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Transcript of Breast 2 Neoplastic
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The Breast
Breast
Normal
Pathology
Developmental
Anomalies
Clinical features
InflammationsBenign Epithelial
lesions
Carcinoma Male Breast
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Breast Carcinoma
Arise from epithelial cells,one in nine women develops breast cancer during her life-time (1/3 fatal);
Risk Factors-
1. strong family history first-degree relatives with cancer,
2. Specific genes linked to genetic inheritance , p53 -Li-Fraumeni syndrome, ATM -ataxia-
telangiectasia; BRCA1 and 2 (Genetic inheritance is in < 10% of all breast cancer cases)3. age (rare
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Breast Carcinoma Classified as: in situ (noninvasive) - 15 to 30% of all cancers: can be ( DCIS
(intraductal carcinoma), LCIS (lobular carcinoma); invasive (invasive) MC is invasive ductal carcinoma (80%)
Ductal carcinoma in situ (DCIS) - proliferations of tumor cells within ducts and lobules
confined by the basement membrane, spread from lactiferous ducts into the contiguous skin of
the nipple - Paget disease of the nipple (nipple -eczematous or ulcerated, not detected on the
mammogram; 1/3 can develop carcinoma over time if untreated; Lobular carcinoma in situ- proliferation of small, uniform cells within ducts and lobules that
fill, distend or distort at least 50% of the acinar units of a single lobule; always an incidental
finding ,never forms a mass , calcifications are rare, invasive carcinoma develops in 25 to 30%
, ,
Invasive ductal carcinoma (IDC) MC type - or cannot be classified or no special type(NST); malignant cells with a dense stromal reactionhard consistency (scirrhous carcinoma)
Invasive Lobular Ca.-5 to 10% of invasive carcinomas, multifocal and bilateral diffusely
invasive - difficult to detect clinically and mammographically; composed of small, uniform
cells forming strands of infiltrating tumor cells, sometimes arranged concentrically about ducts
(bull's eye lesions); Behavior- frequently metastasize to CSF (carcinomatous meningitis),serosal surfaces, ovary and uterus, bone marrow
Medullary carcinoma - younger age; with BRCA1 mutations ; Grossly- large, soft, well
circumscribed ; no desmoplasia, a moderately dense lymphoblastic infiltrate,
Others- Colloid (mucinous) ca. Tubular (cribriform) ca. Papillary carcinoma - have
good prognosis
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Paget disease
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Lobular carcinoma
Lobular carcinoma in situ Invasive Lobular carcinoma
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Breast carcinoma
Excess stromal proliferation. Desmoplasia
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Medullary carcinoma
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Colloid (mucinous) carcinoma
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Stromal Tumors
1. Fibroadenoma (Br. Mouse) - MC benign tumor of the female breast, during thereproductive period; cyclosporine A therapy; Clinically- well circumscribed
palpable masses or mammographic densities, (during pregnancy- grow in size and
sometimes infarct), in older women- calcify, Benign & associated with proliferative
changes; slightly increased risk of cancer; Grossly-solitary white, rubbery nodules
from 1 to 10 cm in diameter; Histologically -biphasic (stroma and epithelium
lining cystic spaces)
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women 50 70 yrs. (10 to 20 years older than fibroadenomas) & cellularity,mitotic activity, stromal overgrowth and invasiveness Behavior-Most - benign &
cured by local excision, few recur; few are highly malignant
3. Sarcomas -rare, can leiomyo, chondros and osteosarcoma; Sarcomatousdifferentiation inphyllodes tumors and carcinomas -metaplastic carcinomas;
Lymphangio-sarcomas if arise after radiation therapy for breast cancer or skin of a
chronically edematous arm in a post- mastectomy patient- Stewart-Treves
syndrome
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Fibroadenoma (Br. MOUSE)
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Mammographic Changes
1. Densities - most Neoplasms - radiologically denser than the intermingledconnective and adipose tissue of the normal breast; Invasive carcinomas-
spiculated density with irregular borders ; Benign lesions - well-circumscribed
densities with smooth borders
2. Calcifications - DCIS is the MC malignancy associated with calcifications;
malignancy - small, irregular, numerous and clustered or linear and branching,
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comparison of sequential mammograms for developing densities, architecturaldistortion or increased in the number of calcifications
4. Limitations of Mammography-some carcinomas (even if palpable) may not be
detected by mammography due to surrounding dense stroma (esp. in youngerwomen), absence of calcification, small size, close to the chest wall in the
periphery of the breast
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Mammogram of Young Beast
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Mammogram of aged Beast
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Multiple small Irregular clusters
Cause?
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Large density With Irregular Border
Cause ?
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Features common to all invasive carcinomas
Local invasion into adjacent structures produces tissue fixation, retraction of thenipple and dimpling of the skin,
Extensive lymphatic blockage by tumor can result in Lymphedema, causing the
breast skin to resemble an orange peal (peau d'orange)
Inflammatory carcinomas present as a markedly enlarged erythematous and
,
1/3rd of breast carcinomas present with lymph node metastases, can metastasize to
axillary, supraclavicular or internal mammary nodes (tumors ofouter quadrant -
metastasize to axillary nodes, ofinner quadrants and center to internal mammary
nodes)
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Prognostic indicators in Breast carcinomas
Tumor size; larger the tumor the worse the prognosis
Locally advanced disease; locally advanced disease (invasion into
skin or chest wall) - poor prognosis,
lymph node metastases; Lymph node metastases -most important
prognostic factor, ( no involvement, 10 year survival - 70 to 80%,if 10 are involved it is 10 to 15%);
distant metastases;
a specia su types ave a etter prognosis w en compare to NSTcancers, (tubular and colloid ca. - best prognosis),
Poorly differentiated ca. - worse prognosis;
carcinomas with hormone receptors have a slightly better prognosis
(Rx. with less toxic hormonal therapies);
Lymphovascular invasion - poor prognostic ;
involvement of dermal lymphatics (inflammatory carcinoma) poor
prognosis
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Prognostic indicators in Breast carcinomas
Tumor size; larger the tumor the worse the prognosis
Locally advanced disease; locally advanced disease (invasion into
skin or chest wall) - poor prognosis,
lymph node metastases; Lymph node metastases -most important
prognostic factor, ( no involvement, 10 year survival - 70 to 80%,if 10 are involved it is 10 to 15%);
distant metastases;
a specia su types ave a etter prognosis w en compare to NSTcancers, (tubular and colloid ca. - best prognosis),
Poorly differentiated ca. - worse prognosis;
carcinomas with hormone receptors have a slightly better prognosis
(Rx. with less toxic hormonal therapies);
Lymphovascular invasion - poor prognostic ;
involvement of dermal lymphatics (inflammatory carcinoma) poor
prognosis
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Breast carcinomas contd.
Poor prognostic indicators; - Increased angiogenesis, DNA content if abnormal,increased levels of proliferation markers, expression of Oncogenes (ex. c-erb-B2)
and loss of expression of tumor-suppressor genes, proteases
Current therapy includes -local and regional control using combinations ofsurgery (mastectomy or breast conservation - lumpectomy) and postoperative
radiation and systemic control using hormonal treatment, chemotherapy or both,
newer strategies include inhibition (by pharmacologic agents or specific antibodies)
o mem rane- oun growt receptors ex. c-er - , stroma proteases,
angiogenesis
Cytological features of malignancy Hyperchromatic nuclei dark staining, in
DNA content, N: C ratios large nucleoli, Irregular nuclear membrane, Atypical
mitosis, Pleomorphic large and small cells all mixed & not producing any
recognizable pattern
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Male breast-
Gynecomastia - enlargement of the male breast, key indicator -
imbalance between estrogens and androgens, (during puberty, in
Klinfelter's syndrome, manifestation of hormone-producing tumors -
ex. Leydig cell or Sertoli cell tumors) ; Cirrhosis; side effect of drugs(ex. marijuana, anabolic steroids, some psychoactive agents);
Histologically - proliferation of both epithelial and stromal
com onents
Carcinoma of the male breast -risk factors, prognostic factors are
similar to those of women, male breast cancer is strongly associated
with BRCA2 in some families the same histological types of breastcancer are found in men and women, because the scant amount of
surrounding breast tissue in men, carcinomas tend to invade the skin
and chest wall earlier and present at higher stages
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Carcinoma of BreastCytological features of malignancy
Hyperchromatic nuclei dark staining
in DNA content
N:C ratios largenuc eo
Irregular nuclearmembrane
Atypical mitosis
Pleomorphic large andsmall cells all mixed in
Not producing anyrecognizable pattern
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The Breast Pathology
Carcinoma of Breast
LymphangiosarcomaST syndrome
Breast cancer
Huge breast cancerMetastasis in her axilla is almost as big as thebreast cancerDied within a few days of the picture
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Gynecomastia