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38 Cards in this Set
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Lesion in women 30-70, symptoms: mass, nipple retraction and discharge (serous or creamy), and pain, although mostly are asymptomatic
Gross: dilated ducts with cheesy material Micro:dilated ducts with amorphous material, periductal chronic inflammation, and fibrosis. Macrophages invade the epithelium. U/S shows dilated ducts May have inflammation |
Duct ectasia
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Young women, age 20-40,
h/o recent pregnancy, present with a palpable mass that is tender. Often bilateral with axillary lymphadenopathy. Usually occurs at extra-areolar site Gross: may be up to 8 cm Micro: non-caseating granulomas on lobules, epithelioid macs and giant cells. Often, acute and chronic inflammation are present (microabscesses) |
idiopathic granulomatous mastitis
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patient with autoimmune disease (insulin-dep DM)presents with a breast mass causing pain, mass may be tender
autoimmune disease often seein with insulin-dependednt DM and hashimoto's thyroiditis. Gross: rubbery/firm, grey mass Micro:aggregates of lymphocytes around lobules and vessels. Fibrosis of the intralobular stroma. Mostly B cells. |
Sclerotic lymphocytic lobulitis
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woman with a history of trauma/surgery/radiation presents with a firm breast mass. May have skin retraction and thickening.
rads: hyerechogenicity Gross: yello discoloration of the fat Micro:foamy macs around adipose tissue. May have chronic inflammation, cholestrol clefts, hemosiderin-laden macs R/O lobular breast CA |
Fat necrosis
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young woman with breast mass, skin retraction, nipple inversion. Mammogram: fibrous capsule
U/S: snowstorm Gross: firm tissue, calcifications, liquid material Micro: FBGCR |
Tissue reaction to implant/rupture
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commonly incidental breast lesion, although may rarely present as a solitary mass
Imaging: architectural distortion or mass with microcalcifications Gross: imperceptible Micro: "lobulocentric" pattern of elongated and distorted glands and tubules proliferating with a fibrotic stroma. Myoepithelial cells in fibrotic/sclerotic stroma myoepithelial cells stain with P63, smooth muscle myosin, or Calponin |
Sclerosing adenosis
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Incidental breast lesion, is common (4-28%)
Imaging: rarely cause "spickled" appearance on mommography Gross: rarely visible: may be seen as a stellate lesion Micro: central zone of fibroelastosis from which ducts and tubules eminate. May contain apocrine metaplasia, microcysts, proliferative changes 2. If larger than 1 cm? |
Radial scar
2. If larger than 1cm = complex sclerosing lesion May increase risk of breast CA |
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Incidental breast lesion.
Imaging: may show increased density with irregular borders or microcalcifications Gross: Ill-defined lesion of 3-4 cm Micro: haphazarly arranged small, round tubules infiltrating the mammary stroma or fat. The glands are ligned by a single layer of cuboidal epithelium, without apical snouts. no cytologic atypia. No myoepithelial cells are seen, but the BM is intact. Glandular lumens show an eosinophilic material that is colloid-like and stains for PAS and mucicarmine Epithelial cells are s100, CAM 5.2, CK, CK7, cathepsin D, and EGFR+; and ER/PR/HER2 - |
Microglandular adenosis
associated with recurrence and carcinoma |
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Young woman with multiple peripheral occult lesions or older woman with single central mass; present with bloody or clear nipple discharge; lesions may be several cm
Imaging: smooth walled, well-defined mass with dilated adjecent ducts. Gross: varibly-sized lesion within dilated ducts, may be soft to firm. Micro: multiple branching papillaelined by two cell layers. Fibrovascular cores present. May have apocrine metaplasia. May show epithelial hyperplasia (stain with CK5), forming slit-like spaces |
Intraductal Papilloma
If atypia is seen <3cm= ADH within a papilloma, if >3cm, DCIS |
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rare breast lesion in older women and men- palpable central mass, may have discharge
Imaging: round/lobular mass, may have papillary features and microcalcifications Gross: 1-3 cm mass with fibrous capsule, cystic space common. Is firm/ hemorrhagic. Micro: arborizing papillary network lined by 1 or more layers of epithelium, no myoepithelial layer in fibrovascular cores. May show cribiform or solid patterns.Nuclei show mild atypia. Fairly cellular, FNA mostly bloody. Epithelial cells ER +, HER2- |
Encapsulated Papillary Carcinoma
Good prognosis (95% OS) |
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AA young woman with a mobile, firm, painless breast mass.
Gross: round, rubbery, gray mass Micro: fibroepithelial lesion in intracanalicular (1) and pericanalicular (2) variants. (1) compressed glandular structures in fibrous stroma that is whorled; (2) tubular ducts structures that are disorganized surrounded by fibrous stroma. No atypia, myoepithelial cells present. IHC: not necessary |
Fibroadenoma
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Woman with rapidly growing well-defined breast mass.
Gross: Can be large, lobulated with bosselated borders Micro: Fibroepithelial lesion with clefts lined by 2-layers of epithelium. Project into cystic spaces, forming leaf-like pattern. Atypia varies: borderline and malignant variants on degree of mitoses (<5->10) and spindle-cell atypia. IHC: Ki-67 for proliferation |
Phylloides tumor
True neoplasm |
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Incidental finding- typically adjancent to other lesions.
Gross: rubbery and smooth, up to 10cm Micro: low power DX: intralobular stromal expansion with anasomizing angular slitlike spaces that look like vessels. Background of sclerotic collagen. No atypia. IHC: CD34, vimentin, actin. |
Psuedoangiomatous stromal hyperplasia (PASH)
Hormones may underlie pathogenesis Prominent Golgi aparatus in spindle cells |
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woman with a painless hard breast mass
Gross: infitrative margins, hard to see lesion Micro: broad sheets of interlacing fascicles of spindled cells forming herringbone or storiform pattern. Cells are bland with indistinct cell borders and myxoid background. Can have lymphocytes at the border IHC: vimentin and SMA positive. CK panel (all, can be focal), S100, and P63 required to differentiate from malignant lesion. |
Fibromatosis
Seen rarely, assc. with Gardner syn (APC) |
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rare breast lesion in men and women- slow painless mass
Gross: well-circumscribed rubbery mass, whorled surface. Micro: unencapsulated well-circumscribed lesion, admixture of bland oval-to-spindled cells with thick eosinophilic collagen bands. IHC: SMA, desmin, CD34, vimentin |
Myofibroblastoma
Aunt Minne |
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young woman with a firm, painless breast mass
Gross: well-circumscribed, firm lesion with cystic/myxoid areas Micro: partially-encapsulated, densley cellular lesion or spindle-cells with indistinct borders around thin-walled irregular vessels. May look "staghorn". IHC: SMA, vimentin for spindle cells, endothelial cells are CD31,CD43, factor VIII |
Hemangiopericytoma
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Woman with a firm, painless mass in the breast (although can be anywhere)
Gross: yellow mass Micro: sheets, nests, cords of oval/polygonal cells with abundant eosinophilic granular cytoplasm. Nuclei have inconspicuous nucleoli. cell aggregates separated by thin septa. No atypia. IHC: NSE, S100 |
Granular cell tumor
Granules are lysozomes |
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Premenopausal woman with lumpy, painful breast mass (can be bilateral)
Gross: fibrosis and blue-domed or clear cysts up to 2 cm. Micro: combination of B9 histologic changes that include stromal fibrosis, dilated ducts, cysts, apocrine metaplasia, and mild epthelial hyperplasia without atypia. |
Fibrocystic change
in 60% of all normal breasts No risk of CA |
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pre-perimenopasual woman with incidental breast lesion when biopsied for microcalcification (40%)
Gross: none Micro: enlarged terminal duct units with dilated acini, epithelium with apical snouts present and a variety of histological subtypes: (1)- epithelium replaced by 1-2 laters of columnar cells, (2)- more than 2 layers and crowded nuclei (3)- low-grade cytologic atypia without papillary tufts or bridges (small nucleoli, lack granularity, loss of polarity) IHC: CK8/18, CK19, ER/PR. Negative for HMWCK |
Columnar cell lesions
(1)columnar cell change (2)columnar cell hyperplasia (3)flat epithelial atypia Often occurs with ADH, FEA with lobular neoplasm |
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premenopausal woman with incidental lesion on breast BX (20-30% of cases)
Gross: none Micro: 3 or more cells in the ducts/lobular unit above the basal cell layer. Mild:3-4, moderate: >5, florid. Other features: mild variation in size, shape, and placement of cells. No significant atypia. Streaming pattern of growth. Secondary lumina and slit-like spaces form in florid cases. Can be seen in gynecomastia with pyknotic nuclei |
Usual Ductal Hyperplasia (UDH)
Mod/florid forms increase risk for CA 1.5-2x |
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40 YO woman with incidental breast lesion on BX (10%)
Gross: none Micro: hyperplasia of the luminal cells of a duct or lubular unit that shows: A: at most focal areas of cellular uniformity, B: hyperchromatic nuclei, C:nuclei with fine chromatin D: rigid cellular bars and secondary spaces. Can invovle more than 1 duct, but total lesion <2mm |
Atypical ductal hyperplasia (ADH)
4-5x risk of ipsilateral CA in 10-15 years |
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premenopausal women with microcalcifications on routine breast screening, may present with mass or Padget's
Gross: speckled, ill-defined Micro: a uniform population of neoplastic cells lines the entire BM-bound space, creating uniform secondary spaces. Involves at least 2 such spaces, >2mm. Cells are small with nuclei 1.5-2x RBC, form micropapillae/cribiform pattern, and have well-defined borders. Mitoses are sparse IHC: ER/PR +, HER2 - |
Ductal carcinoma in-situ (DCIS), low-grade
Genetics: 16q del in 70% |
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premenopausal woman with a rare incidental multicentric (50%) or bilateral (2/3) breast lesion
Gross: none Micro: distension of the lobules by uniform dyscohesive small cells with eccentric nuclei and inconspicuous nucleoli. Cells often have intracytoplasmic mucin vacuoles, may look "targetoid". These are contained to less than 50% of the lubules of a terminal ductal lobular unit IHC: loss of E-cadherin |
Atypical lobular hyperplasia (ALH)
4-5x risk of CA, ipsilateral 3x contralateral Genetics: del 16 q E-cadherin/ gain 1q |
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premenopausal woman with a rare incidental multicentric (50%) or bilateral (2/3) breast lesion
Gross: none Micro: distension of the lobules by uniform dyscohesive small cells with eccentric nuclei and inconspicuous nucleoli. Cells often have intracytoplasmic mucin vacuoles, may look "targetoid". These are in more than 50% of the lubules of a terminal ductal lobular unit, and fill up and distend the space. Cells can spread to nearby ducts/lobules in pagetoid fashion IHC: loss of E-cadherin, ER/PR+, HEr2 - |
Lobular carcinoma in-situ (LCIS)
8-10x risk of CA, ipsilateral 3x contralateral Genetics: del 16 q E-cadherin/ gain 1q |
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Variant of LCIS with microcalcifications, large plump cells 3-4x lyphocyte, pleomorphism similar to DCIS grade 3
IHC: loss of E-cadherin, ER/PR/HER2 -, ki-67, p53+ |
pleomorphic LCIS (PLCIS)
Genetics: loss E-cadherin, ER/PR/ HER2 |
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premenopausal women with microcalcifications on routine breast screening, may present with mass or Padget's
Gross: speckled, ill-defined Micro: a uniform population of neoplastic cells lines the entire BM-bound space, creating uniform secondary spaces. Involves at least 2 such spaces, >2mm. Cells are large and pleomorphic with coarse chromatin and multiple nucleoli. 2.5x RBC, form cribiform/solid pattern, and have well-defined borders. Mitoses are frequent. Comedonecrosis with calcification present. IHC: ER/PR +/-, HER2 + |
DCIS, high-grade
Genetics: aneuploidy common. |
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Middle aged woman with a breast mass
Gross: well defined stellate mass Micro: invasive breast cancer with 90% of the lesion forming angulated tubules with a single layer of epithelial cells. apical snouts present, desmoplasia. IHC: ER/PR+, HER2 - |
Tubular carcinoma
Genetics: 16q loss in ~80%, 1q gain in 50% |
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Middle aged woman with a breast mass
Gross: well defined stellate mass Micro: infiltrating islands of tumor cells with 90% having cribiform architecture, amphophilic cytoplasm, and low-grade histology. IHC: ER/PR+, HER2 - |
Cribiform carcinoma
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Middle aged woman with a breast mass
Gross: well defined stellate mass with gelatinous surface Micro: nests of tumor cells floating in mucinous pools- must account for 90% of lesion. IHC: ER/PER+, HER2 |
Mucinous Carcinoma
Confers a BETTER prognosis |
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Middle aged woman with a breast mass
Gross: well defined stellate mass Micro: invasive breast CA with 5 distinctive criteria: 1. syncitial growth pattern 2. absence of glandular structures 3. diffuse mod/marked lymphocytic infitrate 4. grade 3 nuclear grade 5. histologic circumscription IHC: ER-, PR+, HER2-, p53+, |
Medullary carcinoma
Associated with BRCA1 mutations. Basal-like molecular phenotype |
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Elderly woman with palpable breast mass
Gross: large cystic mass Breast lesion of invasive epithelial cells admixed with areas of spindle cells and areas of squamous differentiation. variants: (2) infitrating compressed glands with keratin inside surrounded by spindle cells (3)- contain other malignant elements IHC: triple neg, CK focally positive |
Metaplastic CA
(2) adenosquamous CA (3) metaplastic CA with heterologous mesenchymal elements |
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postmenopausal woman with a breast mass
Gross: well defined lesion Micro: tubular/cribiform architecture with bi-phasic population of cells surrounding pseudocystic areas that contain amorphous esosinophilic material. true glands also seen IHC: material stains with alcian blue, glands stain with PAS(lumen), CK7(cells). |
Adenoid cystic CA
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Breast CA Molecular subtypes/ histologic correlation:
1- Lumenal A: 2- Lumenal B: 3- Basal 4: HER2+ |
1- low grade and ER+, respond to estrogen therapy, indolent
2- ER+, but histologic grade 2/3, more aggressive 3- usually triple negative, still not classified 4- ER-, HER2 amplification. Grade 3, may have apocrine differentiation, lymphoid infiltrate. Agressive, may respond to trastuzumab |
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In order, critical prognostic factors in breast CA
1. 2. 3. 4. |
1. LN status
2. tumor size 3. histologic grade 4. LVSI |
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Breast CA grading: 3 categories
1. (3 points) 2. (3 ponits) 3. (3 points) Total grades: |
1. Differentiation (1- >75%, 2-10-75%, 3- <10%
2. nuclear pleomorphism (1-small, uniform, 2- large with open chromatin, 3- pleomorphism 3. mitoses in 10 HPFs (1-3, varies on size of field) Total: grade 1: 3-5 grade 2: 6,7 grade 3: 8,9 |
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Breast CA susceptibility genes, syndromes, locations, incidence, risk
1. 2. 3. 4. 5. |
1. BRCA1- 17q, 0.1%, 37-80%R
2. BRCA2- 13q, 0.1%, 37-80% R 3. pTEN- COWDEN- 10q, 1:300K, 25-50%R 4.TP53- Li-Fraumeni- 17p, rare, 60%R 5. STK11/LKB1- Peutz-Jeghers, 19p, 7xR |
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What is Stewart-Treves sydrome?
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angiosarcoma arising from chronic lymphedma 2/2 mestectomy
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man or woman with breast mass
Micro: poorly circumscribed area of ductular hyperplasia (not lobular) with periductular fibrosis or edema. |
gynecomastia
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