Pathology of the Breast Flashcards by Michal Trope

What does carcinoma mean?

Malignancy of epithelium

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What are the two types of breast cancer?

Hereditary and Sporadic

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What are the 8 major risk factors for sporadic breast cancer?

Being Female
Being over 50
Geography (western world)
Fam hx
Fibrocystic changes
Prior breast or GYN cancer
Radiation
Unopposed estrogens (women with no pregnancies, early menarche, late menopause, obesity)

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What are the two broad forms of carcinoma of the breast?

In situ carcinoma (CIS)

2. Invasive carcinoma

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What are the two forms of carcinoma in situ of the breast?

Ductal carcinoma in situ (DCIS)

2. Lobular carcinoma in situ (LCIS)

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What does it mean to be in situ?

In its normal position, ie doesn’t push the boundaries of a gland or lobule

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What are the key features of in situ carcinomas?

Microscopic entity (can only be diagnosed by microscope)
CIS cells proliferate “in position” (ie in situ)
Lacks capacity to spread (can be malignant, but are confined to a basement membrane)
Benign-acting (if treated)

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What are the key features of DCIS?

Common form of breast cancer
Lacks capacity to spread
Always curable, if treated
Non-obligate precursor of invasive carcinoma (ie not all DCIS progresses to invasive cancer, but it can)

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What do you look for in a mammogram?

Cluster of calcifications

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How do you diagnose DCIS?

Image-guided core biopsy

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Microscopic features of DCIS

Calcified necrosis (dystrophic calcification)
Enlarged cells
High N/C ratio
Prominent nucleoli
Mitoses
Can have many architectural patterns and mixtures are common

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Describe the architectural patterns of DCIS

Can have many architectural patterns and mixtures are common

Cribriform (looks like big holes)
Comedo-necrosis (ie necrosis in glands)
Micropapillary

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What are the key features of LCIS?

Microscopic entity (can’t see on Xray, need microscope_
CIS cells proliferate “in position” (ie in situ)
Incidental microscopic finding (ie discovered due to another abnormality)

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What are the malignant cellular features of LCIS?

Lack of cohesion (normal cell-cell interactions disrupted)

- Signet-ring cells (contain globules of intracellular mucin)

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What is the clinical significance of LCIS?

Benign
Difficult to excise (no radiologic correlate)
Don’t know if it is a risk factor or precursor (15-20% inc risk of cancer with LCIS)
Usual treatment: Watch and wait, +/- Anti-estrogen

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What are the key features of invasive breast cancer?

Not in situ
Capacity to spread
Potentially lethal (if spreads)
10 year survival=45-50%

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What are the 2 major forms of invasive carcinoma?

Invasive ductal carcinoma

2. Invasive lobular carcinoma

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What is paget’s disease?

Crusting and ulceration of the nipple. Signifies underlying breast cancer that may be in situ, or in situ plus invasive

What is “inflammatory” breast carcinoma?

Carcinoma in dermal lymphatics
Reddened skin
May have a mass
Evolves rapidly
Virulent

What are the microscopic features of invasive lobular carcinoma?

Grows in a linear “box-form” infiltrating pattern. No variants (same in each pt, unlike glandular which has variants)

What categories do we stage breast cancer for?

Tumor size, lymph nodes, metastasis (TNM)

What predictive markers predict response to specific treatment?

EStrogen receptor pos
Progesterone receptor pos
HER 2 over-expression/amplification (only 15-20% of invasive cancers)

–>use tissue stains to determine

Describe Oncotype DX

A breast cancer assay, tests for 16 cancer related genes and 5 reference genes→ predicts recurrence risk (low, med, or high) to inform treatment options

Must be…

Node negative
ER-+
Able to take 5 years of tamoxifen treatment (no hx that prevents it)

We do not do this in men

How common is breast carcinoma in men?

uncommon, 1% of all BC cases

What mutation/syndrome is most likely present for men to get breast carcinoma?

Klinefelters syndrome (XXY) and BRCA mutations

What kind of carcinoma do men have?

Ductal only

What are fibrocystic changes?

Common benign breast disease that occurs during reproductive years. May have a hormonal etiology.

What are the clinical manifestations of fibrocystic changes?

- Cyclic pain, tenderness - Palpable mass - Abnormal mammogram - Mass or calcifications

What are some non-proliferative fibrocystic changes?

1. Fibrosis 2. Blue-domed cysts 3. Adenosis 4. Apocrine metaplasia (replacement of mammary epithelium with sweat-gland like epithelium -->Carries no excess cancer risk

What are some proliferative fibrocystic changes?

- Sclerosing adenosis - Usual ductal hyperplasia (a little proliferation of benign epithelium) - Atypical ductal hyperplasia (some but not all features of DCIS=borderline lesion) - Atypical lobular hyperplasia (some but not all features of LCIS=borderline lesion)

Which benign breast cancer diseases/fibrocystic changes carry no cancer risk?

- Normal breast tissue - Non-proliferative FCCs - Usual ductal hyperplasia, mild

Which benign breast cancer diseases/fibrocystic changes carry a slight cancer risk?

- Sclerosing adenosis | - Moderate and florid usual ductal hyperplasia

Which benign breast cancer diseases/fibrocystic changes carry a moderate cancer risk?

Atypical ductal and lobular hyperplasia

Name 2 benign fibroepithelial tumors (stromal) of the breast

1. Fibroadenoma | 2. Phyllodes tumor (usually benign)

Name 1 benign epithelial tumor of the breast

Intraductal papilloma

Describe fibroadenoma

- Most common benign tumor* - Fibro: epithelium, adenoma: glands - Reproductive years - Solitary, mult or bilateral - Excision is always curative, can be left alone though - No breast cancer risk - Well circumscribed mass

What are the key features of phyllodes tumor?

- LEss common than fibroadenoma - Reproductive years - Solitary - Excision is almost always curative - No breast cancer risk - Not as well circumscribed, invasive borders in some PTs - Stroma not glandular

Intraductal papilloma

- Is a benign epithelial tumor | - Lesion occurs at the lactiferous duct (large duct lesion) and bleeding can occur from the nipple

What are 2 common conditions that cause inflammation of the breast?

1. Postpartum infection | 2. "Traumatic" fat necrosis

What are 2 major pathogens that cause post partum infections?

1. Staph aureus 2. Strept - ->nursing=cracked nipples, these live on skin

What happens with traumatic fat necrosis?

- Get granulomatous inflammation | - Due to trauma resulting in injured fat, get a hard mass

Describe gynecomastia

- Benign breast disease in men - Common in adolescents and elderly - Relative estrogen excess - Not precancerous - Can regress in teenage years, otherwise require surgery - Often bilateral enlargement

Describe normal male breast tissue

Male breast tissue has ducts, no lobules

Describe the process of gynecomastia

Enlargement of breast is often caused by expansion of mammary ducts and supporting fibrous tissue. Fibroblasts produce collagen and surround ducts. Once collagen is in place, breast enlargement is permanent and need to have surgery to get rid of it