10.10 Pathology of Precursor Breast Lesions

rapid growth of breasts at puberty is known as:
thelarce (thee-lar-key)

Relative risk of *non-proliferative* benign breast disease

a. 1
b. 1.5-2
c. 4-6
d. 8-10

A. *1* (3%)

Relative risk of *proliferative w/o atypia* benign breast disease
a. 1
b. 1.5-2
c. 4-6
d. 8-10
B. 1.5-2

Relative risk of *proliferative w/ atypia* benign breast disease
a. 1
b. 1.5-2
c. 4-6
d. 8-10
C. 4-6

Relative risk of *Carcinoma in situ* benign breast disease
a. 1
b. 1.5-2
c. 4-6
d. 8-10
D. 8-10

what are benign histological variants of lobules
– columnarization
– clear cell
– lactational changes – hobnail

what are aberations of normal development?
fibrocytic changes and lactating adenoma

Which hormones influence thelarce?
estrogens
growth hormone
prolactin
(NOT progesterone)

Male breast tissue will not have:
lobules (only ducts)

Lobules will look like this on histology:
bundle of grapes

If the ______ cells are one layer and unbroken, that is GOOD –> broken cells means cells broke out and are spreading
myoepithelial

Increase in ____ lobules w/ pregnancy & preparing for lactation
secretory

dilation of lobules as you age, change from normal ____ cells, to ____ cells
cuboidal
columnar

more clear, expanded cytoplasm (usually its more dense and pink), fried egg appearance
clear cell change

proliferation of ducts without lobules suggest
premature therlarce

rapid and massive enlargement of breasts at puberty. Tons of connective tissue, but NO functional structures of the breast.
macromastia
(big breast)

persistent *epidermal* thickening along milk line
(more common on left hand side) are known as:
supernumerary nipple (extra nipple)

nipple discharge suggests:
papillomas (not cancer usually)

Do stellate shaped cells with circular calcifications on mammography suggest benign or malignant cancer?
malignant
(benign = well circumscribed)

Stereotactic needle-guided biopsy to a cyst that isn’t palpable
Core Biopsy

Problem with core biopsy?
Not always able to grab the entire cyst, so you may miss cancer

This infection is associated w/ lactation. seen in a woman who is nursing, unilaterally (due to unilateral nursing)
a. acute mastitis
b. periductal mastitis
c. duct ectasia
d. fat necrosis
e. foreign body reaction
A

non proliferative breast changes are:
– duct ectasia
– cysts
– adenosis
– fibroadenoma
– apocrine changes
– mild hyperplasia

proliferative w/o atypical changes
– florid hyperplasia
– sclerosing adenosis
– radial scar
– intraductal papilloma

proliferative lesions with atypia
ADH
ALH

How much higher does the risk increase by when there’s multifocalness and atypia?
10 fold

This bacteria get into breast cracks and can lead to abscesses & benign masses that women think is cancer but is actually acute mastitis. The bacteria may not be obvious in culture
Staph

*Keratinized squamous epithelium metaplasia*, keratin debris, and inflammation with neutrophils suggest:
a. acute mastitis
b. periductal mastitis
c. duct ectasia
d. fat necrosis
e. foreign body reaction
B

Red, warm infected mass *Seen in smokers *. Involves *Squamous metaplasia from breast –> *into ducts (inflammation of subareolar ducts)
a. acute mastitis
b. periductal mastitis
c. duct ectasia
d. fat necrosis
e. foreign body reaction
B

Inflammation & dilation (ectasia) of subareolar ducts. *50-60 y/o older women, usually in women who are multiparous* (had multiple children). You might see inversion of the nipple with Green-brown nipple discharge and enlarged, dilated ducts with foamy *macrophages that clean up stagnant colostrum.* *Calcifications common*
a. acute mastitis
b. periductal mastitis
c. duct ectasia
d. fat necrosis
e. foreign body reaction
C
(caused by colostrum still there from pregnancies)

May result from Duct Ectasia, but often comes from *Trauma to the chest * (i.e. soccer, car accident) (compression of fatty tissue caused it to necrose). You’ll see dimpling of the skin
a. acute mastitis
b. periductal mastitis
c. duct ectasia
d. fat necrosis
e. foreign body reaction
D

(IMPORTANT)
This is *Biopsy-related* (in the same place as a past biopsy). Giant cells, cholesterol clefts, foamy macrophages, hemosiderin, material from previous sutures.
a. acute mastitis
b. periductal mastitis
c. duct ectasia
d. fat necrosis
e. foreign body reaction
(IMPORTANT)
This is *Biopsy-related* (in the same place as a past biopsy). Giant cells, cholesterol clefts, foamy macrophages, hemosiderin, material from previous sutures.
a. acute mastitis
b. periductal mastitis
c. duct ectasia
d. fat necrosis
e. foreign body reaction
E

Reactions to Silicone Breast Implants –> chronic inflammatory process in response to silicone
a. acute mastitis
b. periductal mastitis
c. duct ectasia
d. fat necrosis
e. foreign body reaction
E

Diagnosis of exclusion associated w/ Corynebacterium (normal skin flora)
a. Acute mastitis
b. Fibrocystic Changes
c. Lymphocytic Mastitis
d. Granulomatous Mastitis
e. Foreign body reaction
D

Associated with lymphocytes and diabetes
a. Acute mastitis
b. Fibrocystic Changes
c. Lymphocytic Mastitis
d. Granulomatous Mastitis
e. Foreign body reaction
C

Where do Fibrocystic Changes occur?
TDLU (terminal duct lobular units)

These are found in 50% of *PRE-menopausal women (25-45)*; comes in with Blue-dome cysts, “Lumpy Breast”
a. Acute mastitis
b. Fibrocystic Changes
c. Lymphocytic Mastitis
d. Granulomatous Mastitis
e. Foreign body reaction
B

Cysts have *Apocrine Metaplasia –> *cells are more COLUMNAR w/ projections into lumen (as opposed to normally cuboidal and non-projections); “Apocrine Snouts” project into lumen
a. Acute mastitis
b. Fibrocystic Changes
c. Lymphocytic Mastitis
d. Granulomatous Mastitis
e. Foreign body reaction
B

T/F: non proliferative fibrocystic changes lead to significant increase in risk for Brest Canccer.
Fals. it does not cause significant increase in breast cancer risk if they are non-proliferative

What determines if Fibrocystic Changes are cancerous or not?
degree of proliferation and atypia

Lining cells filling the ducts, no open lumen, slit-like fenestrations; Looks like a *Glomerulus. If >4 cell layers, you have a 2x risk of breast cancer*
a. Florid-Duct Hyperplasia
b. Atypical Ductal Hyperplasia
c. DCIS (Ductal Carcinoma In Situ)
d. Intraductal papilloma
e. Nipple Adenoma
A

Would oral contraceptives make FC changes better or worse?
better
(balance out estrogen progesterone effect)

This gives you a 4-5x risk of breast cancer. The risk is higher if you have a relative with it. You may not even realize you have this but just pick it up by accident. *<3 mm*. Can resemble DCIS. a. Florid-Duct Hyperplasia b. Atypical Ductal Hyperplasia c. DCIS (Ductal Carcinoma In Situ) d. Intraductal papilloma e. Nipple Adenoma
B

(know this) Atypical Ductal Hyperplasia resembles this other cancer:
a. Florid-Duct Hyperplasia
b. Atypical Ductal Hyperplasia
c. DCIS (Ductal Carcinoma In Situ)
d. Intraductal papilloma
e. Nipple Adenoma
C

SMALL <3mm; Cells look MONOTONOUS (the same), Round Nuclei, Nucleoli present, *Roman Bridges, Cookie-Cutter holes.* If necrosis is present it could --> DCIS

a. Florid-Duct Hyperplasia
b. Atypical Ductal Hyperplasia
c. DCIS (Ductal Carcinoma In Situ)
d. Intraductal papilloma
e. Nipple Adenoma

B
(It is *atypical* for all cells to be *homogenous/monotonous*)

Lobules are filled-in; MONOTONOUS; 5x risk of breast cancer
a. Florid-Duct Hyperplasia
b. Atypical Ductal Hyperplasia
c. DCIS (Ductal Carcinoma In Situ)
d. Intraductal papilloma
e. Nipple Adenoma
B

(important)
Patient presents with* bloody nipple discharge.* *Fibrovascular cores *are seen on histology:
a. Florid-Duct Hyperplasia
b. Atypical Ductal Hyperplasia
c. DCIS (Ductal Carcinoma In Situ)
d. Intraductal papilloma
e. Nipple Adenoma
(important)
Patient presents with* bloody nipple discharge.* *Fibrovascular cores *are seen on histology:
a. Florid-Duct Hyperplasia
b. Atypical Ductal Hyperplasia
c. DCIS (Ductal Carcinoma In Situ)
d. Intraductal papilloma
e. Nipple Adenoma
D

arborizing pattern; look like cancer
a. Florid-Duct Hyperplasia
b. Atypical Ductal Hyperplasia
c. DCIS (Ductal Carcinoma In Situ)
d. Intraductal papilloma
e. Nipple Adenoma
D & E

*Globby yellow mass in reproductive-aged women*. Hyperplastic Lobules; Usually recedes on its own
– may be an exagerated response to normal response to hormones

a. Lactating adenoma
b. Sclerosing adenosis
c. Radial scar
d. Fibroadenoma
e. Benign Phyllodes tumor
f. Juvenile fibroadenoma

A

proliferation of duct like structures with distortion of lobules. lots of fibroblastic changes of stroma, usually B/L, may not be palpable on exam (<2cm) a. Lactating adenoma b. Sclerosing adenosis c. Radial scar d. Fibroadenoma e. Benign Phyllodes tumor f. Juvenile fibroadenoma
B

(know which is the LEAST and HIGHEST RISK)
What type of benign change has the LEAST risk of becoming a cancer?
fibrotypic change without atypia

(know which is the LEAST and HIGHEST RISK)
What type of benign change has the MOST risk of becoming a cancer?
atypical ductal/lobar hyperplasia

Normal breast tissue surrounded by central scar. stains with elastin stain
a. Lactating adenoma
b. Sclerosing adenosis
c. Radial scar
d. Fibroadenoma
e. Benign Phyllodes tumor
f. Juvenile fibroadenoma
C

Elastin stain shows a lot of black (scar tissue). Does this suggest cancer or something else?
a. Lactating adenoma
b. Sclerosing adenosis
c. Radial scar
d. Fibroadenoma
e. Benign Phyllodes tumor
f. Juvenile fibroadenoma
Elastin stain shows a lot of black (scar tissue). Does this suggest cancer or something else?
a. Lactating adenoma
b. Sclerosing adenosis
c. Radial scar
d. Fibroadenoma
e. Benign Phyllodes tumor
f. Juvenile fibroadenoma
C
elastin stains the myoepithelial cells, if it was cancer the myoepithelial cells wouldnt be there.

MOST COMMON, Benign tumor of the breast
a. Lactating adenoma
b. Sclerosing adenosis
c. Radial scar
d. Fibroadenoma
e. Benign Phyllodes tumor
f. Juvenile fibroadenoma
D

(know this)
What age group would you most likely find a fibroadenoma in?
25-35

(know this)
White, circular mass that has *increased in size in pregnancy.* Sharp demarcations, <3cm, white/tan: a. Lactating adenoma b. Sclerosing adenosis c. Radial scar d. Fibroadenoma e. Benign Phyllodes tumor f. Juvenile fibroadenoma
D

(know this)
FNA shows cohesive bland nuclei in a Staghorn configuration:
a. Lactating adenoma
b. Sclerosing adenosis
c. Radial scar
d. Fibroadenoma
e. Benign Phyllodes tumor
f. Juvenile fibroadenoma
(know this)
FNA shows cohesive bland nuclei in a Staghorn configuration:
a. Lactating adenoma
b. Sclerosing adenosis
c. Radial scar
d. Fibroadenoma
e. Benign Phyllodes tumor
f. Juvenile fibroadenoma
D
(Mnemonic: E STAGliano has a lot of FIBER in her diet)

1/2 of women who take this drug will develop a fibroadenoma
Cyclosporin A

found in *AA children;* bilateral; low risk of carcinoma but concerning because they grow very quickly
a. Lactating adenoma
b. Sclerosing adenosis
c. Radial scar
d. Fibroadenoma
e. Benign Phyllodes tumor
f. Juvenile fibroadenoma
F

polypoid tumor with a *leaf-like* pattern; Fibroadenoma-like-tumor w/ MORE cells
a. Lactating adenoma
b. Sclerosing adenosis
c. Radial scar
d. Fibroadenoma
e. Benign Phyllodes tumor
f. Juvenile fibroadenoma
E

lactation in men/women who are not breastfeeding:
galactorrhea

Often caused by *Pituitary Adenoma which secretes Prolactin *
galactorrhea

What is a measurable factor in galactorrhea?
prolactin levels (possible pituitary adenoma)

Galcatorrhea is associated with primary:
a. amenorrhea
b. dysmenorrhea
c. hyperthyroidism
d. hypothyroidism
e. hyperparathyroidism
D (more thyroid releasing hormone = increases prolactin and TSH –> galactorrhea)

(Gynectomastia/Galactorrhea) spontaneously resolves?
Gynectomastia

Enlargement of male breasts due to imbalance b/w estrogens & androgens (due to anything that impacts hormone production)
gynecomastia

proliferation of ducts IN MALES without lobules suggests:
gynecomastia

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