L 77, 78 - Breast Path and Breast Cancer Flashcards
what is the functional unit of the breast
Terminal Duct Lobules -
path of milk through the breast during lactation
how do you differentiate between lobules and ducts on histology
Acini –> Terminal Ducts – > subsegmental duct –> Lactiferous ducts –> Nipple
Lobules – small and numerous
Ducts – larger tube through which milk collects after generation in the lobules. Seen as larger diameter circles or tube cut longitudinally
______-lobular stroma is hormone responsive; therefore explaining what symptoms?
□ Intralobular – responsive to hormones which explains breast tenderness in response to porgesterone
Interlobular stroma is not hormone responsive
what are two cell layers of ducts and acinin
Epithelial (luminal) Layer + Myoepithelial layer (outer layer, squeezing function during milk ejection)
Patient presents to clinic with complaints of breast pain; what is likelihood this is a cancer?
what should you ask to differentiate between breast pain etiologies?
Very few cancers present as breast pain (5%); likelihood increases if there is a mass (10%)
Ask if pain is cyclical vs non cyclical with menstruation
If cyclical: non pathologic
If non cyclical: no pathology; may be ruptured cyst
____% of patients presenting with palpable mass have cancer
True/false: younger women are more at risk for malignancy
10-35%
False: likelihood of malignancy increases with age
Patient presents with galactorrhea; what is your ddx? what are odds its malignant
what if the discharge is serous/bloody?
Not associated with malignancy
Usually from prolactinoma, anovulatory syndromes or side effects of TCA, OCP, Methyldopa
serous/bloody– usually benign papilloma or cyst; but risk of malig does increase with age.
Most common bug associated with acute lactation mastitis;
other physical signs
S. Aureus
Signs: cracks and fissures along the nipple; route of entry
Fat Necrosis – usually associated with _____
what is seen on mammography?
a/w trauma
usually see calcifications/densities which are mistaken for malignancies
Patient presents with painful recurrent sub areolar masses
what is it?
what’s seen on histo?
#1 risk factor?
Periductal Mastitis: recurrent subareolar abscess +squamous metaplasia
Histo: Squamous metaplasia and keratinization of nipple ducts
90% of pts are smokers
patient presents with periareolar mass and skin retraction + thick white/green/brown nipple secretions
dx?
is this patient a smoker or non smoker?
Mammary Duct Ectasia:
Non smoker
what is the most common benign breast tumor??
what age group is susceptible?
abnormal growth of what cell type?
Fibroadenoma
Phyllodes Tumor
characteristic cytology architecture?
is this malignant?
abnormal growth of what cell type?
“leaf-like architecture”
low grade malignancy that doesn’t metastasize, but recur locally
Intralobular stroma – therefore responsive to hormones
Patient presents with mass;
gross path is a “blue domed” lesion with apocrine histology
dx
what is the course?
Blue dome = cyst
Apocrine changes = fibrocystic
Entirely benign and very common
Fibrosis may be from ruptured cysts;
4 forms of proliferative breast disease without atypia
what is the relative risk of cancer ?
what is the absolute risk?
Epithelial Hyperplasia - mild, moderate, severe
Sclerosis Adenosis
Intraductal Papilloma
Gynocomastia
AR: 5-7%
RR: 1.5-2x (for moderate and severe hyperplasia, adenosis, and intraductal papilloma)
Epithelial Hyperplasia
what is seen on histo?
what grades have increased RR
Histo: increased proliferation of epithelial cells (luminal and myoepi)
Only moderate and severe
forms have increased RR
Lumen fills with heterogenous, mixed population of luminal and myoepithelial cells
IntraDuctal Papilloma
differences in presentation beween young vs older women?
Older women: subareolar, solitary; “large duct papilloma”
younger women: peripheral, multiple;
what drugs or conditions may cause gynocomastia?
Gynocomastia
Cirrhosis, Testicular Tumor, Klinefelters, Puberty, Old ag
Spironolactone, Digoxine, Cimetidinbe, Alcohol, Ketoconazole (Some drugs create awesome knockers)
2 types of proliferative breast disease with atypia?
what is the relative risk?
what is the absoute risk?
is this for the ipsilateral breast, conralateral or both ?
Atypical Ductal Hyperplasia
Atypical Lobular Hyperplasia –
RR: 4-5x
AR: 13-17% of having BC over the next 15 years
Both Breasts
Atypical Lobular Hyperplasia —
what is the associated mutation ?
E Cadherin mutation
what is the term for breast cancer which is contained to the epithelial layer?
which is much more common
DCIS – much more common
LCIS – not even in FIRST AID
what are the two forms subtypes of DCIS
Comedocarcinoma (Comedo DCIS)
Paget’s Disease of the Nipple
DCIS – what is the RR and AR? is this for the ipsilateral, contralateral or both breasts?
T/F: DCIS is a direct precursor of invasive breast cancer
T/F: majority is found bilaterally
RR: 8-10x
AR: 25-30% of BC if 15 years
Breasts at risk: Ipsilateral only
True: DCIS is the direct precursor
False: DCIS in found bilaterally in only 10-20% of cases
what s comedocarcinoma –
characteristic path?
High grade DCIS which is more likely to progress.
area has central necrosis
what is paget’s disease of the nipple?
clinical appearance?
characterisitc pathology?
DCIS extends into the lactiferous ducts and extends into the nipple epidermis
Clinical: Eczematous/crusting patches on the nipple
Histo: Paget’s Cells – large cells in epidermis with clear halo (abundant pale cytoplasm)
Mutlifocal and bilateral lesions found on mammography – bx reveals carcinoma contained to the epithelium. what is the dx?
LCIS === MULTIFOCAL AND BILATERAL
LCIS –
AR, RR
is this for the ipsilateral, contralateral or both breasts?’
T/F: LCIS is a direct precursor to invasive carcinoma?
associated mutation
T/F — if DCIS does becomes invasive, it will always be invasive ductal carcinoma?
RR: 8-10x
AR: 25-30% of BC if 15 years
BOTH BREASTS
NOT A PRECURSOR, but A MAKER OF INCREASED RISK BILATERALLY of INVASIVE CARCINOMA
Mutation: E Cadherin
False – if a DCIS has bi-allelic mutations to E cadherin, it will become invasive lobular carcinoma
what is the most common form of Invasive breast cancer?
Is this usually bilateral or unilateral?
Invasive Ductal Carcinoma – 80-85% of all breast cancers
Unilateral –
how does an invasive ductal carcinoma appear clinicaly?
Radiographically?
Gross path?
histologically?
Clinically – “rock hard mass”
Radiograph – spiculated mass
Gross: firm, fibrotic center
histo: fibrotic center; ducts and lobules invading surrounding breast tissue; lots of desmoplasia;
Pathognomonic histology for invasive lobular carcinoma
how does lobular invasive present?
what is the prognosis comapred to DCIS?
“Indian File” – orderly row of cells due to loss of E cadherin expression
BILATERAL AND MULTIFOCAL
Prognosis: same as DCIS
three other forms of invasive breast cancer that have favorable prognosis… what age groups are most likely to get each?
Medullary carcinoma – usually in younger patients
Colloid (mucinous carcinoma) – old lady
Tubular carcinoma – most favorable prognosis
two invasive carcinoma forms that have poor prognosis ?
Invasive Micropapillary Carcinoma
Metaplastic Carcinoma
what is Inflammatory breast carcinoma and what are the characteristic findings?
Dermal lymphatic invasion by breast carcinoma
neoplasitc cells block lymphatic drainage
Skin erythema + Peau d’ orange (orange peel skin)
what are important ancillary tests run on breast cancer findings; what is their signifiance ?
what is the marker for proliferation?
Hormone Receptor IHC:
Positive findings = Positive Prognostic and Positive Predictive findings
Her2/Neu (C-erb-2): weakly unfavorably prognostic, but positive predictive (Trastuzumab)
Ki-67: Marker for proliferation rate
Luminal A invasive breast cancer:
postive/negative for what anxcillary tests:
ER+/PR+/HER2- Proliferative low (low Ki-67) Low histological grade Older men and women Long survival
Luminal B invasive breast cancer:
ER+/PR+/HER2-
Medium to high prolifeation (more Ki-67)
Some associated with BRCA2
Behavior: Intermediate
HER2+ invasive carcinoma
May be PR or ER +
Who: young, non white women with P53 mutations
Respond to herceptin
Triple Negative –
ER-/PR-/HER2 -
Extremely High proliferation
Who; young AA and Hispanic women; BRCA1
Prognosis – Dramatic response to chemo; quickly relapse
If BRCA positive – bilateral mastectomy
Luminal A invasive breast cancer:
whats the ancillary test profile?
prognosis ?
ER+/PR+/HER2- Proliferative low (low Ki-67) Low histological grade Older men and women Long survival
Luminal B invasive breast cancer:
whats the ancillary test profile?
prognosis?
ER+/PR+/HER2-
Medium to high prolifeation (more Ki-67)
Some associated with BRCA2
Behavior: Intermediate
HER2+ invasive carcinoma
whats the ancillary test profile?
Prognosis?
May be PR or ER +
Who: young, non white women with P53 mutations
Respond to herceptin
Triple Negative –
whats the ancillary test profile
Prognosis?
ER-/PR-/HER2 -
Extremely High proliferation
Who; young AA and Hispanic women; BRCA1
Prognosis – Dramatic response to chemo; quickly relapse
If BRCA positive – bilateral mastectomy
