Chapter 16: Breast Pathology

Question 1

Histologically, what kind of tissue is the breast ?

Answer 1

Modified sweat gland derived from skin cells

Question 2

Where in the body is breast tissue ‘capable’ of being created ? (in a non-teratoma setting, of course)

Answer 2

Along the ‘Milk Line’

Can lead to supernumerary nipples and breast tissues.

Question 3

What is the functional unit of the breast ?

Answer 3

Terminal Duct Lobule Unit

Question 4

What portion of the TDLU makes the milk ?

Answer 4

Lobules

Question 5

What portion of the TDLU is drains the lobules milk secretions ?

Answer 5

Duct

Question 6

What are the two layers of the TDLU epithelium ?

Answer 6

Luminal Cell Layer ( Inner,Columnar)

Myoepithelium (Outer, meaning closer to the basement membrane)

Question 7

Which epithelial cell type is responsible for milk production in the lobule ?

Answer 7

Luminal cell layer (inner.)

Question 8

Which epithelial cell type is responsible for contraction and ejection of milk from the duct ?

Answer 8

Myoepithelial

Question 9

Breast tissue is hormone sensitive. What hormones are most active on the breast during development ?

Answer 9

Estrogen

Progesterone

Question 10

What quadrant of the breast contains the majority of the breast tissue ?

Answer 10

Upper Outer Quadrant

Question 11

Hyperplasia of the breast during pregnancy is driven by estrogen and progesterone. Where is progesterone produced early in pregnancy ? Late ?

Answer 11

Early: Corpus luteum
Late: Fetus and Placenta

Question 12

Define Galactorrhea

Answer 12

Milk production at a discordant time (not during months of feeding or after pregnancy)

Question 13

What are three causes of galactorrhea ?

Answer 13

Nipple Stimulation
Prolactinoma
Drugs (dopamine inhibitors etc)

Question 14

Is Galactorrhea a symptom of breast cancer ?

Answer 14

NO !!!!!!

Question 15

What is the most common organism seen in Acute Mastitis ?

Answer 15

S. aureus (Acute Mastitis is really a bacterial infection of the breast)

Question 16

What activity increases the risk for acute mastitis ?

Answer 16

Breast Feeding (creates fissures)

Question 17

Along with erythematous breast tissue, what common symptom/sign do you see in Acute Mastitis ?

Answer 17

Purulent Nipple Discharge ! (w/ possible abscess formation)

Question 18

What are the two main treatments for Acute Mastitis ?

Answer 18

Drainage via feeding

Anti-biotics (Dicloxacillin)

Question 19

Where in the breast will you see inflammation in Periductal Mastitis ?

Answer 19

Sub-areolar ducts

Question 20

What patient subgroup is at risk for Periductal Mastitis ?

Answer 20

SMOKERS !

Question 21

What does smoking cause that leads to a squamous metaplasia of the luminal duct epithelium ?

Answer 21

Relative Vitamin A deficiency (Luminal duct epithelium is typically columnar.)

Question 22

What is the overall consequence of squamous metaplasia of the luminal epithelium in Periductal Mastitis ?

Answer 22

Leads to blockage of the duct, this will lead to inflammation thus Periductal Mastitis

Question 23

What are the two findings seen on clinical presentation of Periductal Mastitis ?

Answer 23

Subareolar Mass and Nipple Retraction.

Note: Nipple retraction is often associated with cancer, but not in this case. Caused by proliferation of fibroblasts due to inflammation.

Question 24

Mammary Duct Ectasia presents as inflammation with ____________ of the subareolar ducts .

Answer 24

Dilatation

Question 25

In what patient population do you often see Mammary Duct Ectasia ?

Answer 25

Multiparous, Post-menopausal Women. (rarely seen)

Question 26

Mammary Duct Ectasia is often seen with a mass that is located where in the breast ?

Answer 26

PERI-areolar region ( Periductal Mastitis shows mass that is SUB-areolar)

Question 27

Like Acute Mastitis, Mammary Duct Ectasia can present with _____________.

Answer 27

Nipple Discharge (Green Brown in the case of Mammary Duct Ectasia, more purulent in case of Acute Mastitis)

Question 28

Why is the finding of a mass in Mammary Duct Ectasia an initially troubling sign until you realize the association with nipple discharge ?

Answer 28

Most patients with Mammary Duct Ectasia are Post Menopausal Mass in Post-Menopausal women is very much associated with cancer Green Brown Discharge is NOT a sign of Breast Cancer.

Question 29

On biopsy of Mammary Duct Ectasia, what kind of cells will be seen ?

Answer 29

Plasma Cells ! ( chronic inflammatory state).

Question 30

What is the major etiology of fat necrosis of the breast ?

Answer 30

TRAUMA

Question 31

What two presentations are seen in patients with Fat Necrosis ?

Answer 31

Mass or Abnormal Calcification on Mammography.

Question 32

What is saponification ?

Answer 32

Ca++ + Dead Tissue

Question 33

On biopsy of necrotic fat you will see calcification and....

Answer 33

Giant Cells.

Question 34

What is the most common 'change' seen in the pre-menopausal breast ?

Answer 34

Firbrocystic Change (Benign)

Question 35

Where in the breast do you often see fibrocystic change ?

Answer 35

upper outer quadrant (just like most breast cancers)

Question 36

What appearance do cysts seen in this change have on gross exam

Answer 36

blue dome

Question 37

Fibrosis, cysts and apocrine metaplasia increase the risk for invasive carcinoma by how much ?

Answer 37

None (no correlation)

Question 38

Ductal hyperplasia and sclerosing adenosis ncrease the risk for invasive carcinoma by how much ?

Answer 38

2x

Question 39

Atypical Hyperplasia ncrease the risk for invasive carcinoma by how much ?

Answer 39

5x

Question 40

Papillary growth into a large ductule characterized by benign presentation with bloody nipple discharge is most likely..

Answer 40

Intraductal Papilloma

Question 41

What cell layer is retained in intraductal papilloma that is lost in papillary carcimon ?

Answer 41

Myoepithelial cell layer (both still retain the epithelial (luminal cells)

Question 42

In what age group of patients are you most likely to see papillary carcinoma ?

Answer 42

post menopausal women

Question 43

Tumor of fibrous tissue and glands, well circumscribed, estrogen sensitive and grows/regresses with menstrual cycle causing pain is most likely

Answer 43

Fibroadenoma (benign)

Question 44

Does firboadenoma carry an increased risk for carcinoma ?

Answer 44

NO !

Question 45

Leaf- like projections due to an overgrowth of fibrous components and is most commonly seen in post-menopausal women. What is this tumor and what is its oncogenic potential ?

Answer 45

Phyloddes Tumor Can be malignant in some cases

Question 46

Breast cancer is most often seen in which age group ?

Answer 46

Post menopausal women

Question 47

What is the common link in all risk factors for breast cancer ?

Answer 47

Exposure to ESTROGEN !

Question 48

Is Late Menarche/Early Menopause a risk factor for breast cancer ?

Answer 48

NO !! That would limit your exposure to estrogen (starting later, ending earlier) Early Menarche/Late Menopause is associated with higher risk !

Question 49

Is obesity a risk factor for breast cancer ?

Answer 49

YES ! Adipose tissue converts androgens to estrogens via aromatase --> Increased estrogen

Question 50

Ductal Carcinoma in Situ is a direct precursor to Ductal carcinoma. What is often seen on mammography of a patient with DCIS ?

Answer 50

Calcifications (Also seen in fibrocystic change, fat necrosis and sclerosing adenosis which are benign) For remninder : Carcinoma in situ is cancer which has not invaded past the basement membrane of the structure it is in

Question 51

Describe the Comedo type of DCIS based on histology.

Answer 51

Architecturally there will be necrosis and dystrophic calcification within the ducts.

Question 52

DCIS that extends up to the nipple and cause ulceration, crusting and erythema of the nipple is known as..

Answer 52

Pagets Disease

Question 53

Is Pagets Disease of the breast associated with carcinoma ?

Answer 53

ALMOST ALWAYS !

Question 54

What is the most common kind of invasive carcinoma seen in the breast ?

Answer 54

Invasive DUCTAL Carcinoma.

Question 55

What size Invasive Ductal carcinomas can clinical exam and mammogram find respectively ?

Answer 55

2cm or greater 1cm or greater

Question 56

What are the 4 types of Invasive Ductal Carcinoma ?

Answer 56

Tubular Carcinoma Mucinous Carcinoma Medullary Carcinoma Inflammatory Carcinoma

Question 57

In tubular carcinoma you will see well differentiated tubules that lack what cell type ?

Answer 57

Myoepithelial cells

Question 58

What is the classical description for a mucinous ductal carcinoma ?

Answer 58

"Cancer cells floating in pools of mucous'

Question 59

Medullary Ductal carcinoma is often described as high grade cells in sheets associated with what other 2 kinds of cells ?

Answer 59

Lymphocytes | Plasma Cells

Question 60

Medullary Ductal carcinoma can mimmic what tumor on mammography ?

Answer 60

Firboadenoma (benign, get a biopsy)

Question 61

What disease is Inflammatory Ductal Carcinoma often confused with ?

Answer 61

Acute Mastitis | Inflamed swollen breast due to blockage of lymph canals by ductal carcinoma

Question 62

Does lobular carcinoma in situ present with calcifications ?

Answer 62

No !

Question 63

What adhesion protein is often lacking in Lobular Carcinoma in Situ ?

Answer 63

E-Cadeherin (may explain why it can become malignant)

Question 64

Is obular Carcinoma in Situ multifocal and BILATERAL ?

Answer 64

Yes !

Question 65

What is the best treatment for Lobular Carcinoma in Situ ?

Answer 65

Tomoxifen and close follow up | Low risk of becoming Lobular Carcinoma

Question 66

What pattern of growth is seen in Lobular Carcinoma ?

Answer 66

Single file pattern of cells

Question 67

Like obular Carcinoma in Situ , Lobular Carcinoma lacks what adhesion protein ?

Answer 67

E-Cadherin

Question 68

What characteristic cell type is seen in Lobular Carcinoma ?

Answer 68

Signet Ring (also seen in Kruckenberg tumor of the Ovary)

Question 69

What is the most important factor in staging tumors ?

Answer 69

Metastasis (in this case axillary lymph node involvement)

Question 70

What procedure is used to see which lymph node the tumor is draining to ?

Answer 70

Sentinel Lymph Node Procedure

Question 71

HER2/Neu is often over expressed is breast cancer. What kind of molecule is this ?

Answer 71

Receptor for epidermal growth factors

Question 72

What drug is useful in treating patients with HER2 amplification ?

Answer 72

Trastuzumab (antibody to the receptor)

Question 73

What drug is useful for treating tumors associated with ER and PR over expression ?

Answer 73

Tomoxifen

Question 74

BRCA1 mutations are associated with which tumors ?

Answer 74

Breast and ovarian cancer

Question 75

BRCA2 mutations are associate with which tumors ?

Answer 75

Breast cancer in Men !

Question 76

What kind of mass is seen in male breast cancer ?

Answer 76

subareolar

Question 77

Will there be nipple discharge in male breast cancer ?

Answer 77

Yes

Question 78

What kind of breast cancer is more likely in men Ductal or lobular ?

Answer 78

Ductal (men don't form lobules in most cases)

Question 79

What congenital disease with XXY genetics is associated with male breast cancer ?

Answer 79

Kleinfelter | BRCA2 as discussed earlier is also associated