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49 Cards in this Set
- Front
- Back
Fibrocystic change of the breast*
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Cystic changes of either the glands or duct. This stretches the connective tissue and causes fibrosis.
Most common change in premenopausal woman. Hormone-mediated, normal variation as a consequence of the estrogen and progesterone levels. Vague irregularity to breast tissue "Lumpy breast" in upper outer quadrant Blue domed cysts 1) Cysts: dilation of lobules. Filled with semi-translucent blue-brown fluid. 2) Fibrosis: cysts rupture release secretory material into stroma and inflame 3) Adenosis: Increased acini per lobule. Normally occurs during pregnancy |
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Fibrocystic change risk for cancer?*
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Classically it's benign.
Fibrosis, cysts, apocrine metaplasia means BENIGN |
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What breast changes carry increased risk for invasive carcinoma?*
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Ductal hyperplasia and sclerosing adenosis (too many glands that are fibrosed) = 2x risk
Atypical hyperplasia = 5x risk The risk applies to BOTH breasts |
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Intraductal papilloma pathophysiology*
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Within the large duct that goes to the nipple, you can grow a fibrovascular fingerlike projection covered by epithelium.
This papillary lesion often bleeds and produces bloody nipple discharge. Epithelial cells AND MYOEPITHELIAL CELLS line the papillary projection (myo are absent in papillary carcinoma) Usually premenopausal women. |
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Fibroadenoma pathophysiology*
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Tumor of fibrous tissue + glands
MC benign neoplasm of breast MC tumor in premenopausal Well-circumscribed, mobile, marble-like Estrogen sensitive (can shrink as menopause occurs) Benign; no risk for carcinoma |
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Phyllodes tumor*
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Fibroadenoma-like with overgrowth of fibrous component, increased cellularity
Leaf-like projections Most commonly seen in postmenopausal women CAN be malignant |
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Acute Mastitis
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First month of breastfeeding.
Local bacterial infenction due to crack and fissures in the nipples. Breast erythematous, painful, fever often present. Treat with abx and continued expression of milk from the breast |
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Squamous Metaplasia of Lactiferous Ducts (Zuska disease, periductal mastitis)
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Painful erythematous subareolar mass.
90% are smokers, maybe from a Vitamin A deficiency Keratizing squamous metaplasia of nipple ducts. Keratin sheds and plugs ductal, dilation and rupture eventually. En bloc surgical removal of the involved duct and tract. Plus abx. |
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Duct Ectasia
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Palpable periarolar mass with thick white or green nipple secretions.
50-60yo multiparous women. Fibrosis scar shows nipple retraction Not associated with smoking. Ducts filled with lipid laden macrophages. |
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Sclerosing adenosis morphology and risk
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Increased number of acini compressed and distorted in the central portion.
Stromal fibrosis may completely compress lumens to look like cords of cells (mimicking carcinoma) 2x risk of carcinoma |
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Complex Sclerosing Lesion morphology
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Components of sclerosing adenosis, papillomas, and epithelial hyperplasia.
Radial scar : irregular, looks like invasive carcinoma (central glands surrounded by radiating projections into stroma) |
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Gynecomastia
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Only benign lesion in male breast.
Button-like subareolar enlargement. Imbalance between estrogens and androgens Seen a lot in cirrhosis (since estrogen isn't as metabolized) Also seen in puberty, hyperestrenism, Klinefelter Syndrome (XXY) |
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Ductal Carcinoma in situ
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Malignant proliferation of cells in the duct, hasn't broken through the basement membrane.
Detected as calcification on mammography Comedo type: high grade cells with necrosis and dystrophic calcification in center of ducts. (kind of looks like a bullseye) |
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Paget disease of the breast, treatment
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DCIS that extends (walks up the duct) up to the skin of the nipple
Nipple ulceration and erythema Almost always associated with an underlying carcinoma, poorly differentiated ER- HER2+ Mastectomy is curative in >95% of women |
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Invasive Ductal Carcinoma, NST
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Malignant cells have invaded past the basement membrane
Forms duct-like structures in desmoplastic stroma (connective tissue hooked onto the tumor) "poorly-defined margins and cuts with gritty sensation. The cut surface is gray, opaque, and slightly depressed. Streaks of gray extend into the surrounding fibroadipose tissue." Detected by physical exam or mammography Advanced tumors may result in dimpling of skin or retraction of nipple |
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Subtypes of Invasive ductal carcinoma
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Tubular carcinoma
Mucinous carcinoma Medullary carcinoma Inflammatory carcinoma |
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Tubular carcinoma
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Well-differentiated tubules that lack myoepithelial cells
Good prognosis |
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Inflammatory carcinoma
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Inflammed, swollen breast
Carcinoma in dermal lymphatics blocks drainage of the breast Like mastitis, but much worse.Poor prognosis |
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Medullary carcinoma
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Large, high-grade cells growing in sheets with associated lymphocytes and plasma cells
Most common in 6th decade Increased in BRCA1 carriers Usually no hormone receptors Prognosis slightly better than NST |
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Lobular carcinoma in situ and treatment
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Malignant proliferation of cells in lobules (no invasion of BM)
Discovered incidentally, does not produce mass or calcification. Dyscohesive cells lack E-cadherin Mucin positive signet ring positive cells common Almost always ER/PR +, HER2 - Often multifocal and bilateral Treat with tamoxifen |
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Invasive lobular carcinoma
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Tumor of cells that grow along lobules, but invade BM
Invade in a single-file pattern due to lack of E-cadherin Often involves spread to peritoneum, retroperitoneum, and leptomeninges |
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TNM staging and prognosis of breast cancer
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TNM staging = Tumor size, Node metastases, Metastasis for distant
Metastasis is most important factor Spread to axillary lymph nodes is most useful factor Sentinel node biopsy is used to assess those axillary lymph nodes |
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Predictive factors and treatment of breast cancer
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Most important factors are Estrogen receptor, Progesterone Receptor and HER2/neu gene amplification status.
ER and PR (nucleus) are associated with response to tamoxifen (anti estrogen) HER2/neu (surface receptor) amplification is associated with response to trastuzumab If they're triple negative (no ER, no PR, no HER2/neu) then they have a very poor prognosis. Won't respond to tamoxifen or trastuzumab. |
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Hereditary Breast Cancer
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10% of breast cancer cases
Multiple first-degree relatives with breast cancer, tumor at an early age, or multiple tumors are signifiers BRCA1 and BRCA2 are the most important single gene mutations BRCA1 = breast + ovarian cancer BRCA2 = breast carcinoma in males |
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Male Breast Cacner
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Subareoloar mass in older male
Highest density underneath the nipple Usually invasive ductal carcinoma (lobular is rare) BRCA2 associated Klinefelter syndrome associated |
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Most common form of invasive breast cancer?
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ER + HER2- (like lobular carcinoma)
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Second most common form of invasive breast cancer?
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ER ± HER2+
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Major type of invasive carcinomas in BRCA1 carriers
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ER- HER2-
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Nottingham Histologic Grading
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Grade I: tubular, uniform nuclei low proliferation
Grade II: tubules + cords, mitotic + moderate pleiomorphism + moderate mitoses Grade III: ragged nests or solid sheets of cells + enlarged irregular nuclei + high proliferative rate of necrosis |
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Fat Necrosis
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Usually prior history of surgery or trauma
Mass, thickening with retraction or mammographic density or calcification Acute = hemorrhagic with liquefactive Few days = proliferating fibroblasts + chronic inflammatory cells Eventually = scar |
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Mucinous carcinoma
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Subtype of invasive ductal carcinoma
Older women, grows slowly Tumor is rubbery or soft with pale gray-blue gelatinous cut surface Tumor cells arranged in clusters and small islands floating in lakes of mucin (colloid) Prognosis slightly better than NST |
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Tubular carcinoma
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Women in their late 40's
Consists exclusively of well-formed tubules No myoepithelial cells Sometimes cribiform pattern |
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Definition of Sojourn time
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Duration between when a lesion can be detected on mammography and when it presents clinically (2 years premenopausal, 1 year postmenopausal)
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BIRADS Grade 0
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Need Additional Imaging or prior mammograms for comparison
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BIRADS Grade 1
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Negative - nothing to comment on
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BIRADS Grade 2
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Benign
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BIRADS Grade 3
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Probably benign (<2% malignant)
Initial short follow-up suggested |
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BIRADS Grade 4
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Suspicious (2-95% malignant)
Biopsy suggested |
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BIRADS Grade 5
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Highly suggestive of malignancy (>95%)Appropriate action should be taken
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BIRADS Grade 6
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Known Biopsy - Proven Malignancy
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Medication causes of gynecomastia
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Spironolactone
Hormones CimetidineKetoconazole (Some Hormones Create Knockers) Digoxin |
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Intraductal papilloma presentation
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Bloody discharge, excessive call growth
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Duct ectasia presentation
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Blockage of lactiferous ducts
Greenish, sebaceous, or bloody discharge |
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Galactorrhea presentation
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bilateral, milky or clear/white substance
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Causes of galactorrhea
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Pituitary lesions (microadenoma/macroadenoma)
Antipsychotics that suppress dopamine Hypothyroidism Estrogens |
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Work-up and treatment of galactorrhea
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Take history of meds, check breast discharge
Get TSH levels and PRL (fasting) MRI of sella turcica if PRL > 100 Remove offending agent |
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Microadenoma vs Macroadenoma and treatment
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Microadenoma (<1cm) = bromocriptine or cabergoline, dopamine agonistsMacroadenoma (>1cm) = surgery
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Treatment of mastitis
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Dicloxacillin
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peau d'orange
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Inflammatory breast cancer
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