Final - new material Flashcards
Anytime a male or non-gravid female is producing breast discharge:
galactorrhea
MC from hormonal dysregulation or side-effect from several meds (OCPs)
excess prolactin expressed, mb from prolactinoma
The breasts are modified ___________:
sweat glands
The lactiferous duct system contains _________ ducts, which correspond to ____ openings at the nipple.
4-18
each duct opens to the nipple (equal #)
% of breast cancer found in each quadrant:
Upper Outer - 58%***
Upper Inner - 17%
Lower Outer - 12%
Lower Inner - 13%
The lactiferous ducts and lobules are lined by 2 cell types:
luminal epithelium cells - milk production
myoepithelial cells - assist lactation (ejection); normal structure/function
___% of lymph flow from breast travels to _____ node system:
75%
axillary [includes pectoral, sub-scap, humeral]
How are stroma & parenchyma different?
Stroma - non-functional, connective tissue, supportive framework.
Parenchyma - functional parts of an organ; in cancer, the mutant cells.
Amastia:
absent breast tissue/nipple/areola
Amazia:
absent mammary gland tissue
nipple/areola present
Athelia:
absent nipple or areola
glandular tissue present
In the ___ decade breast stromal tissues begin to involute, and at ________ diminish/disappear, replaced by adipose.
3rd decade
menopause
Estrogen stimulates what:
epithelial cell proliferation
ductal elongation/branching
increased volume & elasticity of CT/ducts
increased adipose tissue
Progesterone stimulates what:
increased lobule formation
increased size of acini/lumen/ducts
The glands on the areola are called _________ and function to:
Montgomery tubercles (sebaceous glands) lubricate nipple
Breast histology - 1st trimester:
3rd trimester:
1st - acinar proliferation
stromal involution
minimal secretory changes
3rd - lobular proliferation
cells enlarged, increased cytoplasm, lg nuclei
dramatic stromal involution
Inverted nipples are familial in ___% of cases,
bilateral in ____% of cases,
and present in ___% of the population.
familial - 50%
bilateral - 90%
incidence - 3%
When is an inverted nipple a red flag sign?
When it is a new onset in absence of a known cause
Galactorrhea is disconcerting when:
unilateral
bloody
assoc w/mass
Inflammation of the parenchyma of the mammary gland:
Mastitis
usu. when lactating -> puerperal
When found to be infectious in cause, mastitis is usu d/t:
staph aureus OR strep epidermitis
generally enters via cracks/fissures in nipple
Peri-ductal mastitis usu presents as:
painful mass in the sub-areolar area
overlying skin erythema
>90% are smokers
nipple inversion may occur
Peri-ductal mastitis - histology:
keratinizing squamous epithelium in the duct system
extends to abn depth
chronic granulomatous inflammatory response
dilation/rupture of ducts
Mammary duct ectasia is:
commonly seen in:
dilatation of the sub-areolar ducts
often unilateral, but mb bilateral
5th or 6th decade
multiparous women
Mammary duct ectasia - clinical presentation:
breast pain overlying erythema palpable areolar or peri-areolar mass poorly defined mass mb thick secretions from nipple mb nipple inversion (30-40%)
Mammary duct ectasia - histology:
dilated lactiferous ducts
granular debris -> inc foamy (lipid) macrophages
infiltration of lymphs & macrophages
inc plasma cells
Condition characterized by fibrous lumps & cords in breast tissue that are non-cancerous:
Fibrocystic breast dz
30-60% of women
frequently dx’d at 20-40 yo
uncommon before adolescence/after menopause
Fibrocystic breast changes are most often found:
Dx:
in the upper outer quadrant
mammography - limited value, mb too dense to visualize
bx or aspiration - definitive
Fibrocystic breast - histology:
fibrosis - dense collagen
sclerosing ductal epithelial proliferation - round ducts inc in size
adenosis - full of glands
apocrine metaplasia - lg cystic spaces, fluid-filled
MC occurs as result of prior breast trauma or 2° to breast surgery:
fat necrosis
adipocyte rupture -> lipolysis, converted to fatty acid + glycerol -> fibroblastic proliferation, inc vascularization -> calcification, hemosiderin deposition
presents as painless breast mass, skin thickening, mb tissue retraction -> looks like malignant neoplasm
Fat necrosis - on mammogram:
central radiolucent area of fat w/inc density
calcifications at fat periphery
bx follows if mammo fails to r/o cancer
Fat necrosis - histology:
irregular fatty spaces
foamy histiocytes surrounding
multinucleate giant cells
Condition characterized by a single hard mass or multiple hard masses that are made up of collagenized stroma surrounding atrophic ducts and lobules:
lymphocytic mastopathy
Lymphocytic mastopathy - histology:
thickening & fibrosis of stromal tissue
lymphocytic infiltrates surround epithelium & vessels
Lymphocytic mastopathy MC found in:
women w/ DM 1
women w/ AI thyroiditis
-> mb LM is also AI dz…? (theory)
Uncommon form of mastitis characterized by the presence of granulomas, formed by epithelioid cells & giant cells:
Granulomatous mastopathy
etio - idiopathic
mb d/t TB, sarcoidosis, Wegener’s granulomatosis
mb seen w/ breast carcinoma, mb draining lymph nodes
What confirms the granulomatous mastopathy dx?
positive cultures for/demonstration of acid-fast bacilli
Adenosis refers to:
increased number of glandular components
grows/organizes -> adenoma (benign)
MC benign tumor of the breast:
fibroadenoma well-circumscribed mass w/fibrotic capsule firm freely movable NTTP MC
Fibroadenoma - histology:
low mag - well-encapsulated
high mag - notable hyperplasia of intraductal epithelial cells, normal nuclei, normal nucleus/cytoplasm ratio
T/F - fibroadenomas commonly increase in size during pregnancy.
True
they are hormonally responsive
also inc during luteal phase of menses
regress after menopause
A localized focus of hyperplastic cells seen in breast tissue during pregnancy:
Lactating adenoma
solitary or multiple
histo - hyperplastic lobules, cytoplasmic vacuolization
Intraductal papillomas are identified in ___% of all breast biopsies.
1-3%
benign, but definite potential for malignant transformation (very small liklihood): solitary ductal papilloma / multiple
Intraductal papilloma - histology:
myoepithelial cells multilayered ductal cells * flattened * nuclei near lumenal surface * long axes align in same direction
Vast majority of breast cancers arise in _______ tissue and are classified as _______________.
Glandular (lobular & ductal)
adenocarcinoma
Risk factors for breast cancer - HIGH:
female
advancing age
PMHx of cancer in one breast
FHx of both mother & sister w/breast cancer
>2 alcoholic bevs/day
high premenopause IGF-1 levels
high post-menopause blood estrogen levels
Risk factors for breast cancer - MOD:
>30 yrs at first pregnancy nulliparity early menarche late menopause post-menopause obesity caucasian, >45yo African-American, <45yo any 1st deg relative w/Hx of breast cancer Hx of endometrial / ovarian cancer tobacco use high fat/sat fat rich diet Hx of benign proliferative lesion, dysplastic mammography changes, & high dose of ionizing radiation to chest
Protective factors against breast cancer:
>15 at menarche (anovulation, early menopause) >1 yr breast feeding physical activity minimal EtOH consumption no tobacco use monounsat fat rich diet
Hereditary breast cancers represent ____% of total:
27%
of inherited -> mutated BRCA 1 & 2 account for 30-40%
BRCA in gen population: ____%
in Ashkenazi Jew population: ____%
0.1%
20%
By their cell proliferating effects on breast epithelium, _________ increase the chance of DNA replication errors leading to greater chance for mutations.
Estrogens
Women in what country have the highest incidence rate of breast cancer?
USA
MC cancer, 2nd MC cause of death - women in USA
What does “ER positive” suggest:
Over-expression of estrogen receptors
found in 70% of breast cancer cases
two kinds - alpha & beta, encoded by ESR1 & ESR2 genes
______ preferentially binds to the alpha ER.
______ preferentially bind to the beta ER.
______ binds to both ERs equally well.
Estrone
Estriol, Raloxifene, Genistein
17-beta-estradiol
BRCA1 & BRCA2 are both _________ genes.
Tumor suppressor genes, involved in DNA repair of double-strand breaks.
BRCA2 also binds/regulates RAD51 to fix DNA breaks.
Heterozygous germ-line mutations in either BRCA1 or BRCA2 gene show inc rates of breast & ovarian cancer.
_____% of women with mutated BRCA1 gene will develop breast cancer during their lifetime.
50-85%
reduced risk with:
prophylactic mastectomy
salpingo-oophrectomy (age 40)
For BRCA2 -> advantage shown only w/concurrent procedures
A genetic risk factor for breast cancer is presence of the proto-oncogene _________, present in _____% of breast cancers.
Also seen in:
HER2/neu (human epidermal growth factor receptor 2)
30%
ovarian cancer
stomach cancer
uterine cancer
assoc w/ worse prognosis, inc recurrence (in all types)
PE findings assoc w/breast cancer:
firm/hard breast mass painless mass (TTP only 10-15%) irregular borders to mass mb fixed to chest wall or skin skin dimpling nipple retraction bloody dc from nipple
PE findings assoc w/benign mass:
firm, rubbery frequently TTP regular margins mobile no dimpling/skin retraction/bloody dc
The 3 main types of breast cancer are:
Ductal
Lobular
Nipple (Paget’s dz of breast/nipple)
MC type of breast cancer:
infiltrating ductal carcinoma [80%]
usu. single hard mass
irreg borders
not easily movable
Infiltrating ductal carcinoma - histology:
cords & nests of neoplastic cells
intervening collagen
dystrophic calcifications
pleomorphic cells strewn through stroma
2nd MC type of breast cancer:
Lobular [5-10%]
high risk for multiple loci
inc risk for BL involvement
Lobular carcinoma is characterized by presence of small homogenous cells that invade the stroma, often seen in a ___________ pattern.
Worse prognosis is assoc w/ presence of ______ appearance.
Single-file pattern
Signet ring appearance
Relatively uncommon dz of the breast involving the nipple & areolar area, presenting w/persistent change in sensation of that area (itching, burning):
Paget’s dz of the breast
classic finding: eczematous changes over nipple/areola
later stage: ulceration/destruction of nipple/areolar complex
Paget’s dz of the breast - histology:
large round cells
pale cytoplasm
pleomorphic nuclei
derived from glandular epithelium
Form of ductal carcinoma distinguished by the markedly inflammed appearance of the affected breast:
Inflammatory breast cancer (IBC)
especially aggressive
presents w/o palpable lump
