Updated: 2/14/2020

Malignant Breast Tumors

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Introduction
  • Epidemiology
    • breast cancer is the most common cancer and second most common cause of death in adult women
  • Risk factors
    • BRCA1 and BRCA2 mutations
      • associated with multiple / early onset breast and ovarian cancer
      • other genetic relationships
        • RAS oncogene gain of function
        • overexpression of estrogen/progesterone receptors
        • overexpression of erb-B2 (HER-2, an EGF receptor)
        • Li-Fraumeni associated TP53 loss
    • increasing age
    • smoking
    • breast cancer in first degree relatives or mother with breast cancer
    • history of contralateral breast cancer
    • history of endometrial cancer
      • also an estrogen induced cancer
    • increased exposure to estrogen
      • obesity
      • nulliparity
      • early menarche (<11 y.o.)
      • late menopause (>50 y.o.)
      • late first pregnancy (>30 y.o.)
    • atypical ductal hyperplasia
Classification
  • Ductal carcinoma in situ (DCIS)
    • arises from progression of ductal hyperplasia
    • non-palpable mass 
      • seen most often on mammography due to microcalcifications
    • histology shows filled ductal lumen without basement membrane penetration
    • subtypes
      • comedocarcinoma
        • ductal carcinoma with caseous necrosis at the mass center 
  • Paget's disease
    • extension of DCIS into lactiferous ducts and skin of nipple
      • eczematous patches on nipple 
    • histology shows Paget cells 
      • large cells in epidermis with clear halo
      • also seen on vulva
  • Invasive/infiltrating ductal carcinoma 
    • worst and most invasive
    • most common type
    • firm, fibrous, "rock-hard" mass
    • histology shows small, glandular, duct-like cells with stellate morphology
    • subtypes
      • tubular carcinoma
        • histology
          • well-differentiated tubules that lack myoepithelial cells
      • mucinous carcinoma
        • histology
          • carcinoma with abundant extracellular mucin
  • Lobular carcinoma in situ (LCIS)
    • non-palpable mass
    • often bilateral
    • histology shows distended lobules with neoplastic cells without BM penetration
  • Invasive lobular
    • often multiple and bilateral
    • histology shows orderly row of cells
  • Medullary
    • associated with BRCA1 and ER/PR negativity
    • histology shows fleshy, cellular, lymphatic infiltrate
  • Inflammatory 
    • poor prognosis (50% survival at 5 years)
    • histology shows dermal lymphatic invasion by tumor
    • peau d'orange seen on exam
      • see below
Presentation
  • Symptoms
    • often asymptomatic
    • breast lump
      • most commonly in upper-outer quadrant
    • nipple discharge
  • Physical exam
    • firm immobile, painless lump
    • some skin changes 
      • redness, ulcerations, edema, and nodularity
    • axillary lymphadenopathy
      • in more advanced cases
    • breast skin edema with dimpling (peau d' orange)
      • represents obstruction of the lymphatics by cancer  
Evaluation
  • Fine needle aspiration
    • can identify whether mass is solid or cystic
    • can also retrieve sample for cancer diagnosis
  • Estrogen/Progesterone receptor assays
    • most often positive in post-menopausal cancers
      • low estrogen state after menopause results in upregulation of receptors
    • positivity confers better prognosis with more effective therapeutics
  • Sentinel lymph node biopsy
    • if negative high likelihood no other nodes in group are involved
    • if positive there is 1/3 chance other nodes in group are involved
Treatment
  • Surgery
    • breast conservation resection
      • resection of tumor with margins
      • sentinel node biopsy
      • radiation
    • modified radical mastectomy
      • resection of nipple, entire breast, pectoralis minor, and level I-II axillary nodes
      • level III axillary nodes removed if involved
      • complications
        • long thoracic nerve damage
          • results in winged scapula 
        • lymphedema
Prognosis, Prevention, and Complications
  • Prognosis
    • lymph node involvement is the single most important prognostic factor
    • TNM staging
      • extranodal metastases has more significance than lymph node metastasis
  • Prevention
    • mammography
      • effective screening tool except in young woman
        • dense breast tissue in young woman interferes with specificity and sensitivity
        • most effective in postmenopausal patients because of less glandular breast
      • identifies microcalcifications or moderate sized masses
      • all woman > 40 should have mammograms
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(M1.ON.13.1) A 52-year-old female was found upon mammography to have branching calcifications in the right lower breast. Physical exam revealed a palpable nodularity in the same location. A tissue biopsy was taken from the lesion, and the pathology report diagnosed the lesion as comedocarcinoma. Which of the following histological findings is most likely present in the lesion? Tested Concept

QID: 101662
1

Orderly rows of cells surrounding lobules

21%

(5/24)

2

Disordered glandular cells invading the ductal basement membrane

12%

(3/24)

3

Extensive lymphocytic infiltrate

0%

(0/24)

4

Halo cells in epidermal tissue

4%

(1/24)

5

Pleomorphic cells surrounding areas of caseous necrosis

58%

(14/24)

M 2 D

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