BREAST PATHOLOGY FLASH POINTS

DR EJAZ WARIS , PROFESSOR OF PATHOLOGY , ASMDC

Updated : 2016 January.

1.Duct ectasia characterized chiefly by dilation of ducts, inspissation of breast

secretions, and a marked periductal and interstitial chronic granulomatous
inflammatory reaction
2.Fat necrosis can present as a painless palpable mass, skin thickening or
retraction, a mammographic density, or mammographic calcifications
3.There are three principal morphologic changes in fibrocystic disease: (1) cystic
change, often with apocrine metaplasia; (2) fibrosis; and (3) adenosis
4. Adenosis is defined as an increase in the number of acini per lobule.
5. Epithelial hyperplasia is defined by the presence of more than two cell layers.
The additional cells consist of both luminal and myoepithelial cell types that fill
and distend ducts and lobules
6. Sclerosing Adenosis. The number of acini per terminal duct is increased to at
least double the number found in uninvolved lobules. The normal lobular
arrangement is maintained
7. Papillomas are composed of multiple branching fibrovascular cores, each
having a connective tissue axis lined by luminal and myoepithelial cells.They
present as nipple discharge complains by the patient.
8. Proliferative disease with atypia includes atypical ductal hyperplasia and
atypical lobular hyperplasia
9. Carcinoma of the breast is the most common non-skin malignancy in women
10. The major risk factors for the development of breast cancer are hormonal
and genetic.
11. Mutations in BRCA1 and BRCA2 account for the majority of cancers
attributable to single mutations and about 3% of all breast cancers
12. The known high-risk breast cancer genes account for only about one quarter
of familial breast cancers
13. The major risk factors for sporadic breast cancer are related to hormone
exposure: gender, age at menarche and menopause, reproductive history,
breastfeeding, and exogenous estrogens
14. Greater than 95% of breast malignancies are adenocarcinomas, which are
divided into in situ carcinomas and invasive carcinomas
15.DCIS is ductal carcinoma in situ.
16. Historically, DCIS has been divided into five architectural subtypes:
comedocarcinoma, solid, cribriform, papillary, and micropapillary
17. Comedocarcinoma is characterized by the presence of solid sheets of
pleomorphic cells with “high-grade” hyperchromatic nuclei and areas of central
necrosis.It is high grade DCIS.
18.In paget’s disease , Malignant cells (Paget cells) extend from DCIS within the
ductal system, via the lactiferous sinuses, into nipple skin without crossing the
basement membrane
19. LCIS , lobular carcinoma in situ , is always an incidental biopsy finding, since
it is not associated with calcifications or stromal reactions that produce
mammographic densities.
20. Palpable tumors are associated with axillary lymph node metastases in over
50% of patients.
21. The term inflammatory carcinoma is reserved for tumors that present with a
swollen, erythematous breast. This gross appearance is caused by extensive
invasion and obstruction of dermal lymphatics by tumor cells.
22. Gene expression profiling, which can measure the relative quantities of
mRNA for essentially every gene, has identified five major patterns of gene
expression in the NST group: luminal A, luminal B, normal, basal-like, and HER2
positive
 23. Estrogen and progesterone receptors are found in breast cancer cells
that depend on estrogen and related hormones to grow.
 24. All patients with invasive breast cancer or a breast cancer recurrence
should have their tumors tested for estrogen and progesterone receptors.
25. If breast cancer cells have estrogen receptors, the cancer is called ER-positive
breast cancer. If breast cancer cells have progesterone receptors, the cancer is
called PR-positive breast cancer. If the cells do not have either of these two
receptors, the cancer is called ER/PR-negative. About two-thirds of breast cancers
are ER and/or PR positive.
26. If a patient's tumor expresses ER and/or PR, as seen in
approximately 70% of invasive breast cancers, we can predict that this
patient will likely benefit from endocrine therapy such as tamoxifen.
27. Her2 expression is associated with a diminished prognosis (e.g.,
higher risk of recurrence), however, it also predicts that a patient will
more likely benefit from anthracycline and taxane-based
chemotherapies and directed therapies that target Her2 (trastuzamab),
but not to endocrine-based therapies
28.Ductal carcinoma of the breast is the most common type.
29.Lobular carcinomas have been reported to have a greater incidence of
bilaterality
30. The histologic hallmark of lobular carcinomas the presence of dyscohesive
infiltrating tumor cells, often arranged in single file or in loose clusters or sheets
with Indian file pattern
31. Lobular carcinomas have a different pattern of metastasis than other breast
cancers. Metastasis tends to occur to the peritoneum and retroperitoneum, the
leptomeninges (carcinoma meningitis), the gastrointestinal tract, and the ovaries
and uterus.
32. Histologically, the medullary carcinoma is characterized by (1) solid,
syncytium-like sheets of large cells with vesicular, pleomorphic nuclei, and
prominent nucleoli, which compose more than 75% of the tumor mass; (2)
frequent mitotic figures; (3) a moderate to marked lymphoplasmacytic infiltrate
surrounding and within the tumor; and (4) a pushing (noninfiltrative) border
33.Tubular,mucinous,secretory , micropapilllary, inflammatory and papillary are
other variants of carcinoma breast
34. “Metaplastic carcinoma” includes a variety of rare types of breast cancer
(<1% of all cases), such as matrix-producing carcinomas, squamous cell
carcinomas, and carcinomas with a prominent spindle cell component
35. prognosis is determined by the pathologic examination of the primary
carcinoma and the axillary lymph nodes.
36. Axillary lymph node status is the most important prognostic factor for
invasive carcinoma in the absence of distant metastases.
37. The most commonly used grading system, the Nottingham Histologic Score
(also referred to as Scarff-Bloom-Richardson), combines nuclear grade, tubule
formation, and mitotic rate to classify invasive carcinomas into three groups that
are highly correlated with survival.
38.Fibroadenoma is the most common benign tumor of the female breast
39. Phyllodes tumors, like fibroadenomas, arise from intralobular stroma
40. Phyllodes tumors are distinguished from the more common fibroadenomas
on the basis of cellularity, mitotic rate, nuclear pleomorphism, stromal
overgrowth, and infiltrative borders.
41.FNAC and biopsy are used to diagnose breast cancer.
42.E cadherin loss is seen in lobular carcinomas.
43.There are three categories of carcinoma breast according to immuno
prognosis :
ER positive HER 2 neu negative ( most common ) , HER 2 neu positive and ER
can be positive and negative , ER negative- HER 2 neu negative ( poorly
differentiated).
44.In inflammatory carcinoma of breast , carcinoma invades dermal lymphatics.
45.Notthingham / bloom grading in details show
Mitoses 0-9 , 10 – 19 and more than 20 , ( grading of 1,2,3 respectively )
Tubules More than 75%, 10 to 75% and less than 10% ( grading of 1,2,3
respectively)
Pleomorphism atypia mild , moderate and severe (1,2,3)
Numbers are added and than low , intermediate and high grade are given.
46.Phyllodes word means leaf like.
47.Sentinel lymph node is first nearby positive lymph node drained by the tumor.

Topics must not be missed before test and prof :

Bloom Richardson / notthingham grading system
Role of ER PR and HER 2 neu in prognosis and clinical outcome.
Morphologies of ductal , lobular and medullary
DCIS – note.
Fibrocystic disease components list.
Precancerous lesions list.
Prognostic / predictive major minor factors.

Classical associations:
Indian file pattern – lobular carcinoma
Apocrine metaplasia – fibrocystic disease
Fat necrosis – macrophages / giant cells seen
Nipple discharge – duct papilloma
Pushing borders – medullary
E-cadherin – lobular