily driven by?

A

estrogen and progesterone; lobules and small ducts form and are present in highest density in the upper outer quadrant.

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11
Q

What happens to the breast during the menstrual cycle?

A

Breast tenderness during the menstrual cycle is a common complaint, especially prior to menstruation.

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12
Q

What happens to the breast during pregnancy?

A

breast lobules undergo hyperplasia.

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13
Q

What is hyperplasia driven by?

A

estrogen and progesterone produced by the corpus luteum (early first trimester), fetus, and placenta (later in pregnancy)

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14
Q

What happens to breast tissue after menopause?

A

breast tissue undergoes atrophy.

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15
Q

What does galactorrhea refer to?

A

milk production outside of lactation.

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16
Q

Is galactorrhea related to breast cancer?

A

It is not a symptom of breast cancer.

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17
Q

What causes galactorrhea?

A

include nipple stimulation (common physiologic cause), prolactinoma of the anterior pituitary (common pathologic cause), and drugs.

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18
Q

What are the inflammatory conditions of the breast?

A

Acute mastitis, periductal mastitis, mammary duct ectasia, fat necrosis,

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19
Q

What is acute mastitis?

A

Bacterial infection of the breast, usually due to Staphylococcus aureus

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20
Q

What is acute mastitis associated with?

A

breast-feeding; fissures develop in the nipple providing a route of entry for microbes.

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21
Q

What does acute mastitis present as?

A

an erythematous breast with purulent nipple discharge; may progress to abscess formation

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22
Q

What does the treatment of acute mastitis involve?

A

continued drainage (e.g., feeding) and antibiotics (e.g., dicloxacillin).

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23
Q

What is periductal mastitis?

A

Inflammation of the subareolar ducts

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24
Q

What is periductal mastitis usually seen in?

A

smokers

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25
Q

In periductal mastitis, relative vitamin A deficiency results in what?

A

squamous metaplasia of lactiferous ducts, producing duct blockage and inflammation

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26
Q

How does periductal mastitis clinically present?

A

as a subareolar mass with nipple retraction

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27
Q

What is mammary duct ectasia?

A

Inflammation with dilation (ectasia) of the subareolar ducts

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28
Q

What is the frequency of mammary duct ectasia?

A

Rare

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29
Q

In whom does mammary duct ectasia classically arise?

A

in muciparous postmenopausal women

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30
Q

What does mammary duct ectasia present as?

A

a periareolar mass with green-brown nipple discharge (inflammatory debris)

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31
Q

What is seen on biopsy of mammary duct ectasia?

A

Chronic inflammation with plasma cells

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32
Q

What is fat necrosis for the breast?

A

It is necrosis of breast fat

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33
Q

What is fat necrosis usually related to?

A

trauma; however, a history of trauma may not always be evident

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34
Q

What does fat necrosis present as?

A

a mass on physical exam or abnormal calcification on mammography (due to saponification)

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35
Q

What does biopsy of fat necrosis of the breast show?

A

shows necrotic fat with associated calcifications and giant cells.

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36
Q

What is fibrocystic change?

A

Development of fibrosis and cysts in the breast

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37
Q

What is the most common change in the premenopausal breast?

A

Fibrocystic change; thought to be hormone mediated

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38
Q

What does fibrocystic change present as?

A

vague irregularity of the breast tissue (lumpy breast), usually in the upper outer quadrant

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39
Q

In fibrocystic change what is seen on gross exam?

A

Cysts have a blue-dome appearance on gross exam.

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40
Q

Is fibrocystic change malignant or benign?

A

benign, but some fibrocystic-related changes are associated with an increased risk for invasive carcinoma (increased risk applies to both breasts)

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41
Q

For what type of fibrocystic change is there no increased risk for carcinoma?

A

Fibrosis, cysts, and apocrine metaplasia

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42
Q

For what type of fibrocystic change is there 2x increased risk for carcinoma?

A

Ductal hyperplasia and sclerosing adenosis

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43
Q

For what type of fibrocystic change is there 5x increased risk for carcinoma?

A

Atypical hyperplasia

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44
Q

What is intraductal papilloma?

A

Papillary growth, usually into a large duct

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45
Q

What is intraductal papilloma characterized by?

A

fibrovascular protections lined by epithelial (luminal) and myoepithelial cells

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46
Q

What does intraductal papilloma classically present as?

A

bloody nipple discharge in a premenopausal woman

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47
Q

What must intraductal papilloma be distinguished from?

A

papillary carcinoma, which also presents as bloody nipple discharge

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48
Q

What is papillary carcinoma characterized by?

A

fibrovascular projections lined by epithelial cells without underlying myoepithelial cells

49
Q

When does the risk of papillary carcinoma increase?

A

with age; thus, it is more commonly seen in postmenopausal women.

50
Q

What is fibroadenoma?

A

Tumor of fibrous tissue and glands

51
Q

What is the most common benign neoplasm of the breast?

A

fibroadenoma; usually seen in premenopausal women

52
Q

What does fibroadenoma present as?

A

a well-circumscribed, mobile marble-like mass

53
Q

Does the fibroadenoma respond to estrogen?

A

Yes it is estrogen sensitive and grows during pregnancy and may be painful during the menstrual cycle

54
Q

Is fibroadenoma malignant or benign?

A

it is benign with no increased risk of carcinoma

55
Q

What is phyllodes tumor?

A

Fibroadenoma-like tumor with overgrowth of the fibrous component;

56
Q

What is characteristically seen on biopsy of phyllodes tumor?

A

leaf-like projections are seen on biopsy

57
Q

In whom is phyllodes tumor most commonly seen?

A

in postmenopausal women

58
Q

Is phyllodes tumor benign or malignant?

A

It can be malignant in some cases

59
Q

What is the frequency of breast cancer?

A

It is the most common carcinoma in women by incidence (excluding skin cancer)

60
Q

What is the 2nd most common cause of cancer mortality in women?

A

Breast cancer

61
Q

What are the risk factors for breast cancer?

A

they are mostly related to estrogen exposure; 1. Female gender 2. Age?Cancer usually arises in postmenopausal women, with the notable exception of hereditary breast cancer. 3. Early menarche/late menopause 4. Obesity 5. Atypical hyperplasia 6. First-degree relative (mother, sister, or daughter) with breast cancer

62
Q

What is ductal carcinoma in situ?

A

Malignant proliferation of cells in ducts with no invasion of the basement membrane

63
Q

What is ductal carcinoma often detected as on mammography?

A

Often detected as calcification on mammography; DCIS does not usually produce a mass.

64
Q

Mammographic calcifications can also be associated with what?

A

benign conditions such as fibrocystic changes (especially sclerosing adenosis) and fat necrosis.

65
Q

For calcification of breast tissue what is necessary to distinguish between benign and malignant conditions?

A

biopsy of breast calcifications

66
Q

What are the histologic subtypes of DCIS based on?

A

architecture; comedo type is characterized by high-grade cells with necrosis and dystrophic calcification in the center of ducts

67
Q

What is Paget disease of the breast?

A

is DCIS that extends up the ducts to involve the skin of the nipple

68
Q

What does Paget disease presents as?

A

nipple ulceration and erythema

69
Q

What is Paget disease of the breast almost always associated with?

A

an underlying carcinoma.

70
Q

What is invasive ductal carcinoma?

A

Invasive carcinoma that classically forms duct-like structures

71
Q

What is the most common type of invasive carcinoma in the breast?

A

Invasive ductal carcinoma, accounting tor > 80% of cases

72
Q

What does invasive ductal carcinoma present as?

A

a mass detected by physical exam or by mammography

73
Q

For invasive ductal carcinoma, what is the size of clinically detected masses?

A

they are usually 2 cm or greater

74
Q

For invasive ductal carcinoma what is the size of mammographically detected masses?

A

They are usually 1 cm or greater

75
Q

For invasive ductal carcinoma what is the size of advanced tumors?

A

they may result in dimpling of the skin or retraction of the nipple.

76
Q

For invasive ductal carcinoma, what deos biopsy usually show?

A

duct-like structures in adesmoplastic stroma; special subtypes of invasive ductal carcinoma include

77
Q

What is tubular carcinoma characterized by?

A

well-differentiated tubules that lack myoepithelial cells;

78
Q

What is the prognosis for tubular carcinoma?

A

relatively good prognosis

79
Q

What is mucinous carcinoma characterized by?

A

carcinoma with abundant extracellular mucin (tumor cells floating in a mucus pool)

80
Q

In whom does mucinous carcinoma tend to occur?

A

in older women (average age is 70 years)

81
Q

What is the prognosis for mucinous carcionoma?

A

Relatively good prognosis

82
Q

What is medullary carcinoma characterized by?

A

large, high-grade cells growing in sheets with associated lymphocytes and plasma cells

83
Q

How does medullary carcinoma grow?

A

as a well-circumscribed mass that can mimic fibroadenoma on mammography

84
Q

What is the prognosis for medullary carcinoma?

A

Relatively good prognosis

85
Q

In whom is there an increased incidence of medullary carcinoma?

A

in BRCA1 carriers

86
Q

What is inflammatory carcinoma characterized by?

A

carcinoma in dermal lymphatics

87
Q

What does inflammatory carcinoma present as classically?

A

as an inflamed, swollen breast (tumor cells block drainage of lymphatics) with no discrete mass; can be mistaken for acute mastitis

88
Q

What is the prognosis for inflammatory carcinoma?

A

Poor prognosis

89
Q

What is lobular carcinoma in situ?

A

(LCIS) Malignant proliferation of cells in lobules with no invasion of the basement membrane

90
Q

How is LCIS usually discovered?

A

Its usually discovered incidentally since it does not produce a mass or calcifications

91
Q

What is LCIS characterized by?

A

dyscohesive cells lacking E-cadherin adhesion protein

92
Q

Describe LCIS.

A

It is often multifocal and bilateral

93
Q

What is the treatment for LCIS?

A

Treatment is tamoxifen (to reduce the risk of subsequent carcinoma) and close follow-up; low risk of progression to invasive carcinoma

94
Q

Can LCIS become invasive?

A

low risk of progression to invasive carcinoma

95
Q

What is invasive lobular carcinoma?

A

Invasive carcinoma that characteristically grows in a single-file pattern, cells may exhibit signet-ring morphology

96
Q

In invasive lobular carcinoma, what happens to the duct?

A

No duct formation due to lack of E-cadherin

97
Q

What is the prognosis in breast cancer based on?

A

TNM staging.

98
Q

What is the most important factor in breast cancer?

A

Metastasis is the most important factor, but most patients present before metastasis occurs,

99
Q

What is the most useful prognostic factor (given that metastasis is not common at presentation)? How is this performed?

A

Spread to axillary lymph nodes; sentinel lymph node biopsy is used to assess axillary lymph nodes.

100
Q

In breast cancer, what are predictive factors used for?

A

predict response to treatment.

101
Q

What is the most important predictive factor for breast cancer?

A

estrogen receptor (ER), progesterone receptor (PR), and HER2/neu gene amplification (overexpression) status.

102
Q

In breast cancer what is the presence of ER and PR associated with?

A

a response to antiestrogenic agents (eg tamoxifen); both receptors are located in the nucleus

103
Q

What is the HER2/neu amplification associated with?

A

response to trastuzumab (Herceptin), a designer antibody directed against the HER2 receptor

104
Q

What is HER2/neu?

A

it is a growth factor receptor present on the cell surface

105
Q

In breast cancer, what are triple-negative tumors?

A

they are negative for ER, PR, and HER2/neu

106
Q

What is the prognosis for triple negative tumors?

A

They have a poor prognosis; African American women have an increased propensity to develop triple-negative carcinoma,

107
Q

What percentage of breast cancer cases does hereditary breast cancer represent?

A

10% of breast cancer cases

108
Q

What are the clinical features that suggest hereditary breast cancer?

A

includes multiple first-degree relatives with breast cancer, tumor at an early age (premenopausal), and multiple tumors in a single patient

109
Q

What are the most important single gene mutations associated with hereditary breast cancer?

A

BRCA I and BRCA2 mutations

110
Q

What is the BRCA1 mutation associated with?

A

breast and ovarian carcinoma.

111
Q

What is the BRCA2 mutation associated with?

A

breast carcinoma in males.

112
Q

What might women with a genetic propensity to develop breast cancer choose to do?

A

undergo removal of both breasts (bilateral mastectomy) to decrease the risk of developing carcinoma.

113
Q

What is the risk associated with bilateral mastectomy?

A

a small risk for cancer remains because breast tissue sometimes extends into the axilla or subcutaneous tissue of the chest wall.

114
Q

What is male breast cancer?

A

Breast cancer is rare in males (represents 1% of all breast cancers).

115
Q

How does breast cancer usually present?

A

as a subareolar mass in older males; 1. Highest density of breast tissue in males is underneath the nipple. 2. May produce nipple discharge

116
Q

What is the most common histological subtype for breast cancer in males?

A

invasive ductal carcinoma.

117
Q

What is the frequency of lobular carcinoma in males?

A

it is rare (the male breast develops very few lobules),

118
Q

What is breast cancer in males associated with?

A

Associated with BRCA2 mutations and Klinefelter syndrome

Pathoma Notes (19 decks)

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