BREAST PATHOLOGY FLASH POINTS

DR EJAZ WARIS , PROFESSOR OF PATHOLOGY , ASMDC

Updated : 2016 January.

1.Duct ectasia characterized chiefly by dilation of ducts, inspissation of

breast secretions, and a marked periductal and interstitial chronic
granulomatous inflammatory reaction
2.Fat necrosis can present as a painless palpable mass, skin thickening
or retraction, a mammographic density, or mammographic
calcifications
3.There are three principal morphologic changes in fibrocystic disease:
(1) cystic change, often with apocrine metaplasia; (2) fibrosis; and (3)
adenosis
4. Adenosis is defined as an increase in the number of acini per lobule.
5. Epithelial hyperplasia is defined by the presence of more than two
cell layers. The additional cells consist of both luminal and
myoepithelial cell types that fill and distend ducts and lobules
6. Sclerosing Adenosis. The number of acini per terminal duct is
increased to at least double the number found in uninvolved lobules.
The normal lobular arrangement is maintained
7. Papillomas are composed of multiple branching fibrovascular cores,
each having a connective tissue axis lined by luminal and myoepithelial
cells.They present as nipple discharge complains by the patient.
8. Proliferative disease with atypia includes atypical ductal hyperplasia
and atypical lobular hyperplasia
9. Carcinoma of the breast is the most common non-skin malignancy in
women
10. The major risk factors for the development of breast cancer are
hormonal and genetic.
11. Mutations in BRCA1 and BRCA2 account for the majority of cancers
attributable to single mutations and about 3% of all breast cancers
12. The known high-risk breast cancer genes account for only about
one quarter of familial breast cancers
13. The major risk factors for sporadic breast cancer are related to
hormone exposure: gender, age at menarche and menopause,
reproductive history, breastfeeding, and exogenous estrogens
14. Greater than 95% of breast malignancies are adenocarcinomas,
which are divided into in situ carcinomas and invasive carcinomas
15.DCIS is ductal carcinoma in situ.
16. Historically, DCIS has been divided into five architectural subtypes:
comedocarcinoma, solid, cribriform, papillary, and micropapillary
17. Comedocarcinoma is characterized by the presence of solid sheets
of pleomorphic cells with “high-grade” hyperchromatic nuclei and
areas of central necrosis.It is high grade DCIS.
18.In paget’s disease , Malignant cells (Paget cells) extend from DCIS
within the ductal system, via the lactiferous sinuses, into nipple skin
without crossing the basement membrane
19. LCIS , lobular carcinoma in situ , is always an incidental biopsy
finding, since it is not associated with calcifications or stromal
reactions that produce mammographic densities.
20. Palpable tumors are associated with axillary lymph node
metastases in over 50% of patients.
21. The term inflammatory carcinoma is reserved for tumors that
present with a swollen, erythematous breast. This gross appearance is
caused by extensive invasion and obstruction of dermal lymphatics by
tumor cells.
22. Gene expression profiling, which can measure the relative
quantities of mRNA for essentially every gene, has identified five major
patterns of gene expression in the NST group: luminal A, luminal B,
normal, basal-like, and HER2 positive
 23. Estrogen and progesterone receptors are found in breast cancer
cells that depend on estrogen and related hormones to grow.
 24. All patients with invasive breast cancer or a breast cancer
recurrence should have their tumors tested for estrogen and
progesterone receptors.
25. If breast cancer cells have estrogen receptors, the cancer is called ER-
positive breast cancer. If breast cancer cells have progesterone receptors,
the cancer is called PR-positive breast cancer. If the cells do not have
either of these two receptors, the cancer is called ER/PR-negative. About
two-thirds of breast cancers are ER and/or PR positive.
26. If a patient's tumor expresses ER and/or PR, as seen in
approximately 70% of invasive breast cancers, we can predict
that this patient will likely benefit from endocrine therapy such
as tamoxifen.
27. Her2 expression is associated with a diminished prognosis
(e.g., higher risk of recurrence), however, it also predicts that a
patient will more likely benefit from anthracycline and taxane-
based chemotherapies and directed therapies that target Her2
(trastuzamab), but not to endocrine-based therapies
28.Ductal carcinoma of the breast is the most common type.
29.Lobular carcinomas have been reported to have a greater incidence
of bilaterality
30. The histologic hallmark of lobular carcinomas the presence of
dyscohesive infiltrating tumor cells, often arranged in single file or in
loose clusters or sheets with Indian file pattern
31. Lobular carcinomas have a different pattern of metastasis than
other breast cancers. Metastasis tends to occur to the peritoneum and
retroperitoneum, the leptomeninges (carcinoma meningitis), the
gastrointestinal tract, and the ovaries and uterus.
32. Histologically, the medullary carcinoma is characterized by (1)
solid, syncytium-like sheets of large cells with vesicular, pleomorphic
nuclei, and prominent nucleoli, which compose more than 75% of the
tumor mass; (2) frequent mitotic figures; (3) a moderate to marked
lymphoplasmacytic infiltrate surrounding and within the tumor; and
(4) a pushing (noninfiltrative) border
33.Tubular,mucinous,secretory , micropapilllary, inflammatory and
papillary are other variants of carcinoma breast
34. “Metaplastic carcinoma” includes a variety of rare types of breast
cancer (<1% of all cases), such as matrix-producing carcinomas,
squamous cell carcinomas, and carcinomas with a prominent spindle
cell component
35. prognosis is determined by the pathologic examination of the
primary carcinoma and the axillary lymph nodes.
36. Axillary lymph node status is the most important prognostic factor
for invasive carcinoma in the absence of distant metastases.
37. The most commonly used grading system, the Nottingham
Histologic Score (also referred to as Scarff-Bloom-Richardson),
combines nuclear grade, tubule formation, and mitotic rate to classify
invasive carcinomas into three groups that are highly correlated with
survival.
38.Fibroadenoma is the most common benign tumor of the female
breast
39. Phyllodes tumors, like fibroadenomas, arise from intralobular
stroma
40. Phyllodes tumors are distinguished from the more common
fibroadenomas on the basis of cellularity, mitotic rate, nuclear
pleomorphism, stromal overgrowth, and infiltrative borders.
41.FNAC and biopsy are used to diagnose breast cancer.
42.E cadherin loss is seen in lobular carcinomas.
43.There are three categories of carcinoma breast according to
immuno prognosis :
ER positive HER 2 neu negative ( most common ) , HER 2 neu positive
and ER can be positive and negative , ER negative- HER 2 neu negative
( poorly differentiated).
44.In inflammatory carcinoma of breast , carcinoma invades dermal
lymphatics.
45.Notthingham / bloom grading in details show
Mitoses 0-9 , 10 – 19 and more than 20 , ( grading of 1,2,3 respectively
)
Tubules More than 75%, 10 to 75% and less than 10% ( grading of
1,2,3 respectively)
Pleomorphism atypia mild , moderate and severe (1,2,3)
Numbers are added and than low , intermediate and high grade are
given.
46.Phyllodes word means leaf like.
47.Sentinel lymph node is first nearby positive lymph node drained by
the tumor.

Topics must not be missed before test and prof :

Bloom Richardson / notthingham grading system
Role of ER PR and HER 2 neu in prognosis and clinical outcome.
Morphologies of ductal , lobular and medullary
DCIS – note.
Fibrocystic disease components list.
Precancerous lesions list.
Prognostic / predictive major minor factors.

Classical associations:
Indian file pattern – lobular carcinoma
Apocrine metaplasia – fibrocystic disease
Fat necrosis – macrophages / giant cells seen
Nipple discharge – duct papilloma
Pushing borders – medullary
E-cadherin – lobular