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GU / GYN & Renal > Pathoma: Breast Pathology > Flashcards

Pathoma: Breast Pathology Flashcards

1
Q

General

Breast

Mammary Gland

A
  • Modified sweat gland embryologically derived from skin
    • Breast tissue (and pathology) can develop anywhere along the milk line
    • Milk line runs from axilla to vulva
  • Functional unit of breast: terminal duct lobular unit (TDLU)
    • Lobules make milk that drains via ducts to nipple
  • Lobules & ducts are lined by 2 layers of epiehlium
    • Luminal layer: inner layer; responsible for milk production
    • Myoepithelial layer: outer layer; contractilons propel milk towards nipple
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2
Q

Breast

A

Terminal duct lobular unit (TDLU)

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3
Q

General

Breast

Hormone Sensitivity

A

Breast tissue is hormone sensitive
* Before puberty, male & female breast tissue primarily consists of large ducts under nipple
* Development after menarche is primarily driven by estrogen & progesterone
* Lobules & small ducts form and are present in highest density in the upper outer quadrant
* Breast tenderness during menstrual cycle is a common complaint, especially prior to menstruation
* During pregnancy, breast lobules undergo hyperplasia
* Hyperplasia is driven by estrogen & progesterone produced by the corpus luteum (early 1st trimester), fetus, and placenta (later in pregnancy
* After menopause, breast tissue undergoes atrophy

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4
Q

General

Galactorrhea

A

Milk production outside of lactation
* Not a symptom of breast cancer
* Causes include:
* Nipple stimulation
* Normal, physiologic cause
* Prolactinoma of anterior pituitary
* Common pathologic cause
* Drugs

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5
Q

Inflammatory Conditions

Bacterial infection associated with breast-feeding
* Fissures develop in nipple providing route of entry for microbes

Pathophysiology

A

Acute mastitis

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6
Q

Inflammatory Conditions

Usually due to S. aureus

Etiology

A

Acute mastitis

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7
Q

Inflammatory Conditions

Presents as a warm, erythematous breast with purulent nipple discharge
* May progress to abscess formatiom

Clinical Presentation

A

Acute mastitis

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8
Q

Inflammatory Conditions

Treatement of acute mastitis

Approach to Therapy

A
  • Continued drainage
    • e.g., feeding
  • Antibiotics
    • e.g., dicloxacillin
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9
Q

Inflammatory Conditions

Inflammation of subareolar ducts

Pathophysiology

A

Periductal mastitis

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10
Q

Inflammatory Conditions

Usually seen in smokers
* Relative Vit A deficiency results in squamous metaplasia of laciferous ducts producing duct blockage & inflammation

Epidemiology

A

Periductal mastitis

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11
Q

Inflammatory Conditions

Presents as a subareolar mass with nipple retraction

Clinical Presentation

A

Periductal mastitis

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12
Q

Inflammatory Conditions

Inflammation with dilation (ectasia) of subareolar ducts

Pathophysiology

A

Mammary duct ectasia

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13
Q

Inflammatory Conditions

Rare; classically arises in multiparous post-menopausal women

Epidemiology

A

Mammary duct ectasia

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14
Q

Inflammatory Conditions

  • Presents as a periareolar mass with green-brown nipple discharge (inflammatory debris)
  • Chronic inflammation with plasma cells seen on biopsy

Clinical Presentation

A

Mammary duct ectasia

Green-brown nipple discharge = hallmark symptom

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15
Q

Inflammatory Conditions

Necrosis of breast fat

Pathophysiology

A

Fat necrosis

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16
Q

Inflammatory Conditions

Usually related to trauma

Etiology

A

Fat necrosis

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17
Q

Inflammatory Conditions

  • Presents as a mass on physical exam or abnormal calcification on mammography
    • Calcification due to saponification
  • Biopsy shows necrotic fat associated with calcificatins & giant cells

Clinical Presentation

A

Fat necrosis

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18
Q

Inflammatory Conditions

Usually related to trauma

Etiology

A

Fat necrosis

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19
Q

Benign Tumors & Fibrocystic Changes

Development of fibrosis & cysts in breast

Pathophysiology

A

Fibrocystic change

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20
Q

Benign Tumors & Fibrocystic Changes

Most common change in premenopausal breast
* Thought to be hormone driven

Pathophysiology

A

Fibrocystic change

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21
Q

Benign Tumors & Fibrocystic Changes

Presents as vague irregularity of breast tissue (“lumpy breast”), usually in upper outer quadrant

Clinical Presentation

A

Fibrocystic change

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22
Q

Benign Tumors & Fibrocystic Changes

Cysts have blue-done appearance on gross exam

Gross Appearance

A

Fibrocystic change

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23
Q

Benign Tumors & Fibrocystic Changes

Benign, but some fibrocystic-related changes are a/w increased risk for invasive carcinoma
* Fibrosis, cysts, apocrine metaplasia: 0
* Ductal hyperplasia; sclerosing adenosis: 2x
* Atypical hyperplasia: 5x

Potential Complications

A

Fibrocystic change

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24
Q

Benign Tumors & Fibrocystic Changes

A

Fibrocystic change

Apocrine metaplasia, abundant pink cytoplasm; no increased cancer risk

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25
Q

Benign Tumors & Fibrocystic Changes

Papillary growth, usually into large duct
* Characterized by FV projections lined by epithelial (luminal) & myoepithelial cells

Histopathology

A

Intraductal papilloma

Papilloma = benign

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26
Q

Benign Tumors & Fibrocystic Changes

Classically presents as bloody nipple discharge in premenopausal woman

Clinical Presentation

A

Intraductal papilloma

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27
Q

Benign Tumors & Fibrocystic Changes

Intraductal papilloma

Approach to Diagnosis

A
  • Must be distinguished from papillary carcinoma
  • Papillary carcinoma also presents as bloody nipple discharge
    • Histology: no underlying myoepithelial cells
    • Epidemiology: more common in postmenopausal women
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28
Q

Benign Tumors & Fibrocystic Changes

Tumor of fibrous tissue & glands
* Estrogen sensitive: grows during pregnancy; may be painful during menstrual cycle

Histopathology

A

Fibroadenoma

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29
Q

Benign Tumors & Fibrocystic Changes

  • Most common benign neoplasm of the breast
  • Usually seen in premenopausal women

Epidemiology

A

Fibroadenoma

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30
Q

Benign Tumors & Fibrocystic Changes

Presents as a well-circumscribed, mobile marble-like mass

Clinical Presentation

A

Fibroadenoma

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31
Q

Benign Tumors & Fibrocystic Changes

Benign, with no increased risk of carcinoma

Potential Complications

A

Fibroadenoma

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32
Q

Benign Tumors & Fibrocystic Changes

A

Fibroadenoma

Fibrous tissue, glands; sharply demarcated from adjacent tissue

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33
Q

Benign Tumors & Fibrocystic Changes

Fibroadenoma-like tumor with overgrowth of fibrous componenet
* Characteristic “leaf-like” projections seen on biopsy

Histopathology

A

Phyllodes tumor

“Leaf-like” projections = histological hallmark

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34
Q

Benign Tumors & Fibrocystic Changes

Most commonly seen in postmenopausal women

Epidemiology

A

Phyllodes tumor

35
Q

Benign Tumors & Fibrocystic Changes

Can be malignant in some cases

Potential Complications

A

Phyllodes tumor

Cancer is more common in post-menopausal women

36
Q

Benign Tumors & Fibrocystic Changes

A

Phyllodes tumor

“Leaf-like” projection = hallmark; overgrowth of fibrous component

37
Q

General

Breast Cancer

Epidemiology

A
  • Most common carcinoma in women by incidence (excluding skin cancer)
  • 2nd most common cause of cancer mortality in women
  • Risk factors related to estrogen exposure
38
Q

General

Breast Cancer

Risk Factors

A
  • Female gender
  • Age: cancer usually arises in postmenopausal women, except hereditary breast cancer
  • Early menarche / late menopause
  • Obesity
  • Atypical hyperplasia
  • First-degree relative with breast cancer
39
Q

Breast Cancer

Malignant proliferation of cells in ducts with no invasion of basement membrane

Histopathology

A

Ductal carcinoma in situ (DCIS)

Malignant cells are bound by basement membrane

40
Q

Breast Cancer

  • Calcifications detected on mammogram
    • Usually does not produce mass
  • Biopsy of calcifications required for Dx

Approach to Diagnosis

A

DCIS

Note: calcifications can also be a/w benign conditions & fat necrosis

41
Q

Breast Cancer

Characterized by high-grade cells with necrosis & dystrophic calcification in center of ducts

Histology

A

DCIS, comedo type

42
Q

Breast Cancer

A

DCIS, comedo type

Duct full of cells with central necrosis & calcification

43
Q

Breast Cancer

DCIS that migrates along duct to involve nipple epidermis

Pathology

A

Paget’s disease of the breast

44
Q

Breast Cancer

Presents as nipple ulceration & erythema

Clinical Presentation

A

Paget’s disease of the breast

45
Q

Breast Cancer

Almost always associated with underlying carcinoma

Complications

A

Paget’s disease of the breast

Unlike Extramammary Paget’s disease

46
Q

Breast Cancer

A

Paget disease of the breast

47
Q

Breast Cancer

A

Paget disease of the breast

48
Q

Breast Cancer

Invasive carcinoma that forms duct-like structures

Histopathology

A

Invasive ductal carcinoma (IDC)

49
Q

Breast Cancer

Most common type of invasive carcinoma in the breast

Epidemiology

A

IDC

Accounts for >80% of cases

50
Q

Clinical Presentation

  • Presents as a mass detected by physical exam or mammography
    • Clinically: masses >2 cm
    • Mammography: masses >1 cm
  • Advanced tumors may result in dimpling of skin or retraction of nipple

Clinical Presentation

A

IDC

51
Q

Breast Cancer

Biopsy shows duct-like structures in desmoplastic stroma

Histology

A

IDC

52
Q

Breast Cancer

Subtypes of IDC

Histology

A
  1. Tubular carcinoma
  2. Mucinous carcinoma
  3. Medullary carcinoma
  4. Inflammatory carcinoma
53
Q

Breast Cancer

Characterized by well-differentiated tubules that lack myoepithelial cells

Histology

A

Tubular carcinoma

IDC; very good prognosis

54
Q

Breast Cancer

A

Tubular carcinoma

Well-differentiated tubules, no myoepithelial cells; desmoplastic stroma

55
Q

Breast Cancer

Characterized by carcinoma with abundant extracellular mucin

Histology

A

Mucinous carcinoma

IDC; older women (age > 70); very good prognosis

56
Q

Breast Cancer

A

Mucinous carcinoma

“Tumor cells floating in pool of mucus”

57
Q

Breast Cancer

Characterized by large, high-grade cells growing in sheets containing lymphocytes & plasma cells

Histology

A

Medullary carcinoma

IDC; relatively good prognosis

58
Q

Breast Cancer

Increased incidence in BRCA1 carriers

Epidemiology

A

Medullary carcinoma

IDC

59
Q

Breast Cancer

Well-circumscribed mass that can mimic fibroadenoma on mammography

Morphology

A

Medullary carcinoma

IDC; relatively good prognosis

60
Q

Breast Cancer

Characterized by carcinoma in dermal lymphatics

Histology

A

Inflammatory carcinoma

IDC; poor prognosis

61
Q

Breast Cancer

Presents as an inflamed, swollen breast with no discrete mass

A

Inflammatory carcinoma

Tumor cells block drainage of lymphatics; can be mistaken for mastitis

62
Q

Breast Cancer

A

Inflammatory carcinoma

IDC; inflamed, swollen breast; can be mistaken for acute mastitis

63
Q

Breast Cancer

A

Inflammatory carcinoma

Tumor cells in dermal lymphatics

64
Q

Breast Cancer

Malignant proliferation of cells in lobules with no invasion of basement membrane
* Often multifocal & bilateral
* Low risk of progression to invasive carcinoma

Histopathology

A

Lobular carcinoma in situ (LCIS)

65
Q

Breast Cancer

Discovered incidentally on biopsy
* No mass or calcifications

Approach to Diagnosis

A

LCIS

66
Q

Breast Cancer

Characterized by dyscohesive cells lacking E-cadherin adhesion protein

Histopathology

A

LCIS

E-cadherin = protein that holds adjacent celsl together

67
Q

Breast Cancer

Treatment of LCIS

Approach to Therapy

A
  • Tamoxifen: reduces risk of subsequent carcinoma
  • Close follow-up

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68
Q

Breast Cancer

Invasive carcinoma that characteristically grows in single-file pattern
* May exhibit signet-ring morphology

Histopathology

A

Invasive lobular carcinoma (ILC)

No duct formation due to lack of E-cadherin

69
Q

Breast Cancer

A

ILC

Tumor cells growing in single-file pattern = histological hallmark

70
Q

Prognostic & Predictive Factors

Breast Cancer: Prognostic Factors

A

Prognosis is based on TNM staging
* Metastasis is most important factor, but most patients present before metastasis occur
* Spread to axillary lymph nodes is most useful prognostic factor
* Sentinel lymph node biopsy is used to assess axillary lymph nodes

71
Q

Prognostic & Predictive Factors

Breast Cancer: Predictive Factors

A

Predictive factors predict response to treatment
* Most important factors: estrogen receptor (ER), progesterone receptor (PR), and HER2/neu gene amplification (overexpression) status
* Presence of ER & PR: responsive to anti-estrogenic agents (e.g., tamoxifen)
* HER2/neu amplification: responsive to trastuzumab (designer Ab against HER2 receptor)
* “Triple negative tumors”: ER-neg, PR-neg, HER2/neu-neg; poor progrnosis
* African-American women have increased risk of triple-negative carcinoma

72
Q

Breast Cancer

A

IHC: estrogen receptor (ER)

ER & PR are located in nuclei; ER/PR-pos = resposive to tamoxifen

73
Q

Breast Cancer

A

IHC: HER2/neu amplification

GF receptor on cell surface; HER2-pos = responsive to trastuzumab

74
Q

Breast Cancer

Prevalence of hereditary breast cancer

Epidemiology

A
  • 10% of breast cancer cases
75
Q

Breast Cancer

Features suggesting HBC

Epidemiology

A
  • Multiple first-degree relatives with breast cancer
  • Tumor at early age (premenopausal)
  • Multiple tumors in a single patient
76
Q

Breast Cancer

BRCA1 & BRCA2 mutations

Etiology

A

Most important single-gene mutations associated with HBC

77
Q

Breast Cancer

BRCA1 mutation

Etiology

A

Associated with breast & ovarian carcinoma
* Increased propensity for medullary carcinoma
* Ovary: classically serous carcinoma

78
Q

Breast Cancer

BRCA2 mutation

A

A/w breast carcinoma in males

79
Q

Breast Cancer

Male Breast Cancer

Epidemiology

A
  • Rare: 1% of all breast cancers
  • Presents as subareolar mass in older males
    • Highest density of breast tissue in males is underneath nipple
    • May produce nipple discharge
  • Most common histological subtype = IDC
    • Lobular carcinoma is rare; male breast develops very few lobules
  • Associated with BRCA2 mutations & Klinefelter syndrome
80
Q

Breast Cancer

Male Breast Cancer

Epidemiology

A
  • Rare: 1% of all breast cancers
81
Q

Breast Cancer

Male Breast Cancer

Presentation

A
  • Presents as subareolar mass in older males
    • Highest density of breast tissue in males is underneath nipple
    • May produce nipple discharge
82
Q

Breast Cancer

Male Breast Cancer

Most common type of carcinoma

A
  • Most common histological subtype = IDC
    • Lobular carcinoma is rare
    • Male breast develops very few lobules
83
Q

Breast Cancer

Male Breast Cancer

Most common type of carcinoma

A
  • Most common histological subtype = IDC
    • Lobular carcinoma is rare
    • Male breast develops very few lobules

GU / GYN & Renal (23 decks)

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