L31- Breast Pathology I Flashcards
Breast Development:
- (1) status at birth
- (2) occurs at menarche
1- not fully formed
2- terminal duct development + inc in interlobular stroma
breast changes during menstrual cycle
- quiescent in follicular phase
- vacuolization and edema in secretory phase
breast changes during pregnancy, postpartum
Pregnancy- functional and mature development
Postpartum- incomplete regression + further involution after 30 y/o
breast changes during menopause
- lobular atrophy
- interlobular stroma becomes fatty
Breast Tissue, list the main structures: base, supportive structures, functional structures
Base: sits on Pectoralis Major muscle
Functional: lobules (+ extralobular, intralobular ducts) –> terminal ducts –> large duct
Support: intralobular and interlobular stroma
describe structure and composition of breast lobule
(produces milk)
- acinus is lined with cuboidal secretory cells
- initial duct is lined with centroacinar cells
- lobule leads into terminal duct
describe the layers of breast ducts (include functions)
(outside in)
-BM (basement membrane)
- myoepithelial cells: assist in milk ejection during lactation + structural support to lobules
- luminal epithelial cells: produces milk during lactation
define these breast congenital anomalies:
- (1) Polythelia
- (2) Polymastia
- (3) Amastia
- (4) Inversion of nipple
1- accessory nipples, supernumerary nipples
2- accessory true mammary gland (can have same pathologies as normal breasts)
3- absence of breast
4- unilateral or bilateral, failure of nipple eversion – often mistaken for cancer
name the congenital anomaly:
- (1) absence of breast
- (2) accessory mammary glands
- (3) accessory nipples
- (4) often mistaken for breast CA
1- amastia
2- polymastia
3- polythelia
4- inverted nipple
list the types of Breast clinical presentations
Lumps / Nodules: CAs, fibroadenoma, cysts
Pain (mastodynia): 95% are benign – infection, trauma, ruptured cyst, hormones
Discharge:
- milky: pituitary adenoma, hypothyroidism, drugs
- serous/bloody: papilloma, cyst, pregnancy
list the breast symptoms by frequency (high to low)
- lumpiness / ‘other symptoms’
- pain (mastodynia)
- palpable mass
- nipple discharge
describe the most common clinical presentations of breast cancer (by symptom, high to low frequency)
Asymptomatic / Abnormal Mammogram
palpable mass
mastodynia
nipple discharge
what are the main breast investigations
(mainly imaging)
Mammogram: screening
-densities / calcifications (small, irregular, clustered –> worrisome) are breast cancer signs
- US
- MRI
list the many techniques for sampling breast specimen and processing samples
- FNAC (fine-needle aspiration cytotology)
- excision biopsies
- Mastectomies (simple skin sparing, only areola-nipple complex)
- Radical Mastectomy- includes Pec major muscles
- Modified Radial Mastectomy: includes axillary LNs
- Subcutaneous mastectomy (w/o skin, for men)
- Prophylactic Mastectomy
- Therapeutic Mastectomy
Galactocele, aka (1):
- (2) definition
- (3) symptoms
- (4) complication
1- lacteal cyst, milk cyst
2- cystic dilatation after lactation b/c of obstructed duct during lactation
3- painful fluctuant lump (obstruction of lactiferous ducts)
4- infection- persistent induration / pain
what are the DDx for clinical presentation of breast pain and tenderness
Inflammatory Disorders
- acute mastitis (abscess)
- mammary duct ectasia
- traumatic fat necrosis
- reaction to implants
Acute Mastitis:
- usually occurs during (1)
- (2) is the brief mechanism
- (3) general Sxs
- (4) general Tx
1- breast feeding
2- cracks/fissure + infection (Staph. spp or Strep. spp)
3- red painful breast, fever
4- antibiotics, rarely surgical drainage
describe the specific Sxs of acute mastitis depending on causal organism
Staph. spp: small, localized under nipple –> may leave indurated scar
Strep. spp.: whole breast, marked swelling and tenderness –> heals w/o scar
Duct Ectasia:
- aka (1)
- commonly occurs during (2)
- clinical presentation mimics (3)
1- plasma cell mastitis
2- 40-50 y/o around menopause
3- mimics carcinomas clinically and radiographically
Duct Ectasia clinical presentation
- peri-areolar mass
- induration, thick greenish brown nipple discharge
- skin/nipple retraction
Duct Ectasia histological changes
- Ducts are inspissated secretion, dilatation, rupture
- chronic granulomatous inflammatory reaction
- ducts are lined filled by granular debris, lipid laden macrophages
Dust Ectasia pathogenesis:
- (1) occurs first to elicit (2) response
- (3) results from the (2) response
1- dilated duct rupture
2- inflammatory response –> plasma cells, lymphocytes, macrophages –> granulomas
3- large dilated distorted duct with large amounts of fibrosis with inflammatory cells
Traumatic Fat Necrosis:
- (1) causes / frequency of occurrence
- (2) clinical presentation
- (3) histological appearance
1- possible h/o trauma / breast surgery —- uncommon
2- painless, palpable mass with skin thickening / retraction (mimics carcinoma)
3- fat necrosis, cholesterol clefts, neutrophils, lipid laden macrophages —-> lymphocytes, fibrosis, cysts +/- calcifications
Breast implants are made of (1), and (2) are the possible complications
1- paraffin, silicone
2- abscess, foreign body granuloma, fistula
describe the grouping of epithelial breast lesions
(RR = relative risk)
1) non-proliferative = simple FCC (fibrocytic changes), RR = 1
2) proliferative disease w/o atypia, RR = 1.5-2
3) proliferative disease w/ atypia, RR = 4-5
- ADH (atypical ductal hyperplasia, ALH (atypical lobular hyperplasia)
FCC:
- mainly affects (1) age group, and affects (2)% of women
- (3) clinical features
Firocystic Changes
1- reproductive age (may persist after menopause)
2- ~50%
3- lumpiness (lumpy bumpy), pain, tenderness: continuous or cyclical
-mammographic densities, calcifications
FCC:
- (1) pathogenesis
- (2) morphology
- (3) radiological appearance
Fibrocystic Changes
1- exaggerated / distorted cyclical changes, associated with changes in menstrual cycle
2- cysts, fibrosis, adenosis = blue dome ysts
3- Mammography: micocalcifications in concretions of secretions or necrotic epithelial cell heaps (mistaken for carcinoma)
describe each of the histological changes seen in FCC
(Fibrocystic Changes)
Cystic:
-small cysts, formed from dilatation / unfolding of lobules
-unopened cyst with turbid / semi-translucent fluid –> brown/blue color –> Blue Dome Cyst
-lined with apocrine cells: round nuclei, abundant cytoplasm
-luminal calcifications –> forms secretory debris
Fibrosis: cystic rupture –> secretory material on adjacent stroma –> chronic inflammation + fibrosis (=> palpable breast firmness)
Adenosis: inc acini per lobule (usually occurs in pregnancy, focal change in adenosis)
Proliferative breast disease w/o atypia:
- (1) histological appearance
- (2) mammographic appearance
- (high/low) risk of carcinoma development
(aka radial scar or complex sclerosing lesion)
1:
-Epithelial Hyperplasia- inc number of luminal and myoepithelial cells
-inc acini containing double strands of cells
-hard rubbery mass on palpation
2- (usually incidental on mammography) densities, calcifications that mimic carcinoma
3- low
Proliferative breast disease w/o atypia – Intraductal Papilloma:
- arises from (1), and has (2) physical description
- (3) describe large type
- (4) describe small type
1- lumen of large duct
2- single, <1cm in size
3- solitary, situated in lactiferous sinuses of nipple, bloody discharge
4- multiple, deeper w/in ductal system
Proliferative breast disease w/o atypia – Intraductal Papilloma: clinical presentation
- small sub-areolar palpable masses, density, or calcification on mammogram
- Nipple Discharge: serous/bloody discharge, nipple retraction
Proliferative breast disease w/o atypia – Intraductal Papilloma: describe histological changes
- delicate branching papillae in lumen
- fibrovascular core
- double layer of epithelial cells
- NO atypia, mitosis
If multiple = recurrence and In risk of cancer
-management = excision of whole duct system
list the Proliferative breast diseases w/ atypia
Atypical Ductal Hyperplasia
Atypical Lobular Hyperplasia (usually incidental finding)
list the types of breast tumors
Stromal: fibroadenoma, phyllodes tumor
Intraductal papilloma and papillary carcinoma
Carcinoma
(1) is the most common breast tumor, it is (benign/malignant). It is related to (3) as risk factors and is associated with (4).
1- fibroadenoma (stromal tumor)
2- benign
3- excess estrogen, prepubertal / young women, certain drugs (cyclosporin)
4- FCC (fibrocystic changes)
Fibroadenoma clinical features
-single / multiple discrete, mobile, encapsulated nodules 1-10cm
- may enlarge with menstration, pregnancy
- may regress with menopause
- large lobulated popcorn calcification
- small clustered calcification on mammogram (requires biopsy to exclude CA)
fibroadenoma development is closely associated with…..
(FCC) cysts larger than 0.3cm, sclerosing adenosis, epithelial calcification, papillary apocrine changes (complex fibroadenoma)
describe the histological features of fibroadenoma
- stromal cell tumor
- loose edematous myxoid fibroblastic stroma + duct like epithelial lined spaces (cyst like)
i) Peri-canalicular: oval ducts surrounded by stroma
ii) Intra-canalicular: elongated, compressed, distorted ducts
iii) mixed pattern
Pattern => no clinical significance
Phyllodes tumor = (1):
- (2) size / location
- mostly affects (3) age group
- mostly (benign/malignant)
- (5) Tx
(stromal tumor of breast) 1- Cystosarcoma Phyllodes 2- few cm to massive lesion involving entire breast -- palpable mass usually 3- 40-60 y/o females 4- benign 5- wide local excision w/o LN dissection
Phyllodes tumor histological features
- lobulated, cut surface slits / cleft-leaf like
- nuclear pleomorphisms, cellularity, mitotic rate, stromal overgrowth, infiltrative border
Majority low grade- local recurrence issues
Rare high grade- aggressive behavior w/ hematogenous metastasis / differentiation (rhabdomyosarcoma, liposarcoma)
describe Phyllodes tumor types
Benign: zonal hypercellularity, mild atypia stromal cells, no stromal overgrowth, mitosis <5/HPF, pushing borders
Borderline: zonal hypercellularity, moderate atypia stromal cells, no stromal overgrowth, mitosis 5-10/HPF, pushing borders
Malignant: zonal hypercellularity, moderate atypia stromal cells, stromal overgrowth, mitosis >10/HPF, infiltrative borders
