Reproductive - Breast pathology Flashcards
Acute Mastitis
P: Erythematous breast with purulent nipple discharge; absess formation
M: Fissure in nipple from breast feeding -> S. aureus enters
Tx: continued drainage and antibiotics (dicloxacillin)
Periductal Mastitis
P: subareolar mass with nipple retraction
M: smokers with low vitamin A -> squamous metaplasia of lactiferous ducts -> duct blockage and inflammation
Mammary Duct Ectasia
P: periareolar mass with green-brown nipple discharge (inflammatory debris), multiparous postmenopausal women
Biopsy: Chronic inflammation with plasma cells
M: dilation of subareolar ducts
Fat Necrosis
P: Painless mass on exam or abnormal calcification on mammography (saponification)
Biopsy: necrotic fat with associated calcification and giant cells
M: trauma (many not reported) -> necrosis of fat
Fibrocystic Disease
P: lumpy breast, usually in upper outer quadrant
M: development of fibrosis and cysts in breast
Benign, but some (ductal hyperplasia, sclerosing adenosis, atypical hyperplasia) are associated with increased risk for invasive carcinoma to both breasts
Fibrocystic Changes: Fibrosis
Hyperplasia of breast stroma
No increase risk for invasive carcinoma
Fibrocystic Changes: Cystic
Fluid-filled, blue dome. Ductal dilation
No increase risk for invasive carcinoma
Fibrocystic Changes: Sclerosing adenosis
Increased acini and intralobular fibrosis; calcifications
2x increased risk for invasive carcinoma to both breasts
Fibrocystic Changes: Apocrine metaplasia
Apocrine phenotype changes
No increase risk for invasive carcinoma
Fibrocystic Changes: Atypical epithelial hyperplasia
Increased number of epithelial cell layers in terminal duct lobule
5x increased risk for invasive carcinoma to both breasts
In women > 30 years of age
Intraductal Papilloma
P: Serous or blood nipple discharge in premenopasual woman
M: papillary growth of luminal and myoepithelial cells into large laciferous ducts. Typically beneath aerola
Slight increased risk for carcinoma with age
Suspect papillary carcinoma (no underlying myoepithelial cells) in post-menopausal women
Fibroadenoma
P: well circumscribed, marble-like mass in premenopausal woman
Most common benign neoplasm of the breast
M: tumor of fibrous tissue and glands
Estrogen sensitive - growth and tenderness during pregnancy and menstruation
No increased risk of carcinoma
Phyllodes tumor
P: large bulky mass in post-menopausal women (60s)
M: fibroadenoma-like tumor with overgrowth of fibrous component
Biopsy: “Leaf-like” projections
Can be malignant in some cases
Breast cancer epidemiology
Most common carcinoma in woman (excludes skin)
2nd most common cause of cancer mortality in women
Breast cancer risk factors
Gender Age (postmenopausal, except hereditary) Early menarche/late menopause Obesity Atypical hyperplasia First-degree relatives (mother, sister, daughter) with breast cancer
Ductal Carcinoma In Situ (DCIS)
P: calcification on mammography; no mass
(other calcifications include sclerosing adenosis and fat necrosis)
M: malignant proliferation of cells in ducts -> fills ductal lumen
No basement membrane penetration
Comedocarcinoma
Subtype of DCIS
P: high-grade cells with necrosis and dystrophic calcifications in center of ducts
Paget’s diseasse
Subtype of DCIS
P: eczematous patches on nipple; ulceration and erythema
M: DCIS extends up the ducts into skin of nipple
Paget cells: large cells in epidermis with clear halo
(also seen in vulva)
Invasive ductal carcinoma
P: physical exam (>2cm) or mammography (>1cm)
firm, fibrous, “rock-hard” mass with sharp margins and small, glandular, duct-like cells. Classic “stellate” morphology.
M: invasive carcinoma that forms duct-like structures; dimpling of skin or retraction of nipple
Worst and most invasive (most - 76% of breast cancers)
4 subtypes: tubular, mucinous, medullary, inflammatory
Tubular carcinoma
Subtype of ductal carcinoma
P: premenopausal
M: well-differentiated tubules that lack myoepithelial cells
good prognosis
Mucinous carcinoma
Subtype of ductal carcinoma
P: older women (70s)
Abundant extracellular mucin (“tumor cells floating in mucus pool”)
Good prognosis
Medullary carcinoma
Subtype of ductal carcinoma
P: BRCA1 carriers, well-circumscribed mass that can mimic fibroadenoma on mammography
M: large, high-grade cells with lymphocytes and plasma cells (fleshy, cellular, lymphocytic infiltrates)
Good prognosis
Inflammatory carcinoma
Subtype of ductal carcinoma
P: inflamed, swollen breast; can be mistaken for acute mastitis
Peau d’orange (breast skin resembles orange peel)
M: carcinoma in dermal lymphatics -> block drainage
Poor prognosis (50% at 5 years)
Lobar Carcinoma in Situ (LCIS)
P: no mass or calcifications; incidental finding on biopsy
M: malignant proliferation of cells in lobules with no invasion of basement membrane
Lack E-cadherin adhesion protein
Often multifocal and bilateral
Tx: tamoxifen to reduce risk of subsequent carcinoma
Low risk of progression to invasive carcinoma
Invasive lobular carcinoma
P: bilateral with multiple lesions in same locations
Single-file pattern cells may exhibit signet-ring morphology (Indian file)
Loss of E-cadherin
What is the best prognostic factor for breast cancer staging (TNM)
Metastasis (but many present before)
Spread to axillary lymph nodes most useful (sentinel lymph node biopsy)
Predictive factors for treatment response:
ER, PR, and Her2/neu gene amplication
Triple negative tumors - African American, poor prognosis
BRCA1 and BRCA2 mutations
Multiple first-degree relatives with breast cancer, premenopausal tumor, multiple tumors
BRCA 1: breast and ovarian carcinoma
BRCA 2: male breast cancer
Risk remains after bilateral mastectomy (axilla or subcutaneous tissue of chest wall)
Male Breast Cancer
P: subareolar mass in older males; nipple discharge (1% of all breast cancers)
M: invasive ductal carcinoma (lobular is rare because male develop few lobules)
Associated with BRCA2 and Kleinfelter syndrome
