Pathology of the Breast Flashcards by Chris Allison

2 major divisions of carcinoma by location?

Carcinoma in situ (CIS)

Invasive carcinoma

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What are 8 major risk factors for sporadic breast cancer?

Sex = female.
Age > 50.
Geography?
Family Hx of breast cancer.
Fibrocystic changes (some of them).
Prior breast or Gyn cancer.
Radiation (e.g. lymphoma Tx).
Unopposed estrogen.

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2 forms of carcinoma in situ (CIS)? Which is more commonly diagnosed?

Ductal CIS (DCIS) - more commonly diagnosed.
Lobular CIS (LCIS).
Note we're not really sure of LCIS incidence/prevalence because it's harder to diagnose.

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Can DCIS progress to invasive carcinoma?

How curable is DCIS?

Yes, but not all of it does.

DCIS is “always” curable when treated.

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How is DCIS usually picked up?

Focal cluster of calcifications on mammogram.

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What’s the histology term for what DCIS-associated calcifications look like?

Calcified necrosis / dystrophic calcification.

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Why is DCIS even called carcinoma if it’s not invasive?

Histologically, the cells have malignant-looking features: Large cells, high N:C ratio, open chromatin, nucleoli, increased mitoses.
(also the ducts can look ugly: cribriform, comedo-necrosis, etc.)

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What do you do when you see DCIS? Why?

“Treat it.” - apparently this usually involves lumpectomy +/- radiation +/- tamoxifen (not in lecture).
We don’t currently know which DCIS will progress and which ones won’t.

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How is LCIS usually picked up?

As an incidental finding on a biopsy done for other reasons.

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What are the histological features of LCIS?

Lack of cohesion, and mucin-filled “signet-ring” cells.

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What do you do when you find LCIS?

Usually watch and wait +/- anti-estrogen (such as tamoxifen).

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What’s a common clinical presentation for invasive carcinoma on mammogram?

Stellate mass.

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10 year survival for all invasive breast cancer?

45-50%

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What are the 2 ways invasive breast cancer spreads to distant sites?

Hematogenously.

Through lymphatics.

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What are 2 location-based categories of invasive carcinoma of the breast?

Ductal and lobular. They’re categorized for the associated CIS, which will always be there.

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What is Paget Disease of the Nipple?

Crusting and ulceration of nipple (due to squamous metaplasia of duct cells there).
Indicative of invasive carcinoma or CIS.

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What structures are being invaded in inflammatory breast carcinoma?

Dermal lymphatics.

It’s really virulent.

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Histologic buzzwords for invasive lobular carcinoma?

Linear infiltration.

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What are the 4 keys tasks of a pathologist with regard to breast cancer?

Diagnose
Stage
Identify predictive markers
Get molecular profile

What’s the shorthand notation for breast cancer stage?

TNM
T: Tumor size (Tis - T3)
N: Lymph nodes (N0 - N3)
M: Metastasis (M0, M1, Mx)
Stage: 0 - IV

What are 3 markers always tested for in invasive breast cancer?

Estrogen receptor (ER)
Progesterone receptor (PR)
HER2/neu overexpression

How positive do tumors have to be for ER, PR, HER2/neu in order to merit specific treatment?

If they’re at all positive, specific treatment is indicate.

What drug is used for HER2/neu positive cancers?

Herceptin

What’s one molecular profiling assay that’s commonly used? What is its utility?

Oncotype DX

For node-negative tumors with low-risk profile, can treat with just lumpectomy + tamoxifen instead of using chemo.

What type of breast carcinoma do men get?

Ductal. Male breast tissue does not have lobules.

What's 1 predisposing factor for breast cancer in males?

Klinefelter syndrome (XXY).

How does staging, prognosis, and treatment differ between male and female breast cancer?

It doesn't.

4 clinical manifestations of fibrocystic breast changes?

Cyclic pain / tenderness. Palpable mass. Abnormal mammogram. Mass or calcifications.

What are the 2 major categories of fibrocystic changes?

Proliferative and non-proliferative.

4 non-proliferative fibrocystic changes?

Fibrosis Cysts Adenosis Apocrine metaplasia

4 proliferative fibrocystic changes?

Sclerosing adenosis Usual ductal hyperplasia Atypical ductal hyperplasia Atypical lobular hyperplasia

Which two proliferative fibrocystic changes are called "borderline" lesions?

Atypical ductal hyperplasia | Atypical lobular hyperplasia

What fibrocystic changes pose no additional cancer risk?

All the non-proliferative changes. | Mild usual ductal hyperplasia.

Which fibrocystic changes are associated with moderate increased risk for breast cancer?

Sclerosing adenosis. | Moderate to "florid" usual ductal hyperplasia.

Which fibrocystic changes are associated with a moderate to high risk of breast cancer? What increases the risk?

Atypical ductal and lobular hyperplasia. | Family Hx of breast cancer further increase this risk.

3 benign tumors of the breast?

Stroma: Fibroadenoma and phyllodes tumor. Epithelial: Intraductal papilloma.

What's the most common benign tumor of the breast? Prognosis?

Fibroadenoma. 100% curable and never malignant.

What's the deal with phyllodes tumor? What does it look like? Treatment? Prognosis?

Is (usually) benign, but has an invasive border. Almost always can be cured by excision. Has a mortality rate of 6%. (doesn't sound that benign to me...)

How does an intraductal papilloma usually present?

Nipple discharge / bleeding.

Intraductal papilloma prognosis?

Completely benign.

2 common inflammatory breast conditions?

Post-partum infection. | Traumatic fat necrosis.

2 most common organisms causing breast abscess and cellulitis?

Staph. aureus | Streptococci

How can traumatic fat necrosis present?

As a hard mass that forms after trauma.

What kind of inflammation do you see in histology of traumatic fat necrosis?

Granulomatous inflammation.

2 processes in gynecomastia?

Duct epithelia proliferate. | Myofibroblasts lay down collagen.

What part of gynecomastia is irreversible?

The collagen deposition.