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The Breast

The Breast. Acute mastitis S. aureus Breastfeeding Fever, erythema, pain Strep infections tend to cause diffuse spreading infection of entire breast Periductal mastitis AKA recurrent subareolar abscess, squamous metaplasia of lactiferous ducts, Zuska disease

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The Breast

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  1. The Breast

  2. Acute mastitis S. aureus Breastfeeding Fever, erythema, pain Strep infections tend to cause diffuse spreading infection of entire breast Periductal mastitis AKA recurrent subareolar abscess, squamous metaplasia of lactiferous ducts, Zuska disease Painful erythematous subareolar mass smoking Keratinizing squamous metaplasia of nipple ducts Inverted nipple Fibrocystic disease “LUMPY, BUMPY” Non proliferative dense with cysts (blue-dome cysts) “milk of calcium” (mammograph term to describe calcifications that line bottom of rounded cyst) Adenosis (increase in # of acini per lobule) lactational adenomas = palpable masses in pregnant or lactating women The Breast

  3. Breast Cancer • Carcinoma of the breast is the most common non-skin cancer in women • If lives to age 90 years 1/8 chance • Main benefit of screening with mammograms is the detection of small, predominantly ER-positive invasive carcinoma and insitu carcinoma (DCIS) • The major risk factors are hormonal and genetic

  4. Breast CA risk factors Hormonal • Postmenopausal hormone replacement therapy increases risk • Progesterone addition increases further • Age at menarche/menopause • Reproductive Hx, breastfeeding Genetic • BRCA1 associated breast CA • Poorly differentiated • Medullary features • Triple negative phenotype (ER-, PR-, and HER2/neu-) • BRCA2 associated breast CA • Poorly differentiated • More often ER+ than BRCA1 • P53 (Li-Fraumeni) • Most commonly mutated gene in sporadic breast CA

  5. DCIS • Most detected as calcifications on mammo • Limited to ducts and lobules by BM • Intraductal carcinoma • Divided into 5 architectural types: 1) Comedocarcinoma(pleomorphic cells; microinvasion most common) 2) Solid (monomorphic; fills spaces) 3) Cribiform (monomorphic; cookie-cutter) 4) Papillary (monomorphic; grows along cores no myoepithelial layer) 5) Micropapillary(monomorphic; no core) Paget disease of nipple (erythema, crust, extend from DCIS; palpable mass in most)

  6. Invasive (Infiltrating) Carcinoma • Palpable tumors are associated with axillary lymph node metastases 50% of the time • **axillary lymph node status is the most important prognosis factor for invasive carcinoma in the absence of distant metastases • Dimpling of skin • Peau d’orange • Inflammatory carcinoma • Tumors presenting with swollen, erythematous breast • Extensive invasion and obstruction of dermal lymphatics by tumor cells • Many metastases at diagnosis • Rapid recurrence

  7. Invasive carcinoma, NST (invasive ductal carcinoma) • Majority of carcinomas are NST • Firm to hard and have an irregular border • Grate sound when cut • Streaks of chalky-white elastotic stroma • Desmoplasia • 5 major patterns of gene expression: 1) Luminal A ER+, HER2/neu – largest group, well differentiated, postmenopausal 2) Luminal B Triple+ high proliferation rate, lymph node metastases 3) Normal breast-like ER+, HER2/neu – 4) Basal-like Triple –, BRCA1 like metaplastic carcinoma, high grade/metastases 5) HER2 positive ER –

  8. Invasive Lobular Carcinoma • Usually present as palpable mass • 25% have little desmoplasia rarely palpable • Greater incidence of B/L • Dyscohesive infiltrating tumor cells, no tubules • Signet-ring cells • Resembles signet-ring gastric carcinoma (loss of E-cadherin) • Metastases to peritoneum, retroperitoneum, leptomeninges, GI tract, uterus, ovaries

  9. Medullary 6th decade Well-circumscribed Rapid growing Soft, fleshy Overexpression of adhesion molecules: Pushing borders Syncytial growth pattern Lymph node metastases rare Overexpression of adhesion molecules BRCA1 promoter hypermethylation Mucinous (colloid) Median age = 71 Slow growing over many years Soft, rubbery Pale blue gelatin Pushing or circumscribed borders Tubular (cribiform) Detected as small irregular mammographic densities Late 40s Well-formed tubules Myoepithelial layer absent Apocrine snouts LCIS or lobular carcinoma associated Excellent prognosis Other carcinomas

  10. More carcinomas Invasive papillary • ER + • good prognosis Invasive micropapillary • ER – • HER2 + • poor prognosis Metaplasticcarcinoma • prominent spindle • triple negative • Poor prognosis

  11. Stromal Tumors Fibroadenoma • most common benign tumor of female (20s and 30s) • Multiple, B/L • sharply circumscribed, freely mobile • From intralobularstroma • popcorn calcifications • post renal transplant treated w/ cyclosporin A Phyllodes tumor • 6th decade • Leaflike • From intralobularstroma • EGFR amplification

  12. Stromal tumors Interlobular stromal tumors (benign) • Pseudoangiomatous stromal hyperplasia • Myofibroblastoma • Lipomas & hamartomas • Fibromatosis • Locally aggressive but doesn’t metastiasize • Mostly sporadic • Some associated with familal adenomatous polyposis and Gardner syndrome • B-catenin in nucleus is useful diagnostic feature Angiosarcoma (malignant) • malignant post radiation therapy • Young women • Stewart treves syndrome – angiosarcoma from edematous extremity after mastectomy

  13. Male Breast Gynecomastia • puberty, elderly, cirrhosis, Klinefelter, steroids Carcinoma • Klinefelter • BRCA2 • Usually present as palpable subareolar mass • Nipple discharge common symptom • Distant metastases to lungs, brain, bone, liver common

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