WEEK 14 SLIDES FINAL "FOLLOW UP SECTION"-USE W/PICTURE SLIDES!!

Question 1

PATHOLOGY OF THE HEPATOBILIARY SYSTEM X 8

Case # 1, Alcoholic liver cirrhosis

• 1. Alcoholic Micronodular cirrhosis of the liver:
• This is a liver specimen with an irregular scarred capsular surface and shows fine, diffuse, __________, the nodules varying from 1-3 mm in diameter. Note also the yellowish-brown discoloration
• • Hepatic cirrhosis is defined as a _____ _________, irreversible condition characterized by hepatocellular injury leads to compensatory hyperplasia (regenerative nodules) with disruption of the normal architecture. Subclassified into 2 TYPES on the basis of the SIZE of nodules; MICOR-nodular is less than 3 mm. and MACRO-nodular is larger than 3 mm. up to 5 cm.(is not value)
• The most important classification of the cirrhosis is according to the cause; ___% of the cases are due to alcoholic liver disease. The second cause of the cirrhosis is chronic hepatitis B and C viruses.
• • Complications: hepatic failure which leads to hepatic encephalopathy, portal hypertension (with associated splenomegaly, ascites and esophageal varices) and renal failure.

Answer 1

nodularity

diffuse fibrosis

65

Question 2

PATHOLOGY OF THE HEPATOBILIARY SYSTEM X 8

2. Budd-Chairi syndrome of the liver:

• This is a post-mortem liver specimen, at autopsy there were extensive thrombosis within the efferent __________ _________. The cut surface of the liver shows irregular areas of intense congestion and mottling, separated by rather pale, yellowish-brown parenchyma. Many of the VEINS are visibly occluded by __________..
• • Budd-Chairi syndrome results from___________ of the major hepatic veins, most often by thrombus, while many cases remain idiopathic, recognized causes include any coagulopathy (particularly polycythemia rubra vera), occlusion of major hepatic veins or inferior vena cava by tumor, thrombophlebitis of the hepatic veins and various drugs (e.g. birth control bills) or chemical toxins

Answer 2

hepatic veins.

thrombus

occlusion

Question 3

PATHOLOGY OF THE HEPATOBILIARY SYSTEM X 8

3. Chronic Active Hepatitis and Cirrhosis of the Liver:

This is a post-mortem liver specimen, with the cut surface of the liver shows an obvious __________ macronodular cirrhosis with evidence of active hepatitis histologically by presence of PIECEMEAL necrosis.

*Chronic hepatitis, which most often complicates hepatitis B or hepatitis C infection. Rare causes by drugs (such as methyl dopa) or autoimmune hepatitis.

*Chronic active hepatitis usually represents a particularly
aggressive host response to type B or C infection. Its significance lies in the fact that changes in the_________ liver architecture leads to cirrhosis in ____% or more of patients.

Answer 3

irregular

lobular

50

Question 4

PATHOLOGY OF THE HEPATOBILIARY SYSTEM X 8

4. Acute Fulminant Viral Hepatitis of the Liver with massive necrosis:

• This is a post-mortem liver specimen of elderly man died from hepatic failure after infection by acute viral hepatitis.
• The cut surface of the liver is notably pale, ENLARGED in size (normally, the liver in fresh state weighing only 670 gram = approximately 11/2 pound) and representing almost TOTAL ___________ with a few islands of viable hepatic parenchyma remaining as brownish foci on the left.
• *Microscopic finding : Multifocal areas of necrosis with lymphocytic infiltrate, ____________ of hepatocyte cells, hyperplasia of KUPFFER CELLS and councilman bodies (fragmented, eosinophilic staining and shrunken cells).

.
• *Complications: Patients become CARRIERS of infection or may develop chronic hepatitis, cirrhosis or hepatocellular carcinoma

Answer 4

necrosis

degeneration

Question 5

PATHOLOGY OF THE HEPATOBILIARY SYSTEM X 8

5. Hepatocellular Carcinoma with Micronodular Cirrhosis of the Liver:

• This is a post-mortem liver specimen.

• The cut surface of this liver shows a fine, UNIFORM, micronodular cirrhosis. A ______, partly bile-stained tumor, measuring 6.5 cm in diameter, arises near the diaphragmatic surface and appears well circumscribed.
A similar tumor is apparent at the bottom right.

• *Hepatocellular carcinoma is relatively uncommon in Caucasians but appears increasing incidence in _____ & _________. This tumor most often affects adults between the ages of 40 and 60 with pre-existing cirrhosis (This is the most common cause), also cirrhosis of chronic active hepatitis B&C. A well-recognized environmental carcinogen, is aflatoxin derived from a fungus (such as aspergillus flavus) in food.
• • Prognosis is very poor with few patients surviving more than one year.

Answer 5

rounded

Asia and Africa.

Question 6

PATHOLOGY OF THE HEPATOBILIARY SYSTEM X 8

6. Cholelithiasis of the Gall Bladder:

• These calculi were removed from a woman who had undergone cholecystectomy.
• The specimen consists of a very large number of yellowish-brown _______, ranging in diameter from 0.2 -2 cm. Many of the stones have ________ surfaces, a result of their rubbing against one another in the gall bladder.
• Cholelithiasis is an extremely common condition, particularly with advancing age, but is often ___________. FEMALES are affected twice as often as males and recognized predisposing factors include obesity, multiparity, diabetes mellitus, chronic hemolytic anemia, there is also an increased familial incidence.
• Types: cholesterol, bile pigment or MIXED type (the MIXED type is the most common type).

Answer 6

calculi

facetted

asymptomatic.

Question 7

PATHOLOGY OF THE HEPATOBILIARY SYSTEM X 8

7. Acute Cholecystitis of the Gall Bladder:

• This specimen was excised from a woman, following a long history of non-specific dyspepsia. NO gall stones were found.
• The gall bladder has been opened to show marked mucosal and transmural congestion and _______, associated with a multifocal fibrinopurulent exudate. Acute cholecystitis in the absence of cholelithiasis is UNCOMMON, but may be idiopathic or _____ infection.

Answer 7

edema

bacterial

Question 8

PATHOLOGY OF THE HEPATOBILIARY SYSTEM X 8

8. Acute Hemorrhagic Pancreatitis of the Pancreas:

• The pancreas is markedly swollen and extensive hemorrhagic necrosis, particularly in the body. A small fragment of adjacent adipose tissue (portion of the greater omentum) shows multiple foci of bright yellow
necrosis.

• *Acute pancreatitis is VERY COMMON, accounting for approximately 1 in 500 hospital admissions in the western world. 70% of the cases associated with ________ and GALL STONE diseases.
• *It results from the sudden onset of ENZYMATIC _____________ of the pancreatic parenchyma and adjacent tissues. Activation of PROTEASE and LIPASE leads to the DESTRUCTION of the pancreatic tissue, blood vessel wall (hence the hemorrhage) and adjacent adipose tissue.
• *This extensive tissue damage, associated with loss of blood and body fluids, may lead to the development of __________&_______ _______.

*Prognosis : death in up to 10% 0f the cases

SLIDE BELOW SAID
“Peritonitis due to acute pancreatitis” WITH A PICTURE

Answer 8

alcoholism

autodigestion

shock and renal failure.

Question 9

PATHOLOGY OF THE RENAL SYSTEM WEEK 10 X 8

1. Horseshoe kidney:

• Both kidneys with the aorta, renal arteries and ureters are shown. The kidneys are ENLARGED and UNITED at their _____ ______ by an isthmus of renal tissue which lies OVER the aortic bifurcation.

• *Renal fusion is NOT rare abnormality, being found in about 1 in 250 autopsies results from an _____________ failure of ASCENT of nephrogenic tissue. Associated abnormalities of the vascular supply and ureters are common. This deformity is more common in MALES
than females

Answer 9

Lower poles

embryological

Question 10

PATHOLOGY OF THE RENAL SYSTEM WEEK 10 X 8

2. Adult POLYcystic disease with renal transplant:

• These are post-mortem specimens from adult male who was found to have polycystic disease 6 years before his death. Later he underwent renal transplantation.

• * The two diseased kidneys are grossly ENLARGED and the parenchyma is replaced BILATERALLY by numerous _____ of varying size. They are smooth-walled and some contain gelatinous material. Hemorrhage is apparent within a few of the cysts. The renal hemograft (CENTER) is
NORMAL in appearance and serves to demonstrate the size of the patient’s own kidneys.

• • Adult polycystic disease is a common condition which has an _________ dominant inheritance.
• Patients most often present in _______ age, either hematuria, hypertension or pyelonephritis. * Associated with other anomalies such as liver cysts and Berry aneurysms in the circle of wills.
• • Complications of hypertension (as MI), and chronic renal failure

Answer 10

cysts

autosomal

middle

Question 11

PATHOLOGY OF THE RENAL SYSTEM WEEK 10 X 8

3. Acute Tubular Necrosis:

• This is a post-mortem specimen from a person who committed suicide by taking drug (paracetamol).

• The kidney shows pallor and swelling of the _____ and intense congestion of the _________.
• • Acute tubular necrosis is an important cause of acute renal failure. * It most often results from sever RENAL ischemia as seen in HYPOtensive or HYPOvolemic _______ , it may be nephrotoxic in origin, for example after ingestion of heavy metals, antibiotic (aminoglycosides) and anesthetic.
• • Prognosis: better prognosis with nephrotoxic than ischemic type.

Answer 11

cortex

medulla.

medulla.

Question 12

PATHOLOGY OF THE RENAL SYSTEM WEEK 10 X 8

4. Acute Suppurative Pyelonephritis:

• This specimen was excised from a young woman who was acutely ill with Escherichia Coli septicemia. Because of severe pain in the left flank, ureteric catheter specimens of urine were examined and only that on the left was infected. Nephrectomy was performed and the patient mad a rapid recovery.
• • The kidney has been sectioned to show numerous abscess, mainly in the cortex, surrounded by zone of hyperemia, with thickened, edematous renal pelvis
• • Acute pyelonephritis is due to gram ______ bacilli (E.coli or Proteus) in the majority of the cases. Infection is most commonly __________ in origin. In young adult FEMALES are most often affected, while in OLDER adults MALES predominate.
• Common predisposing causes include urinary obstruction, instrumentation of the urinary tract, pregnancy, vesicouretric reflux and diabetes mellitus.
• • Modern antibiotic therapy had led to greatly improved treatment of these cases, nephrectomy is very rarely necessary

Answer 12

negative

ascending

Question 13

PATHOLOGY OF THE RENAL SYSTEM WEEK 10 X 8

5. Oxalate Stones from Renal Pelvis:

• The specimen on the left was removed from a person who had a history of intermittent PAINLESS hematuria for long time, but NO clinical details on the right specimen.
• Both stones have formed a cast of the renal pelvis and are covered with small, sharp crystalline projections.

While the one on the left is pale, the right side stone is dark brown in color due to deposition of BLOOD
pigment from pelvicalyceal hemorrhage caused by _________ by rough surface of the stone. * Calcium oxalate stones are the most common type of the renal stones (____________).

Answer 13

abrasion

urolithiasis

Question 14

PATHOLOGY OF THE RENAL SYSTEM WEEK 10 X 8

6. Renal Cell Carcinoma of the Kidney
   (Adenocarcinoma, previously known as Hypernephroma):

• This is a nephrectomy specimen from old person who had suffered intermittent hematuria for 7 years.

• A section through the kidney shows virtual replacement of the parenchyma by a tumor mass measuring 13 X 10 cm. It has the characteristic appearance of a renal carcinoma, being predominantly golden-yellow in color with area of hemorrhage, fibrosis, necrosis and
cyst formation. The adjacent renal pelvis is compressed.

• * Adenocarcinoma of the kidney is the most common primary renal ________ tumor and predominantly occurs in OLDER adults, affecting MALES more than females.

• *These TUMORS are derived from renal tubular epithelium and usually arise in the _____ . Associated systemic manifestations are common and include fever, hypercalcemia (due to parathormone), polycythemia
(due to erythropoietin) and hypertension (due to renin).

• • Spread :LOCAL invasion, grow along renal vein (blood metastasis) to the LUNGS and lymphatic to the periaortic lymph nodes.
• • Treatment : surgery and radiotherapy

Answer 14

malignant

cortex

Question 15

PATHOLOGY OF THE RENAL SYSTEM WEEK 10 X 8

7. Cystitis of the Urinary Bladder:

• This is a post-mortem specimen from a person who suffered from severe URINE infection with foul-smelling of the URINE.
• The bladder has been opened to show intense ____________ of the POSTERIOR wall. On the left, the ostium of a small diverticulum is visible just above the ureteric orifice and on the right, there are small flecks of calcific material adherent to the urothelium.

• * Acute infection of the urinary tract is most often due to _________ & _________ group.
• * Predisposing factors include diabetes mellitus, radiation therapy,
instrumentation (catheter), neurogenic bladder and chemotherapy.

Answer 15

congestion

E. Coli and Proteus

Question 16

PATHOLOGY OF THE RENAL SYSTEM WEEK 10 X 8

8. Papillary Transitional Cell Carcinoma of the Urinary Bladder:

• This papillary tumor, measuring 2 cm. in diameter, has been excised from the bladder. It has been bisected to show the typical LONG, branching villous processes. At the core is a small fragment of muscle from the bladder wall which shows superficial invasion by tumor. Unknown cause but carcinogenic chemicals (______ dye) are high risk to develop cancer.
• • Transitional cell carcinoma is the most common primary malignant tumor of the ________, predominantly in MALES over the age of 50’s. While these tumors tend to be multiple, the __________ is the single common site. Most of the patients present by PAINLESS hematuria.
• Metastasis by either local invasion or lymphatic spread.
• • Prognosis: high incidence of recurrence and overall, 5 year survival rate is 30%.

Answer 16

aniline

bladder

trigone

Question 17

PATHOLOGY OF THE MALE GENITAL SYSTEM X 5

. Maldescent of Testis:

• The left side of the scrotum was noted to be empty and the corresponding testis was found in the left inguinal canal, at the head of a hernial sac.
• • Both testes have been sectioned to contrast the normal right testis with the imperfectly descended left one, which is markedly ATROPHIC and appears FIBROTIC.
• Incidence : is about 4 % in male neonates and about 1 % in all males over the age of 1. The most common sites of arrest in the normal path are high in the _______, the superficial inguinal pouch, the inguinal canal or within the abdomen. If brought down into the scrotum by the age of 4-6 years, such testes can retain NORMAL function. If left, the affected testis will fail to show spermatogenesis and there is an INCREASED risk of developing a testicular neoplasm, most commonly a ________.

Answer 17

scrotum

seminoma

Question 18

PATHOLOGY OF THE MALE GENITAL SYSTEM X 5

2. Seminoma of the Testis:

• This specimen was excised from a man who had noticed gradual enlargement of the testicle for 6 months.
• The testicle has been sectioned to show a pale solid OVOID tumor, which has replaced the entire body of the testis with nodularity than is usual. The tunica vaginalis is closely adherent over most of the testis, the remaining space containing some recent _____ _______. Notice that the tumor has invaded the epididymis.
• Seminoma is the most common primary malignant tumor of the _______ and arises most often in patients 30-40 years of age. It is classically a well-circumscribed tumor of uniform grayish-pink color, which occasionally shows foci of necrosis but is rarely hemorrhagic.

• It spreads largely by ___________. These tumors are very radiosensitive such that 5-year survival is now at least 95%.

Answer 18

blood clot

testis

lymphatic

Question 19

PATHOLOGY OF THE MALE GENITAL SYSTEM X 5

3. Malignant Teratoma of the Testis:

• The specimen was excised from a young man who presented by a one month history of a painless swollen testis. The testis is ENLARGED and contains a well-defined tumor, composed largely of solid pale tissue with ____ _________.There is a rim of residual normal testis at the UPPER pole and the cord shows NO evidence of invasion.
• • Teratomas account for 30 % of primary testicular tumors and are most common in the ______ decade. A very small proportion arise in undescended testes. * Spread is both lymphatic and hematogenous. Five-year survival has improved dramatically in recent years with the addition of sophisticated chemotherapy to radiotherapy

Answer 19

cystic foci.

third

Question 20

PATHOLOGY OF THE MALE GENITAL SYSTEM X 5

4. Benign Hypertrophy of the Prostate:

• The bladder has been opened to show a symmetrically enlarged prostate gland at its base, with a prominent ‘MIDDLE lobe’ which projects into the trigone and obstructs the bladder neck. The prostate shows marked nodularity and the bladder is __________.

• This is the typical appearance of benign, prostatic, nodular hyperplasia which is increasingly with the age and is almost universal in men in the ___th & ___th decades. It results from proliferation of both the
connective tissue and glandular components, usually of the inner group of glands in the middle and lateral LOBES. It is thought to be due to an imbalance in the __________/__________ ratio. The main complications are those of urinary obstruction.

• This condition does NOT predispose to carcinoma of the prostate.

Answer 20

trabeculated.

**characterized by thick wall and hypertrophied muscle bundles. Typically seen in instances of chronic obstruction.

8th and 9th

androgen / estrogen

Question 21

PATHOLOGY OF THE MALE GENITAL SYSTEM X 5

5. Adenocarcinoma of the Prostate:

• This is a post-mortem specimen of old man who had been treated for carcinoma of the prostate. The enlarged prostate has been sectioned transversely to show diffuse, irregular infiltration by pale, scirrhous tumor, which extended into the adjacent soft tissue.
• • Adenocarcinoma is the MOST commonest __________ malignancy of the prostate arising from major prostatic ducts. Adenocarcinoma, like benign hyperplasia, is increasingly common with AGE .
• • It principally affects the OUTER group of gland particularly the _______ __________ and is often multifocal. It has a tendency to metastasize to BONE, giving rise to osteoblastic secondaries which elevates alkaline phosphatase levels
• • Etiology is unknown, but ________ __________ are thought to be important, prostatic carcinoma is especially common in Western world.
• Treatment: surgical by orchiectomy or medical by a new medicine (Leuprolide)
• Prognosis: Poor

Answer 21

epithelial

posterior lobe

hormonal factors

Question 22

PATHOLOGY OF THE FEMALE GENITAL SYSTEM X 8

1. Endometriosis at the umbilicus:

• This specimen was excised from a woman who noticed a pigmented nodule at the umbilicus for 3 years. The nodule steadily increased in size and bled at the menstrual periods.
• The umbilicus has been sectioned to show a smooth, rounded, _____ ________ projecting from the surface. Numerous tiny cysts and foci of brown discoloration are barely visible within the lesion.
• Endometriosis is an abnormal location of the endometrial tissue outside the uterus and usually causes symptoms during the reproductive years due to the normal cyclical changes that the ectopic tissue undergoes. Some patients with endometriosis present with ______ but others are often cured by undergoing a normal pregnancy. Very occasionally endometriotic foci may develop hyperplasia or even carcinoma.

Answer 22

fibrous nodule

infertility

Question 23

PATHOLOGY OF THE FEMALE GENITAL SYSTEM X 8

2. Endometrial Adenocarcinoma of the Uterus:

• This specimen was excised from a nulliparous old woman in whom the menopause had occurred 9 years previously and who presented with postmenopausal bleeding.
• The uterus has been sectioned in the sagittal plane to show a pale ________ arising in the fundus and projecting into the uterine cavity and widely infiltrating the muscle coat.
• Endometrial carcinoma accounts for about 10 % of female malignant disease. The majority of cases arise _______________ and known associations include infertility, nulliparity, obesity and possibly hypertension and diabetes mellitus.
• Clinical manifestations: patient presents with vaginal bleeding in postmenopausal women.
• Prognosis: it is dependent upon tumor GRADE, DEPTH of myometrial invasion and clinical STAGE, but overall 5-year survival rate is of the order of 85 %.

Answer 23

neoplasm

postmenopausal

Question 24

PATHOLOGY OF THE FEMALE GENITAL SYSTEM X 8

3. Leiomyoma of the Myometrium ( Fibroid of the Uterus) :

• This specimen was excised from a woman who presented with a 3 year history of dysmenorrhea and metrorrhagia. Most recently she had noticed an abdominal mass and she developed intermittent constipation and urinary frequency.

• This grossly enlarged and distorted uterus has been sectioned to show multiple, well-circumscribed intramural and submucosal _______ which have displaced and compressed the uterine cavity. All lesions have
a typical ______ appearance except one on the left which has undergone degeneration and dystrophic calcification.

• *Leiomyomas, known as ____________ are most common BENIGN tumor of uterine smooth muscle which arise only during the REPRODUCTIVE years. They are often multiple and are thought to result from ESTROGENIC stimulation (enlargement is common during pregnancy or with the use of oral contraceptive). Malignant changes are very rare.

Answer 24

tumors

whorled

‘fibroid’,

Question 25

PATHOLOGY OF THE FEMALE GENITAL SYSTEM X 8

4. Pyosalpinx of the Fallopian Tube:

• This specimen was excised from a middle age woman who presented with infertility and dysmenorrhea. A bilateral salpingo-oophorectomy and hysterectomy were done.
• The fallopian tubes attached to the uterus and ovary are shown. There are dense adhesions, the wall of the fallopian tube is ________ & ________ and there are a series of abscesses WITHIN the tube.
• Pyosalpinx is usually _________ and represents the result of prolonged or particularly severe bacterial salpingitis. The most common organisms which responsible for this disease are chlamydia , gonococcus, mycoplasma, ….etc. The predisposing factors include intrauterine devices (IUDs), surgical instrumentation and abortion, but most cases are sexually transmitted.

Answer 25

thickened and fibrotic

bilateral

Question 26

PATHOLOGY OF THE FEMALE GENITAL SYSTEM X 8

5. Squamous Cell Carcinoma of the Uterine Cervix:

This specimen was excised from a 49-year old multiparous woman who had noticed irregular bleeding for the last 3 months.

• A sagittal section through the uterus and upper vagina shows a bulky, polypoid tumor arising from the external cervical os and extending into the vaginal vault. The surface of the tumor is extensively _________
• Carcinoma of the cervix is common but has declined due to screening with yearly _____ ________
• It increased, particularly in younger women and most often in the 4th and 5th decades.
• The most important risk factor is early age at first coitus, of which promiscuity, early marriage or pregnancy, multiparity and lower social class are co-variable.
• Spread: Local spread causing ureteral obstruction and _____ _________ (which is the most common cause of death in case of carcinoma of cervix ), lymphatic and may be hematogenous spread to the lung and liver. Prognosis: overall, 5-year survival chance is 60 %.

Answer 26

ulcerated.

pap smears.

renal failure

Question 27

PATHOLOGY OF THE FEMALE GENITAL SYSTEM X 8

6. Fibrocystic Disease of the Breast:

• This specimen was excised from a woman who had noticed lumpiness and pain in both breast for several years, which was aggravated during menstruation.
• The breast tissue shows numerous _____ ______, some of which contain creamy-white material, mixed with excessive connective tissue.
• • Fibrocystic disease, also known as ____ ________ or cystic mastitis, may affect up to 5 % of females and usually presents in the age of 20 and 40, almost always BEFORE the menopause. It is thought to result of ____________ __________ with exaggeration and distortion of the cyclic changes that normally occur in the menstrual cycle. The typical histological changes of fibrosis, adenosis, cyst formation, apocrine metaplasia and epitheliosis may each be present to a varying degree.

Answer 27

irregular cysts

cystic hyperplasia

hormonal imbalance

Question 28

PATHOLOGY OF THE FEMALE GENITAL SYSTEM X 8

7. Fibroadenoma of the Breast:

This specimen was excised from a young woman who had noticed a SLOWLY growing lump in the right breast for 3 years. The mass was TENDER during menstruation. Examination revealed a ______, ________ mass, which at operation was EASILY separated from the adjacent compressed breast tissue. * A rounded, coarsely lobulated _________ tumor, measuring 8 cm in diameter, is surrounded by a smooth fibrous tissue.

Answer 28

smooth, discrete

benign

Question 29

PATHOLOGY OF THE FEMALE GENITAL SYSTEM X 8

8. Adenocarcinoma of the Breast:

• This specimen was from a 55-year old woman with a 3-month history of a firm painless enlarging lump in the right breast. At presentation, firm axillary _____ _______ were palpable.
• A section through the breast shows an irregular, rounded tumor, measuring 4 cm in diameter. The tumor is adherent to both the skin and pectoral fascia. At the top left of the picture an enlarged lymph node replaced by metastatic tumor is seen.
• • Carcinoma of the breast occurs in 1 out of every 10 woman in the United States, the MOST COMMON CANCER in females and the second most common cause of DEATH due to cancer (LUNG is the first cause).
• • The etiology remains uncertain but the following factors have been noted:
• FAMILY history, increasing AGE (uncommon before age 25), GEOGRAPHIC influences (more in United States), previous history of contralateral breast cancer, early menarche, nulliparity, LATE menopause, obesity, LOW fiber and HIGH fat diet, endometrial cancer or history of irradiation therapy.

• * Adenocarcinoma of the breast may be of _______ OR _________ origin, the latter group –DUCTAL— constituting at least 90 %. Up to 50 % of carcinoma develops in the upper, outer quadrant of the breast, which therefore spread to axillary lymph nodes, approximately 50 % of all cases show metastatic involvement of lymph nodes at
presentation.

Spread by _______ in LATE stage, to the lungs, liver, bone and adrenal.

Answer 29

LYMPH NODES

LOBULAR OR DUCTAL

BLOOD