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Cancer of Breast
(case study)
Scenario
The patient is an anxious-appearing 49-year-old woman who
has come to her physician for evaluation of a lump in her
right breast.
She says she first noticed it 2 weeks ago while she was
taking a shower. She has not noticed any nipple discharge,
skin changes, or alteration in the lump's size.
She is perimenopausal.
Her mother died at age 45 from "a breast tumor." Five
years previously, the patient had a biopsy of her left breast
(Images 1-4).
Scenario
Physical examination reveals a nontender, slightly
movable, 2-cm mass in the upper outer quadrant of her
right breast. In addition, several smaller nodules and illdefined firm areas are present in both breasts. The nipple
and skin appear normal. The lower right axilla contains a
1.5-cm movable nodule.
Laboratory data include hematocrit 31%, hemoglobin 11.5
gm/dL, and total serum calcium 10.5 mg/dL.
A mammogram shows an irregular mass with stippled
calcifications in the upper outer quadrant of the right
breast.
Scenario
A core biopsy is performed (Image 5), after which a
lumpectomy and sentinel lymph node biopsy are
performed. Before sectioning of the lumpectomy
specimen, a radiograph is obtained of it, revealing the
tumor and associated stippled microcalcifications (Image
6).
Breast, carcinoma
specimen - Radiograph
Scenario
Gross examination of the lumpectomy specimen shows a
2-cm, gray, scirrhous mass in the central portion of the
specimen (Images 7-9). The margins of the lumpectomy
specimen are free of tumor. Serial sections of the sentinal
lymph node reveal metastatic ductal carcinoma (Image
10); a completion axillary dissection is performed 1 week
later, revealing 2 additional positive lymph nodes out of
15. Immunohistochemical studies reveal the tumor to be
estrogen and progesterone receptor positive.
The tumor is HER2 positive by FISH analysis. The
patient is given chemotherapy and radiotherapy.
Anatomic origins of
common breast lesions
Duct ectasia
Traumatic fat
necrosis
About half of
affected women
have a history of
breast trauma or
prior surgery
Palpable periareolar
mass +- thick, white
nipple secretions,
skin retraction.
Painless palpable
mass, skin
thickening,
retractions,
calcifications
Histopathology
1.Hemorrhagic
2.Proliferating
fibroblasts
3.Giant cells,
Etiology
Staph abscesses
may be single or
multiple Strep cause
spreading infection
Ductal ectasia
lumpy bumpy
a dense breast
benign histologic
findings, poorly
defined lump
Not associated
with increased risk
of breast cancer
Proliferative
fibrocystic changes
Mammo densities,
calcific, or as
incidental findings
in biopsies perf. for
other reasons
Lesions
characterized by
proliferation of
epithelial cells
w/o atypia
Small increase in
the risk of
carcinoma in either
breast
Biopsies performed
for calcifications
- ADH 5-17%
- ALH - <5%
clonal prolif.
having some, but
not all,of the histo
features that are
req. for the dg of
carcinoma in situ.
Moderately
increased risk of
carcinoma
Come to attention
Has a histologic
benign
Atypical Ductal
Hyperplasia
(ADH)
Epidemiology
Fibroadenoma
Phyllodes tumor
Intraductal
papilloma
About half of
affected women
have a history of
breast trauma or
prior surgery
Histopathology
Papillomas grow
within a dilated
duct and are
composed of
multiple branching
myxoid stroma
resembles normal
intralobular stroma.
(pericanicular
pattern) or
Fibroadenoma &
Phyllodes tumor
Intraductal papilloma
Relative
incidence
Prognosis
high-grade ductal
carcinoma in situ
Without screening
< 5% of all ca-mas
dtct when in situ
>15-30% w scrnin
high-grade have a
higher risk for
progression to
invasive car-ma
low-grade ductal
carcinoma in situ
Cribriform,
Micropapillary
DCIS
low-grade DCIS
develop invasive
cancer at a rate of
1% per year
1% to 6% of all
carcinomas
Same as above 1%
per year
8. Define gynecomastia.