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RGU Exam 2 > Pathology Breast Lesions > Flashcards

Pathology Breast Lesions Flashcards

1
Q

Thelarche

A
  • Rapid growth of breasts at onset of puberty, usually age 10-11 in females
  • Entry into Tanner stage II of development
  • Growth is due to fat deposition, periductal connective tissue and elongation and thickening of ductal system
  • Influenced by estrogens, growth hormone and prolactin, but not progesterone
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2
Q

Premature Thelarche

A
  • Prior to 9 y/o
  • Isolated or part of precocious puberty
  • No lobules are present
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3
Q

Tanner Stage I

A
  • Preadolescent; no breast buds
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4
Q

Tanner Stage II

A
  • Breast budding (Thelarche) w/ small area of surrounding glandular tissue
  • Areola begins to widen
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5
Q

Tanner Stage III

A
  • Enlargement of areolar diameter
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6
Q

Tanner Stage IV

A
  • Areola/papilla form secondary mound w/ separation of contours
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7
Q

Tanner Stage V

A
  • Mature female breast
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8
Q

Nonproliferative Breast Change (Fibrocystic changes) Lesions

A
  • Duct ectasia
  • Cysts
  • Apocrine change
  • Mild hyperplasia
  • Adenosis
  • Fibroadenoma w/o complex features
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9
Q

Proliferative Disease W/O Atypia Lesions

A
  • Moderate or florid hyperplasia
  • Sclerosing adenosis
  • Complex sclerosing lesion (radial scar)
  • Fibroadenoma w/ complex features
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10
Q

Proliferative Disease W/ Atypia Lesions

A
  • Atypical ductal hyperplasia (ADH)
  • Atypical lobular hyperplasia (ALH)
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11
Q

Carcinoma In Situ Lesions

A
  • Lobular carcinoma in situ (LCIS)
  • Ductal carcinoma in situ
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12
Q

Pathologic Lesions Ductal Morphology Chart

A
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13
Q

Histologically where most breast pathology occurs

A
  • Terminal duct-lobular unit
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14
Q

Breast Lobule Structure

A
  • Breast composed of 15-25 lobes, emptying into separate major duct terminating in nipple
  • Lobule is divided into 10-100 alveoli
  • Pregnancy increases the lobuloacinar differentiation
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15
Q

Breast Lobules Immunohistochemical Histology

A
  • Immunohistochemical stain for lactalbumin showing secretory product in lobules and secretory tissue
  • Smooth muscle actin demonstrating myoepithelial cells
  • Normally have the grape like cluster of smooth like ovals, usually ~1 cell layer thick, cells are fairly uniform in size and shape and pretty bland looking w/ no prominent nuclei or atypia

***NOTE: When looking at a immunohistochemical stain blue is usually the background stain just showing that the dye is working, brown is usually the targeted substance we are trying to highlight

*in the attached histology slide they are staining for lactablumin; a product found in breast milk

*the stained brown rim around the lumen is smooth muscle actin which is important to look at for carcinoma insitu b/c smooth muscle actin will highlight epithelial cells that are suppose to surround normal lobules and ducts and help squeeze the milk out; if we lose myoepithelial cells or breaking thru of this layer this is then a sign of either invasive cancer or indication of losing the myoepithelial structure thru some pathologic process

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16
Q

Macromastia

A
  • Condition in females where breasts undergo rapid and massive enlargement at puberty
  • Exuberant connective tissue w/ minimal lobular formation
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17
Q

Supernumerary Nipples/Breast

A
  • Persistent epidermal thickenings along milk line
  • Primordial breast cells that fail to involute
  • Combinations of breast glandular tissue and nipple
  • Occurs in 2-6% of females and 1-3% of males; may be more common on left side in males
  • In women, may not be noticed until pregnacy
  • Can get breast cancer in these regions if theres enough ductal tissue
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18
Q

Presentation of Breast Disease Pie Graph

A
  • If the lumps are multiple in that not just one breast mass or lump where pt. describes “lumpy bumpy” feel and especially when it is B/L; this is usually a benign fibrocystic change

*only 1% w/ these presenting symptoms have cancer

  • Breast pain; can also be due to just fibrocystic change and influence of caffeine or and type of trauma; breast discomfort is unusual for breast cancer

*5% of these presenting symptoms have cancer

  • Nipple discharge is usually from a benign intraductal papilloma

*7% actually have cancer

  • Palpable mass indice for cancer goes up w/ age; in younger women more likely to be a cyst or fibrocystic change or other things not cancer

*12% will actually have cancer

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19
Q

Age vs. Likelihood a Breast Mass is Cancer

A
  • <40 more likely benign growth
  • 40-50 chance of cancer is increased
  • >50 more likely to be cancer
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20
Q

Benign vs. Malignant Lesions Mammography Apperance

A
  • Benign lesions tend to be:

*well-circumscribed

*round

  • Malignant lesions tend to be:

*stellate and circular w/o calcifications (64%)

*stellate and circular w/ calcifications (17%)

*calcifications only (19%)

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21
Q

Fine Needle Aspiration (FNA)

A
  • Minimally invasive technique to examine if tissue might have a cyst and is a superficial lesion
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22
Q

Core Biopsy

A
  • Minimally invasive technique
  • Stereotactic needle guided biopsy
  • Digital mammogram machine connected to computer
  • Needle guidance system to sample lesion that is not palpable
  • Enables to the testing of more deep non-palpable lesions
  • Angle of procedure has to be just right for adequete diagnosis
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23
Q

Acute Mastitis

A
  • Assoc. w/ lactation and cracks in nipple
  • Will usually find this if a women is nursing on one side more than the other
  • Mastitis occurs in 5-15% of post-partum primiparous women
  • Usually unilateral
  • Most often due to Staphylococcus, but bacteria may not be isolated from culture
  • Can lead to abscesses
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24
Q

Acute Mastitis Histologically

A
  • Keratinizing squamous epithelium extending into nipple ducts
  • Trapped keratin debris can cause duct dilation and rupture
  • Neutrophils
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25
Q

Periductal Mastitis

A
  • More severe form of acute mastitis; in response to irritation the epithelial cells which instead of being on the surface of the areola, start tracking back which aren’t suppose to; thats the cuboidal epithelium; so we’re getting metaplasia of cells that are suppose to be on the outside, tracking in; this can result in the cells keratin breaking of and forming plugs in the ducts

*majority of pts are smokers

  • AKA subareolar abscess, squamous metaplasia of lactiferous ducts
  • Presents w/ painful, erythematous, subareolar mass; appears infectious
  • Majority are smokersd
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26
Q

Duct Ectasia

A
  • 50-60 y/o women
  • Multiparous, related to stagnant colostrum
  • May cause retraction or inversion of nipple and discharge, clinically looks like cancer
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27
Q

Duct Ectastia Histologically

A
  • Microscopically- dilated large ducts w/ foamy macrophages in lumen
  • Calcifications common
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28
Q

Breast Fat Necrosis

A
  • Duct ectasia or fibrocystic disease—>rupture cysts extravasate luminal content causing reaction
  • Trauma (ie steering wheel in car accident, sports injury) compressing tissue leading to necrosis
  • Can cause dippling on the skin; can be scary looking as cancer can also pull skin inward
  • On Mammography can form “egg-shell” oil cysts and display calcifications
29
Q

Foreign Body Reaction Breast Lesion

A

Often biopsy related

  • Not encapsulated
  • Giant cells
  • Other inflammatory cells
  • Fat necrosis
  • Calcification
  • Cholesterol clefts
  • Hemosiderin
  • May see suture or polarizable material
30
Q

Foreign Body Reaction Histologically

A
  • Foamy clefts w/ foamy macrophages; fat tissue that got compressed leaving behind fat cholesterol crytals
31
Q

Reactions to Silicone Breast Implants

A
  • Silicone can leak allowing for droplets of silicone to initiate a foreign body reaction; foamy macrophages, giant cells, lymphocytes
32
Q

Granulomatous Mastitis

A
  • Rare
  • Young women (avg 36 y/o) w/ inflammatory breast processes
  • Corynebacterium (normal skin flora?)
  • Not related to smoking
  • Grossly can look like breast cancer
33
Q

Granulomatous Mastitis Diagnosis

A
  • Diagnosis of exclusion
  • Must rule out:

*systemic granulomatous disease ie Wegener’s granulomatosis, sarcoidosis

*infections ie mycobacteria, fungi, cat scratch disease (Bartonella henselae)

*panniculitis

*foreign body reaction

*fat necrosis

34
Q

Lymphocytic Mastitis

A
  • AKA diabetic mastopathy, usually DM type I
  • Uncommon
  • Mainly women, but may occur in men w/ gynecomastia
  • Often B/L
  • Treated w/ excision, but often recurs, not serious but can cause clinically confusion w/ looking like cancer
  • Lymphocytes are infiltrating around ductal and lobular tissue; not clear why
35
Q

Benign Breast Diseases

A
  • Fibrocystic “disease”
  • Duct hyperplasia
  • Adenoma
  • Intraductal papilloma
  • Nipple adenoma
  • Adenosis
36
Q

Benign nonproliferative Lesions

A
  • Single nonproliferative lesions are not assoc. w/ increased risk for cancer

*fibrocystic change

*solitary papilloma

*fibroadenoma

  • Unclear if multiple nonproliferative lesions increase the risk for breast cancer
37
Q

Proliferative Lesions Risk of cancer

A
  • Proliferative lesions, w/o cytologic atypia have slightly increased risk of cancer (relative risk 1.3 - 2)

*complex fibroadenoma

*florid hyperplasia

*sclerosing adenosis

*intraductal papillomas

  • Proliferative lesions w/ atypia have a higher risk of cancer (relative risk 4 - 6)

*atypical lobular hyperplasia

*atypical ductal hyperplasia

  • Risk is higher (10-fold) when the atypia is multifocal
38
Q

Fibrocystic Changes

A
  • Freq. seen in 25-45 y/o women
  • More common in Caucasians
  • Hormonal influence? exact pathogenesis unknown
  • Usually B/L
  • Mainly affects TDLU
  • Aberration of normal development
  • Blue-dome cysts contain turbid fluid
  • “Lumpy-bumpy” described as
  • Oral contraceptives decrease fibrocystic changes b/c of balanced estrogen and progesterone effect
  • If “non-proliferative” = no significant increase in risk of breat cancer
39
Q

Fibrocystic Disease Features

A
  • Fibrosis; background stroma may be thicker and denser than it normally would
  • Cysts (apocrine metaplasia)

*cysts line by apocrine epithelium (abundant, granular eosinophilic cytoplasm)

  • Other:

*calcification

*chronic inflammation

*epithelial hyperplasia

40
Q

Fine Needle Aspiration of Fibrocystic Cells Histology

A
41
Q

Florid Duct Hyperplasia

A
  • Filling of duct w/ lining cells, slit-like fenestrations
  • Cells are oval, streaming in pattern
  • Normal ducts have 2 cell layers, if > 4 cell layers then 1.5 - 2x risk of breast cancer
42
Q

How to deal w/ FCC discomfort

A
  • Supportive bras
  • OTC pain relievers such NSAIDs
  • Reduced intake of caffeine and stimulants found in coffee, tea, chocalate, and soft drinks
  • Oral contraceptives may help women w/ severe symptoms
43
Q

Atypical Ductal Hyperplasia

A
  • Increased risk of breast cancer (4 - 5x)
  • Risk equal in both breasts
  • Risk higher (10x) if 1st degree relative has breast cancer
  • Usually small foci (<3mm)
  • Excision recommended b/c assoc. w/ DCIS
44
Q

Atypical Duct Hyperplasia Features

A
  • Bland, monomorphic cell pop.
  • Low-grade cytologic features- minimal nuclear pleomorphism
  • Cells haphazardly arranged
  • Size smaller than 3mm in greatest dimension
  • Can resemble DCIS
45
Q

Usual Hyperplasia vs. Atypical Ductal Hyperplasia Chart

A
46
Q

Atypical Ductal Hyperplasia “Roman bridges” Histology

A
47
Q

Atypical Lobular Hyperplasia

A
  • 4 - 5x usual risk of breast cancer, higher in ipsilateral breast, higher if age <50
  • 19% develop invasive cancer at mean 15yrs, 42% are special subtypes w/ good prognosis
  • Excision is recommended b/c some cases assoc. w/ DCIS
48
Q

Atypical Lobular Hyperplasia Histology

A
49
Q

Intraductal Papilloma

A
  • May present w/ bloody nipple discharge
  • Gross: polypoid mass protruding into dilated duct
  • Histology: arborizing architecture, nuclei generally bland, but may have minor pleomorphism
50
Q

Nipple Adenoma

A
  • Can have complex arborizing pattern—> must be careful not to overdiagnose as cancer
51
Q

Lactating Adenoma

A
  • Reproductive age women
  • Presents as mass <5cm
  • Gross: lobular, yellow mass, vascular (will blee unlike most lesions)
  • Histology: hyperplastic lobules w/ cytoplasmic vacuolization

*will generally recede

52
Q

Sclerosing Adenosis

A
  • Relatively common, often B/L, usually assoc. w/ another form of proliferative fibrocystic change
  • Can present as a palpable mass, well-circumscribed, <2cm
  • Usually microscopic finding
  • Approx. 1.7x risk of invasive carcinoma
  • Retention of loulocentric architecture
53
Q

Sclerosing Adenosis Histology

A
  • Proliferation of small duct-like structures w/ distortion of lobules
  • Retention of myoepithelial cells as evidenced by smooth muscle actin stain
54
Q

Radial Scar

A
  • Often multifocal or B/L
  • Grossly and radiographically can mimic cancer- stellate lesion
  • 1.8x cancer risk
55
Q

Radial Scar Histology

A
  • Histology: normal breast structures surrounding and entrapped by central scar tissue
  • Elastin stain shows scar tissue

*black is scar tissue

*red is normal breast parenchyma

56
Q

Stromal Tumors

A
  • Fibroadenoma
  • Phyllodes tumor
57
Q

Fibroadenoma

A
  • Most common, benign tumor of breast
  • Women 25-35 y/o
  • Incrases in size during pregnancy
  • Tends to regress w/ age
  • Sharply demarcated
  • Usually <3cm

- White, tan, bulging surface

- Whirling pattern of slit-like spaces

  • Can be drug-related; 1/2 of women receiving cyclosporin A after renal transplant develop FA
58
Q

Fibroadenoma Fine Needle Aspiration (FNA)

A
  • Cohesive, bland nuclei
  • Staghorn configuration
59
Q

Fribroadenoma Histology

A
  • Cellular, fibroblastic stroma encasing glandular and cystic spaces, often cleft-like spaces
60
Q

Juvenile Fibroadenoma

A
  • Also called giant fibroadenoma
  • Adolescents, often African-American
  • B/L, w/ rapid growth to >10cm
  • May have ductal hyperplasia but not atypical ductal hyperplacia or ductal carcinoma insitu
  • Low overall risk of carcinoma
  • Follow-up recommended
  • Differential includes phyllodes tumor, but rare in adolescents
61
Q

Juvenile Fibroadenoma Histology

A
  • Stroma may be more cellular than typical FA
  • Ducts may show epithelial hyperplasia
62
Q

Benign Phyllodes Tumor

A
  • Polypoid tumor w/ a leaflike pattern
  • Stroma is similar to a fibroadenoma, but more cellular
  • 75% are benign, trated by local excision
63
Q

Galactorrhea

A
  • Lactation in men or in women who are not breastfeeding
  • Pituitary adenomas can secrete prolactin (classified by the hormone they secrete)

*Dx: measure prolactin lvls and imaging test

*Treatment: tumor inhibition w/ dopamine agonist drugs or resection of adenoma

64
Q

Pituitary Adenoma

A
  • Most are microadenomas (<10mm)
  • Most grow slowly and are considered benign
  • Can invade the cavernous sinus, sphenoid sinus and base of brain
  • Classified by hormone production (growth hormone, prolactin, TSH, ACTH, or FSH)
65
Q

Galactorrhea Causes

A
  • Assoc. w/ certain drugs, including phenothiazines, certain anti-hypertensives ie alpha-methyldopa, opioids
  • Assoc. w/ primary hypothyroidism

*increased lvls of thyroid-releasing hormone increases secretion of prolactin as well as thyroid-stimulating hormone (TSH)

66
Q

Gynecomastia

A
  • Enlargement of the male breast
  • Imbalance b/w estrogens and androgens
  • Puberty or aged
  • Usually resolves spontaneously
67
Q

Gynecomastia Causes

A
  • Klinefelter syndrome
  • Drugs; marijuana, heroin, anabolic steroids, psychoactive drugs
  • Hormone-secreting adrenal or testicular tumors
  • Paraneoplastic production of gonadotropins by cancers
  • Liver disease and hyperthyroidism (increased conversion of androstenedione into estrogens)
68
Q

Gynecomastia Histology

A
  • Proliferation of ducts w/o lobules
  • Dense, periductal stromal fibrosis
  • Can have edema w/ micropapillary hyperplasia and mild lymphocytic infiltrate
  • Myoepithelial cells preserved

RGU Exam 2 (21 decks)

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