L33 Breast Pathology Flashcards
What part of the breast is the origin of most malignant lesions?
Terminal ductal-lobular units (TDLU)
What are the 2 layers of terminal ductal lobular units?
Which layer is affected by most lesions?
- Inner epithelial layer (most lesions)
2. Outer myoepithelial layer
Name 3 differential diagnoses for a breast lump.
- Fibrocystic changes (MC)
- Fibroadenoma (MC tumor)
- CA breast
Mastalgia (breast pain) can be cyclic (1) or non-cyclic (4).
Give ddx for both.
Cyclic: Fibrocystic changes (MC) Non-cyclic: - Acute mastitis - Fibroadenoma - Sclerosing adenosis ( benign proliferative condition of the terminal duct lobular units characterized by an increased number of acini and their glands) - inflammatory CA breast
Give the possible diagnoses for nipple discharge with the below color changes:
- Milky
- Serous
- Yellow serous
- Lactation
- Early pregnancy
- Fibrocystic change
Give the possible diagnoses for nipple discharge with the below color changes:
- Purulent
- Green
- Bright blood
- Acute mastitis
- Ductal ectasia
( benign (non-cancerous) breast condition that occurs when a milk duct in the breast widens and its walls thicken. This can cause the duct to become blocked and lead to fluid build-up.) - Intraductal papilloma (single orifice), fibrocystic change (haemorrhagic), CA breast
What are the triple assessment of breast?
- Clinical examination
- Imaging
- Histopathological
Name the 3 modalities of imaging of the breast.
- USG
- Mammography
- MRI
What lesions do you expect to see in mammography? (3) It is preferred to be done in what patients?
Low dose X-rays
- Spiculated mass lesions
- Pleomorphic calcifications
- Architectual distortion
Preferred in women >35 years old
- Better resolution in less dense breast
What are the malignant features that can be seen on ultrasound? (5)
It is preferred to be done in what patients?
BITCH
- Borders: spiculation, microlobulation, angular margins
- Internal Calcification
- Taller than wide (fir-tree appearance, invasion of fascia)
- Central vascularity/ Compressibility ((malignant lesions displace breast tissue w/o change in height))
- Hypoechoic nodule/ posterior acoustic shadowing
Done in patients <35 years old, breast with higher density
MRI breast can be used to assess? (3)
Mass, blood flow, vascular permeability
What are the histopathological investigations done for the breast? (2) What are studied in these 2 investigations? (2)
- Fine needle aspiration - only cytology (cell morphology)
- Core needle biopsy
- Cytology + Tissue architecture (differentiate invasive and non-invasice)
- Stain for ER/PR status > important for anti-oestrogen treatment
Fibrocystic changes
A. The MC cause of breast mass in women <50 years old
B. MC cause of cyclic breast pain
C. Result of an exaggeration/distortion of cyclic breast changes related to menstrual cycle
D. OCP and hormonal replacement therapies are risk factors
E. Fibrosis and calcifications may be seen
D is incorrect
- OCP and HRT does not increase the incidence
Cysts can be seen in fibrocystic changes, and they often appear to be multiple. There are cystic dilatations with serous blood or fluid, often lined by _______________ cells.
Large cysts often contain brown fluid (post-hemorrhagic), which imparts a blue color onto the intact cyst.
Metaplastic apocrine cells
i.e. the transformation of breast epithelial cells into an apocrine or sweat‐gland type of cells
Other than cysts in fibrocystic changes,
fibrosis occurs when?
Cysts rupture > secretory material into stroma > chronic inflammation
Calcification appears in fibrocystic changes, within the glandular lumen or stroma.
They are made up of ____________ or ___________.
Which is visible in mammography as in most malignancy?
Calcium phosphate*
Calcium oxalate
Acute inflammation/ mastitis usually occurs during ______________, with a damage to the epithelium, causing secondary infection of skin commensals such as?
Redess, swelling, tenderness observed.
Post-partum nursing;
S.aureus
What are the causes of chronic inflammation of the breasts?
A. Ductal ectasia B. Traumatic fat necrosis C. Idoipathic granulomatous mastitis D. Breast augmentation E. Epithelial hyperplasia
All except E
Ductal ectasia
- aged?
- What is the pathology?
Menopause
Duct dilatation with secretion (greenish brown nipple discharge):
leakage of content > chronic inflammation
Duct ectasia A. Greenish brown nipple discharge B. Skin retraction C. Nipple retraction D. Associated with autoimmune cause E. Common in menopause
D is incorrect, not associated
Pathophysiology of traumatic fat necrosis?
Why is this traumatic lesion clinically important?
- Trauma causes disruption of fat > acute inflammation and focal necrotic fat cell
- Lymphocytic infiltrate and histiocytes with ingested fat (foam cells)
Mimic CA clinically
- irregular firm lesion
- painless
- skin retraction
- histological findings
> ask for history of trauma to the breast
Idiopathic granulomatous mastitis A. Rare B. Pathologically same as TB mastitis C. With prominent granuloma and giant cells D. Anti-TB drugs should be given
D is incorrect
- Steroids should be given
Vice versa: Steroids should NOT be given to TB > activate it!!!!
C explains B
Breast augmentation
A. Polyacrylamide gel (PAAG) is an injection into implant bag in the breast, causing inflammation
B. PAAG forms regular and rim mass after fibrosis and inflammation
C. Silicone is one of the choices
D. Silicone may cause rupture of implant bag thus chronic inflammation
A is wrong Polyacrylamide gel (PAAG) - direct injection into breast > inflammation
Epithelial hyperplasia
- Basement membrane*
1. Ductal hyperplasia - Myoepithelium*
@ductal epithelium
- Atypical hyperplasia
- DCIS (Ductal carcinoma in situ?)
- Invasive ductal carcinoma
Which of the above has 4x and 8x malignant potential respectively?
4x: atypical hyperplasia
8x: DCIS
(epithelial hyperplasia and ductal hyperplasia are non-malignant)
What are the 2 types of atypical hyperplasia?
- Atypical ductal hyperplasia
- characteristic geometric (regular pattern) - Atypical lobular hyperplasia
- solid distension of lobular space
Is atypical hyperplasia a pre-malignant lesion?
Require further investigations?
Not a pre-malignant lesion but with increased 4x malignancy risk, requires evaluation and total excision
Sclerosing adenosis is a benign epithelial proliferation, with increased risk of subsequent CA.
It mimics CA in what ways?
- Clinically
- Radiologically (irregular, firm, speculated mass)
- Histologically (pseudo-infiltrating)
- enlarged, complex glands compressed by densely fibrotic stroma > appear as infiltrating rods (cancer-like)
Which benign tumor presented as breast mice?
It is the MC breast tumor in women <50 years old.
Fibroadenoma
Breast mice = lump not fixed to skin or underlying structure
Which of the following about fibroadenoma is correct?
A. Cyclosporin A is a risk factor
B. Excision may not be required
C. There are multi-lobular proliferation of stroma
D. It causes compression of ducts
All of the above
C causes D
A: is a calcineurin inhibitor, used as an immunosuppressant medication.
Phyllodes tumor A. Purely benign B. Bulky tumor derived from stromal cells C. Mobile D. Rare
A is wrong
- can be benign/ malignant;
locally aggressive
What is the MC cause of bloody nipple discharge in women?
Intraductal papilloma
Intraductal papilloma is solitary papillary growth within large ducts with ________________ can causes bloody discharge.
Patient may present with bloody nipple discharge (single duct), sub-areolar nodule and nipple retraction (rare)
Fibrovascular cores
Intraductal papilloma is a benign lesion per se, but complicated by other epithelial changes that increases the risk of CA.
How is it treated?
By Microdochectomy (surgical removal of a lactiferous duct, preserves nipple)
Name the disease
Epithelial hyperplasia
- Non-malignant (1)
- Increased risk of malignancy (2)
Benign tumor
- Non-malignant (2)
- Increased risk of malignancy (2)
- Usual hyperplasia
- Atypical hyperplasia, Sclerosing adenosis
Benign tumor
1. Fibroadenoma, Phyllodes tumor
- Intraductal papilloma, Phyllodes tumor
