Chapter 16: Breast Pathology Flashcards
Histologically, what kind of tissue is the breast ?
Modified sweat gland derived from skin cells
Where in the body is breast tissue ‘capable’ of being created ? (in a non-teratoma setting, of course)
Along the ‘Milk Line’
Can lead to supernumerary nipples and breast tissues.
What is the functional unit of the breast ?
Terminal Duct Lobule Unit
What portion of the TDLU makes the milk ?
Lobules
What portion of the TDLU is drains the lobules milk secretions ?
Duct
What are the two layers of the TDLU epithelium ?
Luminal Cell Layer ( Inner,Columnar)
Myoepithelium (Outer, meaning closer to the basement membrane)
Which epithelial cell type is responsible for milk production in the lobule ?
Luminal cell layer (inner.)
Which epithelial cell type is responsible for contraction and ejection of milk from the duct ?
Myoepithelial
Breast tissue is hormone sensitive. What hormones are most active on the breast during development ?
Estrogen
Progesterone
What quadrant of the breast contains the majority of the breast tissue ?
Upper Outer Quadrant
Hyperplasia of the breast during pregnancy is driven by estrogen and progesterone. Where is progesterone produced early in pregnancy ? Late ?
Early: Corpus luteum
Late: Fetus and Placenta
Define Galactorrhea
Milk production at a discordant time (not during months of feeding or after pregnancy)
What are three causes of galactorrhea ?
Nipple Stimulation
Prolactinoma
Drugs (dopamine inhibitors etc)
Is Galactorrhea a symptom of breast cancer ?
NO !!!!!!
What is the most common organism seen in Acute Mastitis ?
S. aureus (Acute Mastitis is really a bacterial infection of the breast)
What activity increases the risk for acute mastitis ?
Breast Feeding (creates fissures)
Along with erythematous breast tissue, what common symptom/sign do you see in Acute Mastitis ?
Purulent Nipple Discharge ! (w/ possible abscess formation)
What are the two main treatments for Acute Mastitis ?
Drainage via feeding
Anti-biotics (Dicloxacillin)
Where in the breast will you see inflammation in Periductal Mastitis ?
Sub-areolar ducts
What patient subgroup is at risk for Periductal Mastitis ?
SMOKERS !
What does smoking cause that leads to a squamous metaplasia of the luminal duct epithelium ?
Relative Vitamin A deficiency (Luminal duct epithelium is typically columnar.)
What is the overall consequence of squamous metaplasia of the luminal epithelium in Periductal Mastitis ?
Leads to blockage of the duct, this will lead to inflammation thus Periductal Mastitis
What are the two findings seen on clinical presentation of Periductal Mastitis ?
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.
Mammary Duct Ectasia presents as inflammation with ____________ of the subareolar ducts .
Dilatation
In what patient population do you often see Mammary Duct Ectasia ?
Multiparous, Post-menopausal Women. (rarely seen)
Mammary Duct Ectasia is often seen with a mass that is located where in the breast ?
PERI-areolar region ( Periductal Mastitis shows mass that is SUB-areolar)
Like Acute Mastitis, Mammary Duct Ectasia can present with _____________.
Nipple Discharge (Green Brown in the case of Mammary Duct Ectasia, more purulent in case of Acute Mastitis)
Why is the finding of a mass in Mammary Duct Ectasia an initially troubling sign until you realize the association with nipple discharge ?
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.
On biopsy of Mammary Duct Ectasia, what kind of cells will be seen ?
Plasma Cells ! ( chronic inflammatory state).
What is the major etiology of fat necrosis of the breast ?
TRAUMA
What two presentations are seen in patients with Fat Necrosis ?
Mass or Abnormal Calcification on Mammography.
What is saponification ?
Ca++ + Dead Tissue
On biopsy of necrotic fat you will see calcification and….
Giant Cells.
What is the most common ‘change’ seen in the pre-menopausal breast ?
Firbrocystic Change (Benign)
Where in the breast do you often see fibrocystic change ?
upper outer quadrant (just like most breast cancers)
What appearance do cysts seen in this change have on gross exam
blue dome
Fibrosis, cysts and apocrine metaplasia increase the risk for invasive carcinoma by how much ?
None (no correlation)
Ductal hyperplasia and sclerosing adenosis ncrease the risk for invasive carcinoma by how much ?
2x
Atypical Hyperplasia ncrease the risk for invasive carcinoma by how much ?
5x
Papillary growth into a large ductule characterized by benign presentation with bloody nipple discharge is most likely..
Intraductal Papilloma
What cell layer is retained in intraductal papilloma that is lost in papillary carcimon ?
Myoepithelial cell layer (both still retain the epithelial (luminal cells)
In what age group of patients are you most likely to see papillary carcinoma ?
post menopausal women
Tumor of fibrous tissue and glands, well circumscribed, estrogen sensitive and grows/regresses with menstrual cycle causing pain is most likely
Fibroadenoma (benign)
Does firboadenoma carry an increased risk for carcinoma ?
NO !
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 ?
Phyloddes Tumor
Can be malignant in some cases
Breast cancer is most often seen in which age group ?
Post menopausal women
What is the common link in all risk factors for breast cancer ?
Exposure to ESTROGEN !
Is Late Menarche/Early Menopause a risk factor for breast cancer ?
NO !!
That would limit your exposure to estrogen (starting later, ending earlier)
Early Menarche/Late Menopause is associated with higher risk !
Is obesity a risk factor for breast cancer ?
YES !
Adipose tissue converts androgens to estrogens via aromatase –> Increased estrogen
Ductal Carcinoma in Situ is a direct precursor to Ductal carcinoma. What is often seen on mammography of a patient with DCIS ?
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
Describe the Comedo type of DCIS based on histology.
Architecturally there will be necrosis and dystrophic calcification within the ducts.
DCIS that extends up to the nipple and cause ulceration, crusting and erythema of the nipple is known as..
Pagets Disease
Is Pagets Disease of the breast associated with carcinoma ?
ALMOST ALWAYS !
What is the most common kind of invasive carcinoma seen in the breast ?
Invasive DUCTAL Carcinoma.
What size Invasive Ductal carcinomas can clinical exam and mammogram find respectively ?
2cm or greater
1cm or greater
What are the 4 types of Invasive Ductal Carcinoma ?
Tubular Carcinoma
Mucinous Carcinoma
Medullary Carcinoma
Inflammatory Carcinoma
In tubular carcinoma you will see well differentiated tubules that lack what cell type ?
Myoepithelial cells
What is the classical description for a mucinous ductal carcinoma ?
“Cancer cells floating in pools of mucous’
Medullary Ductal carcinoma is often described as high grade cells in sheets associated with what other 2 kinds of cells ?
Lymphocytes
Plasma Cells
Medullary Ductal carcinoma can mimmic what tumor on mammography ?
Firboadenoma (benign, get a biopsy)
What disease is Inflammatory Ductal Carcinoma often confused with ?
Acute Mastitis
Inflamed swollen breast due to blockage of lymph canals by ductal carcinoma
Does lobular carcinoma in situ present with calcifications ?
No !
What adhesion protein is often lacking in Lobular Carcinoma in Situ ?
E-Cadeherin (may explain why it can become malignant)
Is obular Carcinoma in Situ multifocal and BILATERAL ?
Yes !
What is the best treatment for Lobular Carcinoma in Situ ?
Tomoxifen and close follow up
Low risk of becoming Lobular Carcinoma
What pattern of growth is seen in Lobular Carcinoma ?
Single file pattern of cells
Like obular Carcinoma in Situ , Lobular Carcinoma lacks what adhesion protein ?
E-Cadherin
What characteristic cell type is seen in Lobular Carcinoma ?
Signet Ring (also seen in Kruckenberg tumor of the Ovary)
What is the most important factor in staging tumors ?
Metastasis (in this case axillary lymph node involvement)
What procedure is used to see which lymph node the tumor is draining to ?
Sentinel Lymph Node Procedure
HER2/Neu is often over expressed is breast cancer. What kind of molecule is this ?
Receptor for epidermal growth factors
What drug is useful in treating patients with HER2 amplification ?
Trastuzumab (antibody to the receptor)
What drug is useful for treating tumors associated with ER and PR over expression ?
Tomoxifen
BRCA1 mutations are associated with which tumors ?
Breast and ovarian cancer
BRCA2 mutations are associate with which tumors ?
Breast cancer in Men !
What kind of mass is seen in male breast cancer ?
subareolar
Will there be nipple discharge in male breast cancer ?
Yes
What kind of breast cancer is more likely in men Ductal or lobular ?
Ductal (men don’t form lobules in most cases)
What congenital disease with XXY genetics is associated with male breast cancer ?
Kleinfelter
BRCA2 as discussed earlier is also associated
