Breast Disorders | Breast Cancer | Carcinoma

BREAST DISORDERS

y y Extralobular terminal duct, lobule terminal duct Small round acini duct -> groups Histology - What lines ducts? o Single layer of cuboidal cells - More than a single layer, tumor: ABNORMAL

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Developmental Disorders
Supernumeray nipples or breast respond to hormones on menstrual cycle o Occurs along the midline o Occassionally involved in cycle menstrual changes Accessory Axillary Breast Tissue o May be mistaken as metastatic breast cancer or an axillary lymph node lesion Inverted Nipple o Common o May be mistaken for nipple retraction that accompanies invasive cancer or inflammatory disease Macromastia o May be due to:  Variations in body habitus  Ununusual tissue response to hormones  May cause severe back pain Reconstruction or Augmentation o May cause  Thickening of the fibrous capsule  Silicone granuloma o Micro:  Chronic Inflammatory Infiltrate y Lymphocyte, macrophages, giantcells with fibrosis  *Round hollow objects silica y Granulomatous proliferation -

Nipple Discharge o Less common o Galactorrhea milky discharge  Prolactin adenoma  Hypothyroidism  Endocrine anovulatory syndromes  Drugs OCP, TCA, Methyldopa and Phenothiazine o Bloody or serous discharge  Large duct papilloma  Rarely associated with carcinoma

Mammographic Findings - Densities o Invasice carcinoma, fibroadenoma and cysts o DCIS rarely present as a density Calcifications o Associated with malignancy o DCIS most common (Ductal Carcinoma In Situ)

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Inflammatory Breast Diseases
Acute Mastitis o Occurs during lactation o Due to nipple cracks and fissures o Etiologic agents  Staphylococcus aureus most common  Streptococcus spp. o May progress ot abscess formation o Drain lesion Fat Necrosis o Clinical Presentation  Painless palpable mass  Skin thickening or retratcion  Mammographic density or calcification o Micro:  Hemorrhage and early liquifactive necrosis of fat o Associated with trauma Preductal Mastitis o Aka. Recurrent Subareolar abscess, squamous metaplasia of lactiferous ducts, Zuska disease o Strongly associated with smoking 90% of patients o Micro  Keratinizing Mammary Duct Ectasia o Occurs in: th th  5 to 6 decade of life  Multiparous women o Clinical findings  Poorly defined palpable periareolar mass  Skin retractions  Thick, white nipple secretion

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Clinical Presentation - Pain o Most common, cyclical or noncyclical, majority are benign, 10% malignant - Palpable Mass nd o 2 most common, masses do not become palpable until it reaches 2cm

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Breast Disorders| 1

Fibrocytic Change (Non-Proliferative) o Lumpy Bumpy breast o Mimics carcinoma especially when solitary o Mass disappears after FNAB o Morphology  Cysts with apocrine metaplasia  Fibrosis  Aclerosis o No increase risk of cancer Fibrocytic Change (Proliferative) o Epithelial Hyperplasia  More than 2 cell layers of ductal epithelial cells  Intact myoepithelial cell layer o Scleroising Aclerosis  Increase in number of acini  May be associated with calcifications Radial Scar (Complex Sclerosing Lesion)  Stellate lesion with glands that are trapped. half the risk of nulliparous women or women at the age of 35 years old at first birth o 1st degree relatives (mother. Breast Carcinoma o Most common malignancy of the breast o Most common non-skin malignancy in women o Risk factors  70% occur in 54 years old  Menarche before 11 years old 20% increase risk of cancer  Liver birth at < 20 years old. OCP (low) o Radiation Exposure o Carcinoma of contralateral breast or endometriosis o Obesity in <40 years old due to anovulatory cycles o Breast feeding longer duration reduces risk o Not associated with smoking Benign Epithelial Lesions 1. Risk factors o Estrogen exposure HRT (Increase). surrounding  DM Type 1 Granulomatous Mastitis o Rare o < 1% o Secondary to:  Systemic granulomatory disease: Wegener Granulomatous and Sarcoidosis o Infectious mycobacterial ang fungal o Seen only in parous women - Carcinoma of Breast: 1. BRCA 2 Mutations o Caucasians have high risk. Papilloma  Associated with bloody nipple discharge  Multiple branching fibrovascular cores Mild risk for developing breast cancer Ductal Carcinoma In Situ (DCIS) Malignant ductal epithelial cells are confined to the ducts Basement membrane is intact 5 subtypes o Comedocarcinoma o Solid o Cribiform o Papillary o Micropapillary 2. African American have low risk but advanced stage compared to others. sister. Paget Disease Rare manifestation. daugther)  BRCA. 1-2% of cases Unilateral erythematous eruption with a scale crust Paget cells extend from DCIS into nipple skin and does not cross basement membrane Palpable mass is seen in 50-60% of cases o o Lobular Carcinoma In Situ Not associated calcifications or densities Bilateral in 20-40% More common in young women 80-90% occur prior to menopause Lacks expression of e-cadherin o Atypical Proliferative Breast Diseases Atypical Ductal Hyperplasia Atypical Lobular Hyperplasia Resembles DCIS or LCIS but lacks sufficient features of carcinoma in situ Moderate risk for developing breast carcinoma Invasive Carcinoma Palpable mass most common presentation Peau d orange skin due to blockage of dermal lymphatics Nipple retractions Fired to chest wall Upper outer quadrants in 50% of cases Breast Disorders| 2 .- Lymphocytic Mastopathy o Single or multiple hard palpable mass o May be bilateral and appear as densities mammographically o Micro  Collagenized stroma.

Fibroademona Benign o Most common benign lesion o Hormonally responsive o Well circumscribed and freely movable o Frequent multiple and bilateral o Mild cases for caricnoma most well established Phyllodes Tumor o Cystosarcoma phyllodes o Leaf-like pattern o Low and High Grade lesion o Treatment: Wide excision or mastectomy Tubular Carcinoma 2% Well formed tubular Mistaken for sclerosing lesion Lacks BM Well differentiated Excellend prognosis 2. Papillary Carcinoma Better prognosis Metaplastic carcinoma < 1% Includes: Adenocarcinoma. Chondroid Stroma. 3 year survival rate Other Malignancies Lymphomas Malignancies of skin and sebaceous glands and have shafts Breast Disorders| 3 . Squamous Cell Carcinoma Sarcomas Angiosarcoma Rhabdomyosarcoma Liposarcoma Leiomyosarcoma Inflammatory Carcinoma Carcinoma extensively involving dermal lymphatics Enlarged erythematous breast Poor prognosis if present: 3-10%. synction Mucinous (Colloid Sarcoma) 1-6% Skin growth Occurs in older women Stromal Tumors 1. B2 or neu)  Overexpression is associated with poor prognosis  Responds to chemotherapy Trastuzumab Medullary Carcinoma Well circumscribed Soft. fleshy consisting Morphology o Solid.o o - 10% in each remaining quadrants 20% in central or subareolar region Prognostic Factors DCIS better than invasive Distal metastasis Lymph node involvement o 10 year survival rate o 70-80%: no involvement o 35 40% : 1 to 3 nodes involvement o 10-15%: more than 10 lymph nodes Size: o Poor prognosis in > 2 cm Locally advanced disease Inflammatory carcinoma - Ductal (No special type) o Grossly: Ill defined mass o Tan in color Lobular Medullary Mucinous Tubular Papillary Meloplastic - Ductal (No special type) Majority of cases: 70-80% Tumor Grade Grade 1 (Well differentiated) -80%. leptomeninges. ovaries and uterus Lymphovascular Lesion Proliferate rate Breast Receptor Assays Estrogen and Progesterone receptors o Positive assay better prognosis o Response to Tamoxifen o HER 2/ Neu (Human Epidermal Growth factor receptor 2/C-erb. 10 year survival rate Grade 2 (Moderately differentiated) 60% Grade 3 (Poorly differentiated) 15% Lobular Carcinoma Similar to ductal but with a diffuse pattern Single infiltrating tumor cells (single file) Targetoid appearance May metastasize to retroperitoneum. GI tract.

Leydig ) Proliferation of ducts Carcinoma 0-11% risk in males as compared to 13% risk in females Risk factors are similar to that in women Gynecomastia is not a risk factor Associated with BRCA 2 mutation Papillary carcinomas are more common Gestational and Placental Diseases Disorder of Early Pregnancy 1.Abnormal sharing fetal circulations . IUD insertions o Clinical  Severe abdominal pain may lead to shock 2. Listeria.Preeclampsia o Proteinuria Preeclampsia o Edema o Seizure Eclampsia o Common in primipara than multiparous women o Eclampsia DIC o Decreased uteroplaental perfusion Morphology .Begins early in the following o H mole o Presenting kidney disease o Preexisting hyperestrinism o Treatment  Induction delivery Gynecomastia Enlargement of male breast Unilateral or bilateral Indicates hyperestrinism liver cirrhosis or testicular tumor (Sertoli. Complete (swelling) o o o 3.May result to death Inflammation and Infections . 46XY (paternal) Breast Disorders| 4 . and viral o Most do not show fetal products o Chromosomal studies Ectopic Pregnancy o Fetal implantation at any site outside the uterus o Fallopian tube most common (90%) o Abnormal cavity o Intrauterine portion of Fallopian tube (Cornua) o Causes  PID with salpingitis most common  Adhesins due to appendicitis.46XX. monoamnionic Twin-twin Transfusion . Placenta Previa o Placenta implants in lower uterine segment o Cause bleeding Complete .Placenta o Infarcts o Retroplacental hormones o Villous ischemia o Fibrinoid nd . 2. Hydatidiform mole o Cystic swelling of chorionic villi with throphoblastic proliferation o Clinical Presentaion  Vaginal bleeding  Uterine size larger than for AOG  Kyawa:  High Risk: 40-50%  2 Types: Partial.Dichorionic diamnionic .Monochorionic.Starts the 32 week of pregnancy . Mycoplasma.Chorioamniotitis .Fertilization by single sperm and an egg that has lost its chromosome .Placentitis and Villitis .Marked disparity of blood volume . Disorder of Late Pregnancy 1. Spontaneous Abortion o Occurs in 10-15% of pregnancies o Cause: Fetal or Maternal o Defective implantation most common o Infectious  Toxoplasma.Characterized by: o HPN .Funisitis . Accessoring Placental Lobe Placenta accreta y Partial or complete absence of decidue y Placenta adhere directly to the myometrium y Causes bleeding y Placenta previa Increta deep into the myometrium Percreta through the myometrium Ancreta surface of myometrium Gestational Trophoblastic Disease 1.2 routes o Ascending infection most common o Hematogenoma Toxemia .- Metastatic Carcinoma most common Melanoma and Lung Carcinoma frequent Twin Placenta .

Breast Disorders| 5 . Hydatidiform Mole o Spontaneous pregnancy loss or curettage o Watery filled with grape like masses on curettage o UTZ: Snowy pattern o Serial BHCG Invasive Mole o Hydrophic chorionic villi. circumferential Partial Mole Triploid Some Villi 1. invades the myometrium o Pentrates uterine wall o Treatment  Hysterectomy Choriocarcinoma o Malignancy of trophoblastic cells o Rapidly invasive o Widely metastasizing  Lungs (50%) o Morphology  Abnormal proliferation of cytotrophoblast synctiotrophoblast o Treatment  Evacuation of contents  Surgery  Responds well to chemotherapy  Nongestational therapy Placental Site Trophoblastic Tumor o < 2% o Intermediate trophoblasts o Mononuclear cells with abundant cytoplasm o Human Placental Lactogen weakly immunoreactive 2. 4. 3.- Partial o Fertilization of an egg with one or two sperms Feature Karyotype Villous Edema Trophoblast proliferation Complete Mole 46XX. 46 XY All villi Diffuse.

Breast Disorders| 6 .

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