L31 - Pathology of the breast Flashcards
Define the breast tissue type?
modified sweat gland
three major components consist of the skin
the subcutaneous adipose tissue
the functional glandular tissue.
Describe the internal structure of the breast?
15-25 lobes with own terminal duct-lobular unit (milk secreting)
Each lobe has 20-40 lobules
Nipple > Lactiferous sinus > Lactiferous duct > Segmental duct > Terminal duct lobular unit
Correlate the diseases that arise from segmental duct, adipose tissue, terminal duct lobular unit of the breast?
Segmental duct = Papillomas
Adipose tissue = fat necrosis
Terminal duct lobular unit:
- Fibroadenoma, cysts
- Hyperplasia, Most carcinoma
Explain why the breast is predisposed to many pathological conditions?
High sensitivity for ovarian hormones, sex hormones and growth factors
General clinical presentation of breast diseases?
Pain
Presence of dominant lump
Abnormal nipple discharge
Define the most common breast pathologies.
40% - Fibrocystic change **
30% - No disease
13% - Benign lesions
10% - Cancer
7% - Fibroadenoma
List 4 main categories of benign breast pathologies?
Inflammatory lesions
Fibrocystic disease
Proliferative lesions
Benign tumors
List 4 inflammatory lesions of the breast?
Acute mastitis and breast abscess
Mammary duct ectasia
Fat necrosis
Granulomatous mastitis
Typical cause of Acute mastitis and breast abscess?
infection via the nipple due to abrasion or crack from baby’s mouth
Not common except during lactation and breastfeeding
Pathogenesis of mammary duct ectasia?
Ulceration of ducts liberate LIPID into connective tissue stroma
> > Chronic granulomatous inflammatory reaction**
> > Dilated ducts with cheesy material adjacent to aerola
> > Fibrosis, nipple retraction
Pathogenesis of fat necrosis in breast?
Trauma/ obesity
> > Traumatic rupture of fat cells
Foreign-body granulomatous reaction and fibrosis
Localized firm/ hard mass
List some causes of Granulomatous mastitis?
- Paraffin wax or silicone fluid for breast enhancement
- Pulmonary tuberculosis (uncommon)
- Idiopathic granulomatous mastitis (autoimmune)
List 3 Fibrocystic diseases of the breast?
Cystic formation and fibrosis
Apocrine metaplasia
Epithelial hyperplasia
Typical clinical presentation and epidemiology of Fibrocystic disease of the breast?
- 30 years old female, rarely postmenopausal
- PAINFUL, firm, fixed clusters of nodules
- Large cysts CHANGE SIZE with menstrual cycle
Define causes of Fibrocystic disease of the breast?
Hormone imbalance: HIGH ESTROGEN, LOW PROGESTERONE
- Abnormal end-organ hormone metabolism
Compare the pathohistological features of the 3 types of fibrocystic disease of breasts?
Cystic formation and fibrosis: Increase in fibrous stroma + cyst formation
Apocrine metaplasia: ductal epithelium change to apocrine type: pink cells with budding
Epithelial hyperplasia: Proliferation of ductal lining epithelium
Which type of fibrocystic disease of the breast is most likely to progress into malignancy?
EPITHELIAL HYPERPLASIA
increased chance of malignancy, the more severe and atypical the degree of hyperplasia
List 3 proliferative lesions of the breast?
- Hyperplasia: Ductal or Lobular
- Sclerosing adenosis
- Radial scars (complex sclerosing lesions)
Etiology and pathogenesis of Sclerosing adenosis?
- Enlarged breast lobules distorted by fibrous tissue = simulate malignancy
- Child-bearing and premenopausal women
Which type of proliferative lesion is only detected radiologically?
Radial scars (complex sclerosing lesions)
epithelial hyperplasia and fibrosis = distortion of normal architecture
mimic carcinoma both clinically and radiologically
List 2 benign tumours of the breast?
INTRADUCT PAPILLOMA
FIBROADENOMA
What is the most common cause of palpable breast lump up to age 30?
Fibroadenoma
Most common under 30, but can occur at any age
Pathogenesis and clinical presentation of Fibroadenoma of breast?
Benign glandular epithelium + proliferation of connective tissue/ stroma
> > compress ducts into slits
Present as well-circumscribed firm, mobile and painless lump.
What is the most common cause of bloody nipple discharge in women?
Intraduct Papilloma
UNILATERAL discharge if bilateral, consider hormonal origin
Define the anatomical location of Intraduct papilloma of the breast. Etiology?
Solitary large ducts or multiple small ducts involved within 4 cm of the nipple
Occurs any age
Compare Fibroadeoma and Fibrocystic disease clinical presentation?
Fibroadenoma = smooth, painless, mobile, well-circumscribed mass
Fibrocystic disease = painful, not solid, not mobile, well-circumscribed mass
Which breast tumour closely resembles Phylloides tumour? How to DDx the two?
Fibroadenoma
differentiated from a fibroadenoma by a frond-like arrangement of the fibroepithelial element/ overgrowth of stroma
Define whether Phylloides tumour of the breast is benign or malignant? How to ddx the two?
- Majority benign
- 3-12% metastasize
distinguishing the malignant form:
(i) increased mitoses
(ii) cellular atypia,
(iii) invasive edge,
(iv) stromal overgrowth.
Treatment for phylloides tumour?
Benign = wide excision
Malignant = Mastectomy
Describe the etiology of breast cancer?
1 in 15 chance
Incidence increases with age, highest chance postmenopausal
Top cancer in young females
Genetic risk factors for breast cancer?
- Positive family history: 3 or more related individuals
- BRCA-1 and BRCA-2 breast and ovarian cancer susceptibility genes: 85% chance of breast cancer
- Others: HNPCC, Concurrent ovarian tumours
Genetic inheritance pattern of BRCA-1 and 2?
autosomal dominant
Mendelian inheritance: transmitted by either parent
Onset and severity of hereditary breast cancer?
early age of onset
bilateral or multifocal breast cancer
Criteria of assessment of high risk patients for breast cancer?
1) number of affected relatives
2) presence of ovarian cancer in family
3) relationship of affected relatives
4) age at diagnosis of breast cancer
> > 3 or more members of direct lineage with breast and / or ovarian cancer
List some hormonal risk factors for development of breast cancer?
Increased exposure to estrogen peaks:
1) long duration of reproductive life: early menache (<12 years) and late menopause (>54 years)
2) nulliparity (no kids) or late age at first child
3) Functioning ovarian tumours
List some environmental risk factors for development of breast cancer?
Dietary fats
obesity (endogenous hormonal modifications)
Radiation exposure (e.g. multiple CXR for pulmonary TB)
List all the investigative methods for breast cancer screening?
Mammography
Ultrasound and MRI
Fine needle aspiration cytology
What can mammography identify when investigating breast cancer?
size and extent of lesion
presence of DCIS
non-palpable abnormalities
detection of multifocal disease: check for bi-laterality.
Mammography is the definitive Dx test for breast cancer. T or F?
False
10-20% of carcinomas may still be undetectable by mammography
Which investigative technique is used for pre-operative Dx of breast cancer?
Fine needle aspiration cytology: detect palpable and non-palpable lesions
Core-cut biopsies
Most common disease of male breast?
gynaecomastia
Causes of Gynaecomastia?
cirrhosis of the liver with failure of oestrogen breakdown
Klinefelter’s syndrome
testicular tumours
Drugs: FSH, LH therapy, Dopamine receptor blocker antipsychotics (tuberoinfundibular pathway - Prolactin), K+ sparing diuretics, Aldosterone antagonist
