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BREAST PATHOLOGY 1 - Coggle Diagram

- - - - aka basal cells
        
        elongated cells sharing features typical of muscle cells and other typical of epithelial cells
        
        important for pathologist to understand if the tumor has infiltrated the stroma or not
        
        markers: cytokeratins 14 and 5/6, P63, Sm-actin, desmin
      - oxytocin receptors are present
        
        oxytocin:
        
        normally continuously produced at low levels
        
        during lactation, its level spikes
        
        this affects myoepithelial cells causing their contraction (--> facilitating the secretion of milk)
        
        it has positive effects on mood
    - - marker: cytokeratins 7 and 18
        
        look for these markers when investigating on a tumor producing metastases from the breast
      - estrogen, progesterone and androgen receptors are located within the nuclei of luminal cells
        
        prolactin receptors are located at the membrane level: it induces cell differentiation and cells start producing milk
        
        estrogen receptors also have the function to regulate the expression of progesterone receptors
  - - - nipple discharge
        
        nipple eczema
        
        palpable lump
        
        hardening
        
        alteration
    - - calcifications
        
        clustered white spots, variable intensities, divided into fine / powdery and coarse; they are generally located in the alveoli
        
        sometimes calcifications are elongated and branched (coarse branching calcifications), located in the ducts
      - opacities
        
        spiculate mass: always an invasive carcinoma
        
        stellate lesion: radial scar, either benign or invasive (low/intermediate grade)
        
        well-defined mass: either benign or malignant
  - - - normal during lactation
        
        it occurs in 50% of pre-menopausal women
        
        3rd sympyom after pain and palpable lesions
        
        5-8% of causes for breast examination
        
        5-24% is associated with neoplasia
        
        present in 1-4% of patients with carcinona
        
        algorithm
        
        patient presents with nipple discharge
        --> assess discharge
        
        multiple ducts
        (yellow, brown, green)
        
        milky discharge or multiple ducts?
        
        hormonal evaluation
        
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        observe / reassure the patient;
        follow-up if persistent
        
        single duct, bloody / clear, mass present
        
        trauma
        
        intraductal papilloma
        
        perform mammogram and US
        
        refer to surgeon
        (+/- MRI ductography)
    - - opacity
    - - opacity and calcification
      - performed when borderline lesions are present
        
        cellular and architectural evaluation
    - - there is a sort of aspiration that avoids hematoma formation and multiple specimen can be obtained with just one entrance
- - - - cells are heterogeneous, but with no atypia
        
        this condition does no evolve into cancer as it is completely benign
    - - this marker in normal conditions should only be found at the basal layer, but during this condition cells go in the lumen and accumulate there
  - - - typical features:
        
        dilated lumina of acini
        
        lumen may be empty or may contain amorphous material with fine calcifications arranged in clusters
        
        regular cuboid epithelial cells covering the terminal duct lobular units
        
        columnar cells can be with or without atypia
        
        if atypia is not present, nothing will happen
        
        if atypia is present, surgical removal must be considered
  - - - the term "ductal" refers to the fact that in the acini there is a lumen with cribform aspect
      - not stainable with CD14
    - - diameter of the lesion
        
        less than 2 mm
        
        atypical ductal hyperplasia
        
        more than 2 mm
        
        low-grade DCIS
        
        surgery must be performed
      - number of acini
        
        2 acini involved
        
        atypical ductal hyperplasia
        
        more than 2 acini involved
        
        low-grade DCIS
    - - 16: loss and gain
        
        17: loss
        
        7: gain
  - - - myoepithelial cells are intact
        
        no metastatization
        (generally)
      - clustered powdering calcifications
    - - ductal
        (DCIS)
        
        not an obligate precursor of invasive carcinoma
        
        anyway, it may cause the breakage of the cortex (basal lamina), causing the disappearance of myoepithelial cells, leading to an infiltrative carcinoma (infiltrative towards the stoma, where the vessels are --> possible metastasis)
        
        grading
        
        by looking at the nucleus:
        
        low nuclear grade
        (small and roundush nucleus)
        
        intermediate nuclear grade
        
        high nuclear grade (pleomorphic
        nucleus with large nucleoli)
        
        typical finding in high-grade tumor:
        coarse branching calcifications
        
        surgery is needed (even in the absence of other examinations)
        
        high-grade in situ carcinoma is able to invade the skin of the nipple (monolateral)
        
        nipple eczema (Paget disease)
        
        histological classification is no longer important
        
        we should just point out the eventual presence of necrosis (--> aggressiveness index)
        
        on the necrotic lesion, bluish material may be seen
        
        COMEDO NECROSIS
        
        cribform: several small holes inside, presenting like Roman bridges, calcifications inside the lumen of the newly formed in situ tumor
        
        papillary: fibrovascular core with neoplastic epihelial cells covering the fronds (no myoepithelial cells)
        
        micropapillary: bulb-like structures proliferating toward the lumen without a fibrovascular core
        
        typical alterations:
        overexpression of HER2 and neoductogenesis
      - lobular
        (LSIC)
        
        location: TDLU (same as DCIS)
        
        multicentric and bilateral
        
        the acini are completely filled with very small cells (very subtle alteration, possibly missed during mammography)
        
        a mutation causes the defect in e-cadherins expression (negative in lobular neoplasia)
        
        in general, surgery is not performed; the patient is only administered Tamoxifen
        
        the only exception is pleomorphic carcinoma, which is very bad from the histological point of view
- - - - when R3, R4 or R5 lesions are present, a biopsy must be performed
  - - - surgery is required in C4, B4, C5 and B5
- - - - previous mastitis
        
        trauma
        
        intraductal papilloma
      - generally, the diagnosis is clinical
        (discharge is observed)
        
        clinical
        
        US (mammography: calcifications)
        
        no FNA
        
        cytological smears of nipple discharge
        
        pathological examination in ductal ectasia
        
        dilated milk ducts
        
        histiocytes and cellular debris
        
        no cancer cells inside
        
        sometimes, calcifications are seen,
        reproducing glanfular trees
        
        periductal inflammation
        
        found around ducts, which are very enlarged
        
        chronic inflammation (periductal / plasma cellsmastitis)
        
        lymphocytes and plasma cells
        
        complications
        
        rupture of ducts
        
        all the foreign material goes in the breast tissue
        
        inflammatory reaction with cholesterol crystals deposits
        
        granulation tissue and retracting scars are formed
  - - - "MOUSE TAIL" at US
  - - - intraductal papilloma
        
        its nipple discharge is:
        
        unilateral from a single duct
        
        spontaneous
        
        persistent
        
        bloody or transparent
        
        histology
        
        solitary papilloma of the great ducts
        
        benign lesions with fibrovascular core on which epithelium and myoepithelium are present
        
        within the branches, the double layer of the normal gland is visible
        
        if myoepithelial cells are present, we are sure the lesion is benign
        
        surgery is performed
        
        main location
        
        large ducts
        
        multiple papilloma
        
        they grow at the periphery in
        the lobules (within TDLU)
        
        no signs or nipple discharge
        
        low risk of progression
        
        the patient does not undergo surgery, follow-up is enough (we can avoid mastectomy)
        
        at least 5 of them, up to hundreds
        
        diagnosis is based on:
        
        MX (calcifications)
        
        US
        
        FNA
        
        core biopsy
        
        fibrocystic breast disease
        
        80% of female population
        
        the condition is benign, but there is severe pain at palpation (MASTODINIA at ESQ-Q1)
        
        the pain increases especially in the luteal phase
        
        location: TDLU and stroma
        
        these areas have a higher sensitivity to estrogens
        
        cause: hyperestrogenism
        
        APOCRINE METAPLASIA
        
        the epithelium of the lobule is transformed into apocrine epithelium, leading to the production of a specific fluid (blue colour)
        
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        apocrine carcinoma could be present,
        but it does NOT arise from apocrine cysts
        
        types of lesions
        
        proliferative
        
        without atypia
        
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        with atypia
        
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        non-proliferative
        
        "TRUE" fibrocystic disease
        
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        low risk of cancer transformation
        
        parameters for the diagnosis
        
        no calcifications or distortions
        
        cysts, multifocal and bilateral, small or large
        
        generally, based on US
        
        cysts: <1 cm to 5 cm in diameter
        
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        brown-to-blue cysts filled with serous turbid fluid
        
        complications
        
        the same as the ones in duct ectasia
        
        cysts may undergo rupture, causing an inflammatory reaction with consequent formation of granulation tissue and retracting scar
        
        adenosis
        
        increase in gland structure
        
        types
        
        simple adenosis:
        
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        sclerosing adenosis:
        
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        microscopic alterations
        
        non-proliferative lesions
        
        cysts and/or fibrosis and/or adenosis (calcifications)
        
        proliferative
        
        without atypia
        
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        with atypia
        
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