Robbins - Unit 1 - Breast Flashcards
- A 36-year-old woman has noticed a bloody discharge from the nipple of her right breast for the past 3 days. On physical
examination, the skin of the breasts appears normal, and no masses are palpable. There is no axillary lymphadenopathy.
The patient has regular menstrual cycles and is using oral contraceptives. Excisional biopsy is most likely to show which of
the following lesions in her right breast?
□ (A) Fibroadenoma
□ (B) Phyllodes tumor
□ (C) Acute mastitis
□ (D) Intraductal papilloma
□ (E) Sclerosing adenosis
d) intraductal papilloma
1 (D) Intraductal papillomas are usually solitary and smaller than 1 cm. They are located in large lactiferous sinuses or
ducts, and have a tendency to bleed. Fibroadenomas contain ducts with stroma and are not highly vascular; these lesions
are not located in ducts. Phyllodes tumors also arise from intralobular stroma and can be malignant. They do not invade
ducts to cause bleeding. Abscesses complicating mastitis organize with a fibrous wall. Sclerosing adenosis, a lesion
occurring with fibrocystic changes, has abundant collagen, not vascularity
A 28-year-old woman in the third trimester of her third pregnancy discovered a lump in her left breast. The physician
palpated a 2-cm, discrete, freely movable mass beneath the nipple. After the birth of a term infant, the mass appears to
decrease slightly in size. The infant breastfeeds without difficulty. What is the most likely diagnosis?
□ (A) Intraductal papilloma
□ (B) Phyllodes tumor
□ (C) Lobular carcinoma in situ
□ (D) Fibroadenoma
□ (E) Medullary carcinoma
d) fibroadenoma
D) Fibroadenomas are common and may enlarge during pregnancy or late in each menstrual cycle. Most intraductal
papillomas are smaller than 1 cm and are not influenced by hormonal changes. Phyllodes tumors are uncommon and tend
to be larger than 4 cm. Lobular carcinoma in situ is typically an ill-defined lesion without a mass effect. Medullary
carcinomas tend to be large; they account for only about 1% of all breast carcinomas.
3 A 30-year-old woman sustained a traumatic blow to her right breast. Initially, there was a 3-cm contusion that resolved
within 3 weeks, but she then felt a firm lump that persisted below the site of the bruise 1 month later. What is the most
likely diagnosis for this lump?
□ (A) Fibroadenoma
□ (B) Sclerosing adenosis
□ (C) Fat necrosis
□ (D) Ductal carcinoma in situ
□ (E) Mammary duct ectasia
c) Fat necrosis
(C) Fat necrosis is typically caused by trauma to the breast. The damaged, necrotic fat is phagocytosed by
macrophages, which become lipid laden. The lesion resolves as a collagenous scar within weeks to months. The firm scar
can mammographically and grossly resemble a carcinoma, however. A fibroadenoma is a neoplasm, and tumors are not
induced by trauma. Sclerosing adenosis is a feature of fibrocystic changes, a common cause of nontraumatic breast
lumps. An intraductal carcinoma may not form a palpable mass lesion. Mammary duct ectasia from inspissated secretions
can induce chronic inflammation and fibrosis, which mimic a carcinoma.
- A 55-year-old man has developed bilateral breast enlargement over the past year. On physical examination, the
enlargement is symmetric and is not painful to palpation. There are no masses. The patient is not obese and is not taking
any medications. Which of the following underlying conditions best accounts for these findings?
□ (A) Micronodular cirrhosis
□ (B) Chronic glomerulonephritis
□ (C) Choriocarcinoma of the testis
□ (D) ACTH-secreting pituitary adenoma
□ (E) Rheumatoid arthritis
a) micronodular cirrhosis
(A) Micronodular cirrhosis is most often a consequence of chronic alcoholism and impairs hepatic estrogen metabolism,
which can lead to gynecomastia. Chronic renal failure is unlikely to have this consequence. Choriocarcinomas of the testis
produce human chorionic gonadotropin, not estrogens. ACTH-secreting pituitary adenomas cause truncal obesity because
of Cushing syndrome. Rheumatoid nodules can appear in various locations along with rheumatoid arthritis, but they rarely
occur in the breast and are unlikely to be bilateral
- A 44-year-old woman sees her physician because she felt a lump in her left breast 1 week ago. The physician palpates
a firm, irregular mass in the upper outer quadrant of the left breast. There are no overlying skin lesions. The gross
appearance of the excisional biopsy specimen is shown in the figure. Which of the following additional findings is most
likely to be present on physical examination?
□ (A) Axillary lymphadenopathy
□ (B) Bloody discharge from the nipple
□ (C) Painful breast enlargement
□ (D) Mass in the opposite breast
□ (E) Cushingoid face
a) Axillary lymphadenopathy
(A) This irregular, infiltrative mass is an infiltrating (invasive) ductal carcinoma, the most common form of breast cancer.
Breast carcinomas are most likely to metastasize to regional lymph nodes. By the time a breast cancer becomes palpable,
lymph node metastases are present in more than 50% of patients. A bloody discharge from the nipple most often results
from an intraductal papilloma. Pain with breast enlargement suggests inflammation. Lobular carcinomas are more often
bilateral, but they are less common than infiltrating ductal carcinomas. Breast cancers are associated in rare cases with
ectopic corticotropin secretion or Cushing syndrome.
6 A 25-year-old woman sees her physician because she has noticed a lump in her right breast. The physician palpates a
2-cm, firm, circumscribed mass in the lower outer quadrant. The figure shows the excised mass (A) and the mammogram
(B). What is the most likely diagnosis?
□ (A) Phyllodes tumor
□ (B) Fibrocystic changes
□ (C) Fibroadenoma
□ (D) Fat necrosis
□ (E) Infiltrating ductal carcinoma
□ (F) Mastitis
c) fibroadenoma
(C) Grossly and radiographically, this patient has a discrete mass that in a woman her age is most likely a
fibroadenoma. Phyllodes tumors are typically much larger and are far less common. Fibrocystic changes are generally
irregular lesions, not discrete masses. Fat necrosis and infiltrating cancers are masses with irregular outlines. Mastitis has
a more diffuse involvement, without mass effect
- A 47-year-old woman has noticed a red, scaly area of skin on her left breast that has grown slightly larger over the past
4 months. On physical examination, there is a 1-cm area of eczematous skin just lateral to the areola. The figure shows
the microscopic appearance of the skin biopsy specimen. What is the most likely diagnosis?
□ (A) Apocrine metaplasia
□ (B) Paget disease of the breast
□ (C) Inflammatory carcinoma
□ (D) Lobular carcinoma in situ
□ (E) Fat necrosis
b) Paget’s dz of the breast
(B) Paget cells are large cells that have clear, mucinous cytoplasm and infiltrate the skin. They are malignant and
extend to the skin from an underlying breast carcinoma. Apocrine metaplasia affects the cells lining the cystically dilated
ducts in fibrocystic change. “Inflammatory carcinoma” does not refer to a specific histologic type of breast cancer; rather, it
describes the involvement of dermal lymphatics by infiltrating carcinoma. In lobular carcinoma in situ, terminal ducts or
acini are filled with neoplastic cells. The overlying skin is unaffected. The macrophages in fat necrosis do not infiltrate the
skin and do not have the atypical nuclei seen in the figure.
8 Three weeks after giving birth to a normal term infant, a 24-year-old woman is breastfeeding the infant and notices
fissures in the skin around her left nipple. Over the next 3 days, the region around the nipple becomes erythematous and
tender. Purulent exudate from a small abscess drains through a fissure. Which of the following organisms is most likely to
be cultured from the exudate?
□ (A) Listeria monocytogenes
□ (B) Streptococcus viridans
□ (C) Candida albicans
□ (D) Staphylococcus aureus
□ (E) Lactobacillus acidophilus
d) Staph aureus
(D) Staphylococcal acute mastitis typically produces localized abscesses, whereas streptococcal infections tend to
spread throughout the breast. Listeriosis can be spread by contaminated food, including milk products, not by human milk.
Candida may cause some local skin irritation, but is likely to become invasive only in immunosuppressed patients.
Lactobacillus acidophilus is the organism used to produce fermented nonhuman milk.
9 A 27-year-old woman feels a lump in her right breast. She has normal menstrual cycles, she is G3, P3, and her last child
was born 5 years ago. The physician palpates a 2-cm, irregular, firm area beneath the lateral edge of the areola. The
mass is not painful and does not feel firm. There are no lesions of the overlying skin and no axillary lymphadenopathy. A
biopsy specimen shows microscopic evidence of an increased number of ducts, which are compressed because of
proliferation of fibrous connective tissue. Dilated ducts with apocrine metaplasia also are present. What is the most likely
diagnosis?
□ (A) Traumatic fat necrosis
□ (B) Fibrocystic changes
□ (C) Mammary duct ectasia
□ (D) Fibroadenoma
□ (E) Infiltrating ductal carcinoma
b) fibrocystic changes
(B) Fibrocystic changes account for the largest category of breast lumps, statistically about 40% of all breast “lumps.”
These lesions are probably related to cyclic breast changes that occur during the menstrual cycle. In about 30% of cases
of breast lumps, no specific pathologic diagnosis can be made. Fibrocystic changes include ductal proliferation, ductal
dilation (sometimes with apocrine metaplasia), and fibrosis. Fat necrosis may produce a localized, firm lesion that mimics
carcinoma, but histology shows macrophages and neutrophils surrounding necrotic adipocytes, and healing leaves a
Robbins & Cotran Review of Pathology Pg. 482
fibrous scar. Inspissated duct secretions may produce duct ectasia with a surrounding lymphoplasmacytic infiltrate. A
fibroadenoma is a discrete mass formed by a proliferation of fibrous stroma with compressed ductules. Carcinomas have
proliferations of atypical neoplastic cells that fill ducts and can invade stroma.
10 A 44-year-old woman noticed a lump in her right breast. On examination, she has an ill-defined, 1-cm mass in the upper
outer quadrant. The mass is cystic on ultrasound. An excision is done, and the mass shows predominantly fibrocystic
changes, but carcinoma also is present. Fine-needle aspirates of both breasts reveal additional foci of similar malignant
cells. Which of the following breast carcinomas is most likely to produce these findings?
□ (A) Ductal carcinoma
□ (B) Lobular carcinoma
□ (C) Malignant phyllodes tumor
□ (D) Medullary carcinoma
□ (E) Mucinous (colloid) carcinoma
b) Lobular carcinoma
(B) Among primary malignancies of the breast, lobular carcinoma in situ (LCIS) is most likely to be bilateral. LCIS may
precede invasive lesions by several years. Lobular carcinoma may be mixed with ductal carcinoma, and it may be difficult
to distinguish them histologically. The other neoplasms listed are less likely to be bilateral and more likely to produce a
mass effect.
11 A 56-year-old woman sees her physician for a routine health examination. There are no remarkable findings on
physical examination. A mammogram shows a 0.5-cm irregular area of increased density with scattered microcalcifications
in the upper outer quadrant of the left breast. Excisional biopsy shows atypical lobular hyperplasia. The patient has been
on postmenopausal estrogen-progesterone therapy for the past 10 years. She has smoked 1 pack of cigarettes per day for
the past 35 years. Which of the following conclusions is most pertinent to these findings?
□ (A) She has the BRCA1 gene mutation
□ (B) The postmenopausal estrogen replacement therapy should be stopped
□ (C) Her risk of breast carcinoma is increased
□ (D) She should undergo bilateral simple mastectomies
□ (E) She should stop smoking
c) her risk of breast carcinoma is increased
(C) Atypical lobular hyperplasia and atypical ductal hyperplasia increase the risk of breast cancer fivefold; the risk
affects both breasts and is higher in premenopausal women or women who have a family history of breast cancer. The
BRCA1 mutation accounts for about 10% to 20% of familial breast carcinomas and only a few percent of all breast
cancers. Mastectomies are probably not warranted at this time, but close follow-up is needed. Smoking and exogenous
estrogen therapy are not well-established risk factors for breast cancer
12 A 54-year-old woman sees her physician after feeling a lump in her left breast. The physician palpates a firm, irregular
mass in the lower outer quadrant just beneath the lateral margin of the areola. A mammogram shows a 2-cm density with
focal microcalcifications. Excisional biopsy shows intraductal and invasive components of a breast carcinoma.
Immunohistochemical staining shows that the cells are positive for HER2/neu expression, but negative for estrogen
receptor and progesterone receptor expression. Flow cytometry shows a small aneuploid peak and a low S-phase. When
combined with doxorubicin, which of the following drugs is most likely to be useful in treating this patient?
□ (A) Hydroxyurea
□ (B) Celecoxib
□ (C) Raloxifene
□ (D) Tamoxifen
□ (E) Trastuzumab
e) Trastuzamab
(E) The expression of HER2/neu suggests that biotherapy with trastuzumab may have some effectiveness. Drug
names with the suffix -mab are monoclonal antibodies that target a specific biochemical component of cells. This form of
biotherapy is useful because normal breast cells do not have HER2/neu expression. Doxorubicin is a standard
chemotherapeutic agent that is part of various multiagent protocols. Hydroxyurea is a cycle-acting agent that is not useful
in breast cancer. Celecoxib is an inhibitor of cyclooxygenase-2 in the arachidonic acid pathway that forms prostaglandins
as part of an inflammatory reaction. Tamoxifen is an antiestrogenic compound that has effectiveness in the treatment of
breast cancers positive for estrogen receptor.
13 A 55-year-old woman has felt a poorly defined lump in her right breast for the past year. On examination, she has a
nontender, firm, 6-cm mass in the upper inner quadrant. There are no lesions of the overlying skin and no axillary
lymphadenopathy. Needle biopsy is done, and microscopic examination of the specimen shows cellular stroma protruding
into spaces lined by a single-layer cuboidal epithelium. The mass is excised with a wide margin, but recurs 1 year later.
After further excision, the lesion does not recur. What is the most likely diagnosis?
□ (A) Fibroadenoma
□ (B) Fibrocystic changes
□ (C) Lobular carcinoma
□ (D) Phyllodes tumor
□ (E) Tubular carcinoma
d) phyllodes tumor
(D) Phyllodes tumors, although grossly and microscopically similar to fibroadenomas, occur at an older age, are larger,
and are more cellular; they can recur locally, but rarely metastasize. Fibrocystic changes can produce a breast lump, but
usually not as large as 6 cm, and without firm areas of cellular stroma. A lobular carcinoma has malignant-appearing
epithelial cells in clusters and rows and may not even produce a mass effect. Tubular carcinomas of the breast are
uncommon, most are less than 1 cm in diameter, and most have small tubular structures in a noncellular stroma.
14 A 51-year-old woman has noticed an area of swelling with tenderness in her right breast that has worsened over the
past 2 months. On physical examination, the 7-cm area of erythematous skin is tender and firm. There is swelling of the
right breast, nipple retraction, and right axillary lymphadenopathy. Excisional biopsy is most likely to show which of the
following lesions?
□ (A) Atypical epithelial hyperplasia
□ (B) Phyllodes tumor
□ (C) Fat necrosis
□ (D) Sclerosing adenosis
□ (E) Infiltrating ductal carcinoma
e) Infiltrating ductal carcinoma
(E) The gross appearance of the skin is consistent with invasion of dermal lymphatics by carcinoma—the so-called
inflammatory carcinoma. Nipple retraction and axillary lymphadenopathy also suggest invasive ductal carcinoma. Atypical
ductal hyperplasia may increase the risk of carcinoma, but it does not produce visible surface skin changes. A phyllodes
tumor can be large and sometimes tender, but the overlying skin is typically not affected, and spread to lymph nodes is
uncommon. The feel of fat necrosis on palpation can mimic that of carcinoma, but the skin is not involved. Sclerosing
adenosis is a feature of benign fibrocystic changes and has no skin involvement
15 A 39-year-old woman has noticed an enlarging mass in her left breast for the past 2 years. The physician palpates a 4-
cm firm mass. A simple mastectomy is performed with axillary lymph node sampling and plastic reconstruction of the
breast. On gross sectioning, the mass has a soft, tan, fleshy surface. Histologically, the mass is composed of large cells
with vesicular nuclei and prominent nucleoli. There is a marked lymphocytic infiltrate within the tumor, and the tumor has a
discrete, noninfiltrative border. No axillary node metastases are present. The tumor cells are negative for estrogen
receptor and progesterone receptor. What is the most likely diagnosis?
□ (A) Colloid carcinoma
□ (B) Fibroadenoma
□ (C) Infiltrating ductal carcinoma
□ (D) Infiltrating lobular carcinoma
□ (E) Intraductal papilloma
□ (F) Medullary carcinoma
□ (G) Papillary carcinoma
□ (H) Phyllodes tumor
f) medullary carcinoma
(F) Medullary carcinomas account for about 1% to 5% of all breast carcinomas. They tend to occur in women at
younger ages than do most other breast cancers. Despite poor prognostic indicators, such as absence of estrogen
receptors and progesterone receptors (ER-PR), medullary carcinomas have a better prognosis than most other breast
cancers. Perhaps the infiltrating lymphocytes are helpful. Colloid carcinomas occur about as frequently as medullary
carcinomas, but they are often positive for ER-PR, and the prognosis is better than average. Fibroadenomas are small
benign lesions that tend to stop enlarging after menopause, when hormonal stimulation has ceased. Infiltrating ductal and
infiltrating lobular carcinomas tend not to produce large, localized lesions because they are more invasive, and they lack a
distinct lymphoid infiltrate. Intraductal papillomas are unlikely to be larger than 1 cm. True papillary carcinomas are quite
rare, although other types of breast carcinoma may have a papillary component. The phyllodes tumor is typically large, but
it has stromal and glandular components