Pathology--24 Breast Pathology

8/10/2019 Pathology--24 Breast Pathology

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Breast

Acute Mastitis

Associated with breastfeeding

Most common S. aureus

Breast erythematous, painful and fever

Localized area of inflammation

Leading to formation of abscess

Infiltration with neutrophils may show necrosis

Treatment: antibiotic and continued expression of milk

A 38 year old female presents with complaints of a painless palpable mass on her left breast.

On mammography there is a mass with calcification noted which was later removed.

The result of the biopsy shows a gray-white nodule with a chalky white foci.

Which of the following is the most likely diagnosis?

1. Acute mastitis

2. Fat necrosis of the breast

3. Fibrocystic changes of the breast

4. Sclerosing adenosis

5. Pagets disease of the breast

Fat Necrosis

Painless palpable mass

Skin thickening or retraction

Mammographic density or calcification

History of trauma or prior surgery

Poorly defined gray-white nodule with chalky white foci or hemorrhagic debris

Dystrophic calcification occurs in the breast

A 38 year old female presents for evaluation of a breast mass. The mass is removed and

showed a mass with more than two cell lines lining the ducts and lobules.


1. Fat necrosis of the breast

2. Epithelial hyperplasia

3. Non-proliferative fibrocystic changes


5. Papilloma of breast

Fibrocystic Changes

Lumpy bumpy breast on palpation

Dense breast with cysts on radiology

Pathologically benign histology

I.Non-proliferative

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Three morphological components

Cysts: blue domed appearance

Fibrosis: 2nd to cyst rupture and inflammatory reaction

Adenosis: increase number of acini per lobule

Fibrocystic ChangesII.Proliferative fibrocytic changes

Increase risk for cancer

Density, calcifications on mammography

Proliferation of ductal epithelium and/or stroma without histologic feature of carcinoma

1. Epithelial hyperplasia

More than two cell layer lining ducts or lobules (normally only two cell layers)

Fibrocystic Changes

II. Proliferative fibrocytic changes (cont.)


Acini per duct doubleRisk for invasive carcinoma

Myoepithelial cells prominent

Lobular arrangement maintained

Acini compressed and distorted in the center

Acini are dilated in the periphery

Presentation

A.Palpable mass

B.Radiologic density or calcification

A 32 year old female presents with bloody nipple discharge. She has notice some discomfortof her left breast for a few weeks and a few days noticed a slightly bloody discharge.

Biopsy of the lesion showed a fibromuscular core with epithelial hyperplasia as well as

apocrine metaplasia.


1. Papilloma of breast

2. Fibroadenoma

3. Phyllodes tumor

4. Ductual carcinoma in situs

5. Invasive ductal carcinoma

Fibrocystic Changes

II. Proliferative fibrocytic changes (cont.)

3.Papilloma

Multiple branching finger like projections

Covered by epithelial and myoepithelial cells

Central core with blood vessel

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Can lead to bleeding and bloody nipple discharge

A.Most common cause of bloody nipple discharge in women 20-40

Epithelial hyperplasia and apocrine metaplasia frequent

Situated in lactiferous sinuses of nipple

Benign Neoplasm of Breast

1. Fibroadenoma

2. Phyllodes tumor

3. Papillomas (discussed earlier)

A 28 year old woman presents with a breast mass about 2 cm in diameter, rubbery and

movable. The mass was removed and showed macroscopically small slit-like spaces. On

microscopy there was proliferation of stroma, ducts and lobules without calcification or

necrosis.Which of the following is the most likely diagnosis of this patients condition?

1. Papilloma of the breast

2. Fibroadenoma

3. Phyllodes tumor


5. Comedo type ductal carcinoma in situs

6.

Fibroadenoma

Most common benign breast tumor in < 35 years of age

Present with palpable mass, movable and rubbery Macroscopically shows small slit-like spaces

Microscopically proliferation of benign stroma, ducts and lobules

Stimulus cyclosporin A used in renal transplant patient

Multiple and bilateral

A 58 year old female presents with a palpable mass on her right breast. The mass is removed

and on microscopy showed nodules of stroma covered by epithelium, with some cellular

atypia and a leaf-like architecture. Two years after resection the mass started to grow again in

the same area


1. Ductal carcinoma in situs

2. Invasive ductal carcinoma

3. Phyllodes tumor

4. Lobular carcinoma in situs

5. Invasive lobular carcinoma

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Phyllodes tumor

Arise from intralobular stroma

Mostly in the 6th decade of life

Palpable mass

Nodules of stroma covered by epithelium

Breast Cancer

Clinical Manifestations

Palpable mass fix to the chest wall

DCIS has mammographic calcifications

Distortion of the architecture of the breast

Carcinoma of the Breast

Nipple retraction

Skin dimpling

Infiltration of suspensory ligament

Most common upper outer quadrant

Gross examination

Stellate, white-tan, gritty mass

Detected exam at 2cm

Detected on MXM at 1cm


Affect 1 in 9 women in the US

Most common cancer not including skin in women

Second most common cause of cancer death in women after lung cancer


Risk Factors

1. Age (uncommon in young women)

In younger women tumors are

A.ER negative or

B.Human epidermal growth factor receptor (HER2/neu) positive

2. Associated with estrogen

Menarche < 11 years

Late menopause

First live birth > 35 years

3. Race/ethnicity (highest non-Hispanic whites)

4. 1st degree relative with breast cancer

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5. Personal history of breast or endometrial cancer

6. Prior breast biopsy revealing atypical hyperplasia


Risks (cont.)

Hereditary mutation of tumor suppressor genesBRCA1, BRCA2 Genes

Help repair human DNA

Increase risk for breast and ovary cancer

Cancer at a younger

BRCA2 > BRCA1 causes male breast cancer

p53 mutation (Li-Fraumeni syndrome)

Ductal Carcinoma in Situs (DCIS)

NO mass NOT invasive

Calcification on mammography

DCIS is divided into different subtypes: comedo, cribiform, micropapillary, papillary, and

solid.

Subtype based on architecture

Invasive ductal carcinoma

Forms duct like structures

Most common type > 80%

Presentation as mass

Advanced causes Dimpling of skin

Retraction of nipple

Biopsy

Duct like structure in a desmoplastic stroma

Special subtypes

Tubular Carcinoma

well differentiated tubules without myoepithelium

good prognosis

Mucinous carcinoma

abundant extracellular mucin

tumor cells floating in mucous pool

Older women around 70

Good prognosis


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Special subtypes

Medullary Carcinoma

large, high-grade cells forming syncitial groups associated with lymphocytes and

plasma cells

Well circumscribed mimicking fibroadenoma

BRCA1

Good prognosis

Inflammatory Carcinoma

In dermal lymphatics

Presentation inflamed swollen breast

Blockage of lymphatics

No discrete mass and mimicking mastitis

Poor prognosis

Lobular Carcinoma in Situs (LCIS)

Proliferation of cells in the lobules

No invasion of the basement membrane

No mass or calcification

Found incidentally on biopsy

Disorganized cell pattern lacking

E-cadherin adhesion protein

Multifocal and bilateral

Treatment tamoxifen

Low risk of progression

Invasive Lobular Carcinoma

Small bland tumor cell which forms in single file pattern

Cells with signet-ringed morphology

Usually bilateral and multifocal

No ducts lacks E-cadherin

Prognosis

Based on TNM

Metastasis is the most important factor

Metastasis to axillary LNs is most useful prognostic factor

Sentinel lymphnode biopsy used to assess LN biopsy

Response to treatment predictive factors

Response to antiestrogen agents (i.e. tamoxifen)

Receptors located in nucleous

Estrogen receptor positive (ER)

Progesteron receptor postitive (PR)

Associated with response to traztuzumab

Antibodies against HER2/neu receptor

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A.Human epidermal growth factor receptor (HER2/neu)

1)Present in cell surface

Triple negative (ER, PR, HER2/neu) poor prognosis

Higher incidence in African Americans

A.Paget Disease of Breast

DCIS that extends up the duct to invade skin

Presentation nipple and areola ulceration and erythema, oozing and crusting

Pagets disease of breath associated with underlying carcinoma

Epidermal spread of tumor cells (Pagets cells)

Single or multiple in the epidermis

Clear halo surrounds the nucleus

Gynecomastia

Benign breast tissue enlargement in males Favor of estrogen effect over androgen

Microscopically seen as

A. Ductal epithelial hyperplasia

B. Ductal elongation

C. Ductal branching

D. Proliferation of periductal fibroblasts

E. With increase in tissue vascularity

Associated to

Physiologic in adolescents

A. Can also be seen in elderly or newborn

Klinefelter syndrome

Hyperprolactinemic states

Drugs: spironolactone and ketoconazole

A.

Male Breast Cancer

Usually seen in older adults

Subareolar mass

Usually located underneath the nipple

May produce nipple discharge

Most common type invasive ductal carcinoma

Very rarely lobular (no lobules in male breast)

Associated with

BRCA2

Klinefelters syndrome

Mutation in male breast cancer

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BRCA2

Breast tumors with calcification (3)

Fat necrosis, Sclerosing adenosis, DCIS

Most common cause of acute mastitis

Breast feedingMost common cause of bloody nipple discharge in women 20-40

Papilloma

Slit-like spaces macroscopically

Fibroadenoma

Malignancy no mass palpable with calcification on mxm

DCIS

Mass with duct like structures, dimpling of skin and retraction of nipple


Well differentiated tubules without myoepithelium

IDC tubular carcinoma type

Inflamed swollen breast with lymphatic blockage Inflammatory carcinoma

Breast and ovary cancer associated mutation

BRCA 1

Most common organism in acute mastitis

S. aureus

Benign mass with calcification, prominent myoepithelial cells and risk for breast cancer

Sclerosing adenosis

Leaf-like architecture

Pyllodes tumor

Most common in the upper outer quadrant

Breast cancer

> 70 with mass with tubular cells floating in mucous

IDC mucinous type

Tumor cells in single file arrangement

Invasive lobular carcinoma

Incidental finding of disorganized cells lacking E-cadherin

Lobular carcinoma in situs

Ab to HER2/neu receptor

Traztuzumab

Lack e-cadhesin

Lobular carcinomas

Tumor with cells in single file pattern, lacking e-cadhesin and signet-ring cells

Invasive lobular carcinoma

Drugs for HER2/neu positive tumors

Traztuzumab

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Redish nipple biopsy showing cells with halo around the nucleous invading from the

basement membrane upwards

Pagets disease of breast

No mass, no calcification, lacking e-cadhesin

Lobular carcinoma in situs

Drug for estrogen and progesterone receptor positive tomors

Tamoxifen

Redish ulcerated nipple with calcification on mammography

Pagets disease of breast

Male breast cancer associated with mutation of?

BRCA2

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Pathology--24 Breast Pathology