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Pathoma Ch. 16 - Breast Pathology w pics
For educational use only
Terms in this set (46)
What is the functional unit of the breast?
Terminal Duct lobular unit -- the lobules make milk that drains via ducts to the nipple.
Breast tissue is essentially modified sweat glands embryonically derived from the skin. Explain how you can have extra nipples or breast tissue:
Breast tissue can develop anywhere along the
, which runs from the axilla to the vulva
The lobules and ducts are lined by two layers of epithelium -- what are they and what are their functions?
1. Luminal cell layer -- inner cell layer responsible for milk production in the lobules;
2. Myoepithelial cell layer -- outer cell layer with contractile function that propels milk towards the nipple.
Breast tissue is hormone sensitive. Describe the breast (1) prior to puberty and how it changes (2) following puberty, during (3) menstruation and (4) pregnancy, and (5)after menopause:
1. Before Puberty -- M and F breast tissue primarily consists of large ducts under the nipple;
2. Development after menarche is driven by estrogen and progesterone -- lobules and ducts form, esp. in UOQ;
3. Breast tenderness during menstrual cycle, esp. prior to menstruation;
4. Breast lobules undergo hyperplasia during pregnancy (due to E and P produced by corpus luteum, fetus, and placenta);
5. After menopause, breast tissue undergoes atrophy;
Galactorrhea is not a symptom of breast cancer - True or False?
True -- it refers to milk production outside of lactation and causes include nipple stimulation, prolactinoma of anterior pituitary, and drugs;
Bacterial infection of the breast usually
associated with breast-feeding:
presents as an erythematous breast with purulent nipple discharge that may progress to abscess formation. During breast-feeding, fissures develop in the nipple, providing a route of entry for microbes. Treatment involves continued drainage (e.g. feeding) and antibiotics (e.g. dicloxacillin);
Subareolar mass with nipple retraction typically seen in smokers:
-- the epithelium of the breast is highly dependent on Vitamin A. As smokers are typically vitamin A deficient, the epithelium of the duct undergoes
resulting in kertain debris plugging of the ducts, resulting in inflammation,
Peri-areolar mass with green-brown nipple discharge that classically arises in multi-parous postmenopausal women:
Mammary Duct Ectasia
---- inflammation with dilation (i.e. ectasia) of the subareolar ducts. Chronic inflammation with plasma cells are seen on biopsy.
Trauma related breast mass that appears as an abnormal calcification on mammography:
Fat Necrosis of breast fat with calcification due to saponification. Biopsy shows necrotic fat with associated calcifications and giant cells.
Most common change in
breast that is thought to be hormone mediated. Presents as vague irregularity of the breast tissue (i.e. lumpy breast):
Fibrocystic Change -- development of fibrosis and cysts in the breast, usually in the UOQ. Cysts have blue-dome appearance on gross exam.
While most fibrocystic change of the breast is benign, some changes are associated with an increased risk for invasive carcinoma in both breasts. Outline the relative risks for (1) Fibrosis, cysts, and apocrine metaplasia; (2) Ductal hyperplasia and sclerosing adenosis; (3) Atypical hyperplasia
1. Fibrosis, cysts, and apocrine metaplasia -- no increased risk;
2. Ductal hyperplasia and sclerosing adenosis -- 2X increased risk;
3. Atypical hyperplasia -- 5X increased risk;
Classically presents as bloody nipple discharge in a pre-menopausal women. Must be distinguished from papillary carcinoma.
-- papillary growth, usually into a large duct that is characterized by fibrovascular protections lined by epithelial (luminal) and myoepithelial cells.
How can you distinguish papillary carcinoma from intraductal papilloma?
Papillary carcinoma is characterized by fibrovascular projections line by epithelial cells without underlying myoepithelial cells. Risk of papillary carcinoma increases with age, thus it is seen more in post menopausal women.
Most common benign neoplasm of the breast usually seen in premenopausal women that presents as a well-circumscribed, mobile marble-like mass:
-- tumor of fibrous tissue and glands that is benign with no increased risk of carcinoma. It is
-- growing during pregnancy and can cause pane during the menstrual cycle.
Fibroadenoma-like tumor with overgrowth of the fibrous component with characteristic "leaf-like" projections seen on biopsy:
-- most commonly seen in post-menopausal women. Can be malignant in some cases.
Most common carcinoma in women by incidence (excluding skin cancer):
Breast cancer -- 2nd most common cause of cancer mortality in women.
What are the risk factors for breast cancer?
Risk factors are mostly related to estrogen exposure:
1. Female gender;
2. Age (post-menopausal women, except hereditary breast cancer);
3. Early menarche/late menopause;
4. Obesity (estrone);
5. Atypical hyperplasia;
6. 1st degree relative (mother, sister, or daughter) with breast cancer;
Malignant proliferation of cells in ducts with no invasion of the basement membrane that is often detected as calcification on mammography:
Ductal Carcinoma In Situ (DCIS)
-- though mammographic calcifications can be associated with benign conditions such as fibrocystic changes (sclerosing adenosis) and fat necrosis.
Biopsy of calcifications is often necessary to distinguish between benign and malignant conditions
Subtype of Ductal Carcinoma In Situ that is characterized by high grade cells with necrosis and dystrophic calcification in the center of ducts:
Comedo Type of DCIS
Subtype of DCIS that extends up the ducts to involve the skin of nipple, presenting as nipple ulceration and edema:
Paget Disease of the Breast
Nipple ulceration and erythema almost always associated with an underlying carcinoma:
Paget's Disease of the breast;
Invasive carcinoma that typically forms duct-like structures:
Invasive Ductal Carcinoma
-- considered the most common type of invasive carcinoma in the breast, accounting for >80% of cases.
How does invasive ductal carcinoma present?
Presents as a mass detected by physical exam or mammography. Clinically detected masses are usually 2 cm or greater and Mammographically detected masses are usually 1 cm or greater.
Advanced tumors may result in dimpling of the skin or retraction of the nipple.
What does biopsy of invasive ductal carcinoma reveal?
Duct like structures in adesmoplastic stroma
Subtype of invasive ductal carcinoma that is characterized by well-differentiated tubules that lack myoepithelial cells:
-- relatively good prognosis;
Subtype of Invasive ductal carcinoma that is characterized by carcinoma with abundant extracellular mucin -- i.e. tumor cells floating in a mucus pool;
-- tends to occur in older women (70 YO) with relatively good prognosis;
Subtype of Invasive Ductal Carcinoma characterized by large, high-grade cells growing in sheets with associated lymphocytes and plasma cells:
grows as well circumscribed mass that can mimic fibroadenoma on mammography. Has relatively good prognosis.
Increased incidence in BRCA1 carriers
Presents as an inflamed, swollen breast (tumor cells block drainage of lymphatics) with no discrete mass. Can be mistaken as acute mastitis.
-- poor prognosis. No resolution with antibiotics.
Characterized by carcinoma in dermal lymphatics:
Malignant proliferation of cells in lobules with no invasion of the basement membrane:
Lobular Carcinoma In Situ (LCIS)
-- does not produce a mass or calcification and is usually discovered incidentally on biopsy.
LCIS is characterized by dyscohesive cells lacking __________.
What is the treatment for LCIS?
(estrogen receptor antagonist) to reduce the risk of subsequent carcinoma and close follow-up. There is low risk of progression to invasive carcinoma.
Invasive carcinoma that characteristically grows in a single-file pattern. Cells may exhibit signet-ring morphology:
Invasive lobular carcinoma
- no duct formation due to lack of
Prognosis in breast cancer is based on TNM staging. What is the most important factor vs. the most useful factor?
T = tumor size, N = # of metastases to lymph nodes, M = distant mestastases
Metastasis is the most important facto, but most patients present before metastasis occurs. Spread to axillary lymph nodes is the most
prognostic factor. Sentinel lymph node biopsy is used to assess axillary lymph nodes.
What are the 3 most important factors that predict response to treatment in breast cancer?
1. Estrogen Receptor
2. Progesterone Receptor
3. HER2/neu gene amplification
Presence of this factor ("brown stain") is associated with response to tamoxifen:
Estrogen/Progesterone receptor is associated with response to anti-estrogenic agents (e.g. tamoxifen) - both receptors are located in the nucleus.
Associated with response to what drug?
amplification is associated with response to
(herceptin), a designer antibody directed against the HER2 receptor. HER2/neu is a grwoth factor receptor present on the cell surface.
What are "Triple-Negative Tumors? Which population typically gets them?
Tumors are negative for ER, PR, and HER2/neu and have a poor prognosis. African American women have an increased propensity to develop triple-negative carcinoma.
Hereditary breast cancer represents ____ of cancer cases:
What are the clinical features that suggest hereditary breast cancer?
1. Multiple first degree relatives with breast cancer;
2. Tumor at an early age (pre-menopausal);
3. Multiple tumors in a single patient;
Most important single gene mutations associated with hereditary breast cancer:
BRCA 1 and BRCA 2
________ mutation is associated with breast and ovarian carcinoma while _______ mutation is associated with breast carcinoma in males.
BRCA 1; BRCA2
Women with a genetic propensity to develop breast cancer may choose to undergo a ___________ to decrease the risk of developing carcinoma.
bilateral mastectomy (i.e. removal of both breasts) --- a small risk for cancer remains because breast tissue sometimes extents into the axilla or subcutaneous tissue of the chest wall.
Breast cancer is rare in males, representing 1% of all breast cancers. How does it typically present?
Presents as a subareolar mass with or without nipple discharge as the highest density of breast tissue in males is underneath the nipple.
What is the most common subtype of breast cancer in males?
Most common is invasive ductal carcinoma -- lobular carcinoma is rare as the male breast develops very few lobules.
Male breast cancer is associated with __________ and _____________.
BRCA2 mutations; Klinefelter Syndrome
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