Malignant Lesions Flashcards
How many women will get breast cancer?
1 in 8 women living to 85
What percentage of breast lumps are cancerous?
20%
What percentage of breast cancer is genetically linked?
16-25%
In what region of the breast does cancer most often develop?
UOQ
When is there an increased risk of lymph node involvement?
lesion over 1 cm
What factors affect the outcome of breast cancer?
size, multicentricity, lymph node involvement, mets
What are risk factors for developing breast cancer?
- advanced age
- personal or family history
- benign proliferative disease with atypia
- early onset of menstruation, late menopause
- late age of 1st pregnancy
- nulliparity
- radiation exposure
- estrogen use
- post menopausal obesity
What percentage of breast malignancies are invasive and noninvasive?
80% invasive, 20% non
What types of malignancies are invasive?
invasive ductal carcinoma
- tubular
- medullary
- colloid
- papillary
invasive lobular carcinoma
What types of cancer are noninvasive?
- ductal carcinoma in situ (DCIS)
- lobular carcinoma in situ (LCIS)
How does invasive cancer spread? What is it AKA?
- tumor cells grow past basement membrane layer of duct wall into surrounding breast tissue
- gain access to lymphatics and blood vessels
- AKA infiltrating
What is noninvasive cancer? What is it AKA?
- tumor cells are confined to duct in site of origin
- low risk of mets
- AKA in situ, staying in place
What are the major histological categories of breast malignancies?
- ductal epithelial origin
- lobular origin
- stromal tissue origin
- metastatic disease to breast
What is Mondor’s disease?
- aids in early detection
- thrombophlebitis of superficial veins in breast & anterior thorax
What is the clinical presentation of Mondor’s disease?
- pain
- palpable
- red, subcutaneous cords
- fibrous bands
What is the most common noninvasive breast cancer?
ductal carcinoma in situ AKA intraductal carcinoma
What is the earliest detectable form of breast cancer? What percentage of detected malignancies does it make up?
DCIS, 20-40%
What is the etiology of DCIS?
malignant transformation of epithelial cells lining duct without extension past duct wall
Where does DCIS typically arise?
in TDLU near lobule junction
What are clinical signs of DCIS?
- asymptomatic, vis on screening
- variable palp mass
- serous/bloody nipple discharge
What are the grades of DCIS and what are the characteristics of them?
Low nuclear grade/ non-comedo
- well differentiated
- atypical ductal hyperplasia = precursor
-better prognosis
Intermediate grade
High nuclear grade/comedo
- poorly differentiated
- more aggressive & progresses to invasive
- large neoplastic cells fill duct
- duct distention with plug like necrotic material that has calcs
What is Paget’s disease of the nipple?
- uncommon form of DCIS
- involves epidermal layer of the nipple
- tumor cells spread along a subareolar duct, extend to nipple/areola
- progresses to invasive
What is the clinical presentation of Paget’s disease of the nipple?
- erythema
- ulceration
- eczema crusting
- nipple discharge
- itching
What is lobular carcinoma in situ AKA? Who does it affect MC?
AKA lobular neoplasia, perimenopausal women 45-55
What is LCIS?
- marker for increased risk of future development of IDC/ILC
- not considered true cancer
- usually multicentric and bilateral
What is the etiology of LCIS? What are the symptoms?
- originates in epithelium of acini, doesn’t extend past basement membrane
- no palp mass or physical symptoms
What does LCIS look like on US and mamm?
- not usually detected through imaging
- diagnosed microscopically during biopsy
What is papillary carcinoma?
- slow growing, good prognosis
- usually noninvasive but can become invasive
- invasive: well circumscribed, show only focal areas of invasion
Who does papillary carcinoma typically occur in?
older women
What is the etiology of papillary carcinoma?
- central duct lesion: can arise from preexisting papilloma
- peripheral duct lesion: arises within TDLU from area of hyperplasia/papillomatosis
What are the clinical signs of papillary carcinoma?
- bloody nipple discharge: earliest sign
- palp mass, large can bulge skin
- skin dimpling, ulceration, nipple retraction
What is intracystic papillary carcinoma?
- form of DCIS, papillary carcinoma growing in a duct
- can become invasive & extend out of duct
- can cause obstruction & cyst formation
- blood filled cavity if there is infarction or torsion of stalk
- nipple discharge common
What is the MC breast cancer? What percentage of cancers does it make up?
invasive ductal carcinoma, 80%
What type of cancer has the worst prognosis of all breast cancers?
IDC
What is the etiology of IDC?
tumor cells grow past duct wall and invade surrounding fat/connective/stromal tissues
What are the S&S of IDC?
- firm, fixed, painless palp mass
- bloody nipple discharge
- skin or nipple retraction
What are benign masses that mimic IDC?
- fat necrosis
- radial scar
- sclerosing adenosis
- scar
- fibrosclerosis
- fibrous mastopathy
- granular cell tumor
What is the second MC invasive breast malignancy?
invasive lobular carcinoma
What is ILC?
- multicentric and bilateral
- coexists with LCIS
- poor prognosis
What percentage of people with ILC develop a second primary in the same or opposite breast within 20 years?
30-50%
What is the most frequently missed invasive breast cancer by physical exam or mammo?
ILC
Why is ILC commonly missed?
- doesn’t produce significant clinical findings until advanced stages
- diffusely infiltrative growth pattern
What is the etiology of ILC?
- Indian file pattern: small tumor cells infiltrate surrounding stroma in single file rows
- targetoid pattern: circumferential infiltration can occur around ducts and lobules
What are clinical signs of ILC?
- asymptomatic
- ill-defined firm mass
- area of asymmetric thickening
- multiple small areas of nodularity
What is the mean age of ILC?
45-65 yo
How often does ILC display microcalcs?
10%
What is tubular carcinoma associated with?
LCIS and family hx
What is tubular carcinoma?
- uncommon form of IDC
- multicentric and bilateral
- good prognosis, low risk of mets
- small and slow
- desmoplasia
What are the clinical signs of tubular carcinoma?
- small, fixed, hard palp mass
- skin dimpling
What is the mamm appearance of tubular carcinoma?
- small spiculated radiodense mass
- calcs
- satellite lesions
What is medullary carcinoma?
- subtype of IDC
- highly cellular with high grade atypia, causes enhancement
- low risk of mets, good prognosis
What percentage of breast cancers in women under 35 does medullary carcinoma account for? What percentage of all breast cancers?
11% under 35, <5% of all
What are clinical signs of medullary carcinoma?
- smooth, round, lobulated
- mobile, nontender, mildly compressible
- 2-3 cm
- periphery of breast
What is colloid mucinous carcinoma?
- subtype of IDC
- slow growing
- low risk of mets, good prognosis
Who does colloid mucinous carcinoma typically occur in?
older women
What are the two variants of colloid mucinous carcinoma?
pure: well circumscribed, lobulated, soft and gelatinous
mixed: less mucin, larger, more infiltrative
What is the etiology of colloid mucinous carcinoma?
cluster of uniform cells floating in large pools of extracellular mucin, small uniform cells with mild-moderate atypia
What is the clinical presentation of colloid mucinous carcinoma?
- smooth or lobulated palp mass
- mildly compressible and mobile
- high % of cancers in women over 75
What is Phyllode’s tumor?
- malignant counterpart of fibroadenoma
- uncommon, usually benign but undergoes malignant transformation
- larger = more likely to be malignant
What is the MC breast sarcoma?
Phyllode’s tumor
Who does Phyllode’s tumor MC affect?
45-50 yo women
What is the etiology of Phyllode’s tumor?
fibroepithelial tumor with leaflike (phyllodes) growth pattern, clefts of mucus, blood or fluid, stromal tissue turns malignant in 25% of cases
What is the clinical presentation of Phyllode’s tumor?
- rapidly enlarging, nontender, firm, moveable, palp mass
- bulge, stretch, discolored or ulcerated skin
- dilated superficial veins
- solitary, unilateral
- smoothly lobulated
What type of rare malignancy makes up 1% of all breast cancers?
inflammatory carcinoma
What is inflammatory carcinoma?
- highly aggressive, invades and blocks lymphatics of the skin
- rapid and diffuse invasion
- poor prognosis
What are the clinical signs of inflammatory carcinoma?
- skin thickening/erythema (orange peel)
- warm skin with dilated veins
- retracted nipple
- swollen, tender, hard breast
- enlarged lymph nodes
What is the MC lymphoma to affect the breast?
Non-Hodgkin’s
What is the clinical presentation of lymphoma in the breast?
- abnormally enlarged intramammary or axillary lymph nodes
- palpable, rapidly growing masses
What is multifocal carcinoma?
additional tumors within one breast quadrant or in the same ductal system as the primary tumor
What is multicentric carcinoma?
- multiple tumors in diff quadrants of the breast or tumors separated by a distance of >5cm
- less common
- more likely to recur, worse prognosis
- satellite lesions are formed via ducts
- more extensive surgery
What modality can effectively diagnose multicentric carcinoma?
MRI
What defines stage 0 and stage 1 carcinoma?
0: in situ
1: <2 cm, no node involvement, no mets
What defines stage 2 carcinoma?
- <2 cm: positive axillary LN, no mets
- 2-5 cm: positive axillary LN, no mets
- > 5 cm: negative axillary LN, no mets
What are the characteristics of stage 3 malignancy?
- > 5cm
- local and regional spread
- fixed tumor to pectoralis
- fixed tumor with axillary LN
What are the characteristics of stage 4 carcinoma?
- node involvement
- mets
- tumor of any size with extension to skin or chest wall
What is the MC site of nodal mets?
axillary LNs, 75% of lymph from breast drains into them
Where does breast cancer commonly metastasize to?
regional LNs, axillary, ipsilateral internal mammary nodes, supraclavicular nodes
What is the appearance of nodal mets on US?
- enlargement
- round/lobular shape
- asymmetric cortical thickening
- irregular margins
- hypo or hetero
- absent/compressed hilar fat
What are common sites of hematogenous mets?
bone, lung, brain, liver
Where do breast mets commonly arise from?
- contralateral breast ca
- extramammary primary
- melanoma
- lung
- ovary
- sarcoma
- GI tract
- hematological malignancy
When does tumor recurrence typically happen?
2 or more years following therapy
What can tumor recurrence be difficult to differentiate from? What modality can be used to determine?
fat necrosis or scar, contrast MRI
What is the appearance of tumor recurrence on mamm?
- enlarging scar
- architectural distortion
- microcalcs
- new nodular mass in area of previously stable tumor
What modality is more effective at diagnosing DCIS?
Mammography, 70-80% more sensitivity than US
