Breast Histopatholgy: Benign conditions
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Why do fibroadenomas arise?
due to hyperestrogenism
what is the most common benign tumor of the breast?
when are fibroadenomas more common
How can we tell that a mass is a fibroadenoma? PE and mammogram>
- PE: firm, rubbery freely movable mass, multiple, lobulated and/or bilateral
- mam: well circumscribed mass with sharp margins and may have calcifications
What is a fibroadenoma made of?
it is a mixed tumor with proliferating stroma ( that compress the epithelial glands) and epithelial cells
Histologically how do the fibroadenomas look?
- monomorphic cellular with only fibroblasts
- there is proliferation of the stromal fibroblasts and glandular epithelial cell compressed epithelial lined with clefts and cysts
- very uncommon but it is very rapidly growing and can grow up to 40 cm.
- usually benign but if not completely taken out it will recur
What do the fibroadenomas rise from?
What is the difference between the fibroadenma and the phyllodes tumor?
although they both arise from the interlobular stroma, the phylloides tumor has increased stroma fibroblast
In what population do we usually see phylloides tumors?
women in the 60s
What is the histology if ohylloides tumor?
hypercellualr stromal cell proliferation with increased mitotic figures
What do we expect in a physical exam in a fibrocystic breast?
- cobblestone feeling
- younger pre-menopausal women (post menopausal can get them but it is less of a problem)
We have a patient with fibrocystic breast and wants to know if it is safe for her to breastfeed her child, what do you say>
What are they symptoms in a person with fibrocystic breast?
persistent or intermittent aching related to periodic swelling, and the breast or nipples are often tender and tend to peak before each period and decrease after
What is the gross appearance of fibrocysts of the breast?
- duct dilation that can make the cysts both macro and microscopic
- cysts can have either a yellow or a blue liquid inside (blue dome cyst)
What happens if a fibrocyst ruptures?
So they rupture all the time and there is cellular debri that comes out and that induces chronic inflammatory response that leads to fibrosis around the cyst and leads to lymph bumpy lesions
What are ducts lined by in fibrocysts?
- atrophic epithelia due to the increased fluid pressure
- aprocrine metaplasia characterized by large eosinophlic columnar epithelial cells with apical snot
refers to the proliferation in the acini leading to the distortion of the TDLU seen in fibrocysts
What is seen in fibrocyst imaging?
very non-specific: microcalcifcation, mass and/or asymmetric desists and distortion
patient has fibrocysts and whats to know what her risk is to have cancer
no increased risk
what is the cause of fibrocystic changes?
What are the different types of proliferative breast disease? which one do would you rather have?
- mild, moderate and atypical ductal hyperplasia
- mild is bette with no increased risk of cancer
Patient has been dx with proliferative breast diease and wants to know what her possibilities of having breast cancer are, what do you tell her?
- it depends
- mild hyperplasia: none
- Moderate: 1-2 times increased risk
- atypical ductal: 4-5 times increased risk
In what type of women is proliferative breast diease more common?
What is the histology of proliferative breast diease?
- Mild hyperplasia: 3-4 layers cells
- moderatre: more than 4 layers of cells, ducts distended and florid hyperplasia
- Atypical ductal hyperplasia: monomorphic cells with hyperchromatuc cells (hyperplasia with atypia) and punched out spaces
What is the lifetime risk of cancer?
1/8 in caucasian woman and 1/10 for AA women
What are some peculiar risk factors for breast cancer?
- age of menarche: 20% increase risk of before 11 yo
- date of first live birth: decreased if before 20 and increased if after 35 or if no kids
Why does not having a child increase risk of cancer?
lack of exposure of the protective hormonally induced changes of preg of the breast
What is a hormone that increases the risk of breast cancer and why?
estrogen since the metabolites of estrogen can function as an initiator and estrogen is known promoter
What are the 2 most important risk factors of breast cancer?
estrogen and genetics
So if estrogen can cause breast cancer then contraceptives have an increased risk of dev cancer righ?
No. Estrogen alone increases it and progesterone increases it further but the oral contraceptives dont
What races have an incased incidence rates?
What races have increased death rates?
What are the features of heritable breast cancer?
- younger age- less than 45
- higher prevalence in bilateral breast cancer
- increased history of other cancers
- family history of breast cancer
What is the disease progression of carcinoma in situ?
- hyperplasia --> hyperplasia with atypic --> CIS --> ductal carcinoma
- hyperplasia --> hyperplasia with atypic --> CIS or ductal carcinoma
What is the def of CIS?
it doesn't invade through the BM it extends along the epithelium while staying inside
What do we see upon imaging of CIS?
Low grade DCIS
- non-palpable and is detected due to mmicrocalcification
- small uniform neplastic cells with little pleomorphism: small with round nuclei with a few prominent nucleoli and mitotic figures
- ER +
High grade DCIS
- usually palpable with micro calcifications
- pleomorphic cells with irregular nuclei, prominent nucleoli and increased mitoses
- HER2/Neu+ and triple negative is seen
- fibrosis and it may extend the duct
What is the gross appearance of High grade DCIS?
- dense gray irregular fibrosis and the ducts are dilated
DCIS that extends form the lactiferous ducts of the nipple into the epidermis of hthe nipple and the areola that presents with itching and burning and it is o so palpable
Histologically what do we see in pagets diease?
large cells with abundant pink cytoplasm and nicle that have 1 or more prominent nucleoli
pateint has DCIS and wants to know what is the risk of cancer?
well there is a 10% risk of invasive cancer but she tech already has cancer
What is the presentation of LCIS?
What is a characteristic of LCIS?
rare mitotic figures
What is a mammography good for?
to screen for cancer and also as a dx tool
when should a woman have a breast mam?
- 40-49 maybe
- 50-69 for sure
- 70 and above maybe
suspensory ligaments that help keep the glanduar tissue
What is the gold standard for dx of breast cancer?
2D mammography since it allows for a better resolution and can decrease the radiation dose. there is also a 3d which is better but many insurances do not pay for it
What are the mammograohic abnormalities that are suspicious for cancer?
- asymmetry density
What do we see in mam in DCIS? Nodal met? infiltrating carcinoma?
- DCIS: microcalcifications
- Infiltrating carcinoma: palpable mass and density
- nodal met: palpable mass
- used to utilize standard descriptors to characterize mammography findings
- 1: negative
- 2: benign
- 3: prob bening
- 4: suspicios
- 5: suggestive of malignancy
When is a breast ultrasound used?
- when we know what we are going for, not as a mam.
- used to distinguish between cystic and solid
When should you use a breast MRI?
- annual screening in a patient with hereditary breast cancer, all else is still controversial
- breast implants
- monitring chemo effects before sx
- happens within 1 month of breastfeeding
- pain swollen breast with wedged erythematous space
- fevers chills
- staph and strph may gain access via cracks and fissures in the nipple
- treat with heat and AB for 10-14 days
What is the etiology of acute mastitis?
staph and strph may gain access via cracks and fissures in the nipple
painful erythematious subareolar mass with inverted nipple and draining fistulas in the areola
what is periductal mastitis associated with
what is acute mastitis associated with
What is the etiology of periductal mastitis?
doble layer of cuboidal epithelium of duct undergoes keratin squamous metaplasia which gives rise to keratin debri that plugs the ducts causing them to dilate rupturing the dilating duct that leads to a giant body foreign cells or inflammation in response
what is the etiology of duct ectasia?
ducts dilate due to a build up of secretions and rupture causing chronic inflammation
- presents with a poorly defined periareolar mass
Fat necrosis of breast
usually due to trauma or surgery and there is a palpable mass due to scar formation that may or may not result in distortion of the breasy
granulomatous mastitis etiology
- infections TB or fungal
- can be due to sarcoidosis or weighers
breast mass sue to an infection
lymphocytic mastopathy etiology
may be due to DM 1
hard palpable mass that may be bilateral and associated with DM1
what is the histology of lymphocytic mastopathy
pink collagenous stroma atrophic ducts and mononuclear infiltrates
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