Fibrocystic

Change and
Cancer of Breast
(case study)

Robbins and Cotran Pathologic Basis of

Disease, Chapter 23 by Susan C. Lester
Presentation done by Mariana Usatii PGY1

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).

Breast, fibrocystic changes

- Gross, cut surfaces

Breast, fibrocystic changes

- Low power

Breast, fibrocystic changes

- High power

Breast, ductal hyperplasia

5yrs prev-medium power

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, ductal carcinoma, core biopsy

specimen - Low power and high power

Breast, carcinoma
specimen - Radiograph

Breast, carcinoma - Gross,

cut surface

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.

Axillary lymph node, metastatic

carcinoma - Medium power

Tumor in afferent lymphatics

and subcupsular sinus

1. Review breast anatomy

and histology.
Describe normal breast histology.

Infant breast tissue

Life cycle changes

Anatomic origins of
common breast lesions

2. Compare and contrast the following

inflammatory diseases with regard to etiology,
clinical features, and histopathology:
Acute mastitis
Duct ectasia
Traumatic fat necrosis

2. Compare and contrast the following

inflammatory diseases with regard to etiology,
clinical features, and histopathology:
Acute mastitis

Duct ectasia

Traumatic fat
necrosis

Occurs during the

first month of breast
feeding, local
bacterial infection

Occur in the fifth or

sixth decade of life,
usually in
multiparous women

About half of
affected women
have a history of
breast trauma or
prior surgery

Clinical features The breast is

erythematous and
painful, and fever is
often present.

Palpable periareolar
mass +- thick, white
nipple secretions,
skin retraction.

Painless palpable
mass, skin
thickening,
retractions,
calcifications

Histopathology

Duct ectasia. Chronic

infl and fibrosis
surround an ectatic
duct filled with

1.Hemorrhagic
2.Proliferating
fibroblasts
3.Giant cells,

Etiology

Staph abscesses
may be single or
multiple Strep cause
spreading infection

Ductal ectasia

3. Define the following patterns of fibrocystic

changes, and explain their clinical significance:

Nonproliferative fibrocystic changes

Proliferative fibrocystic changes
Atypical ductal hyperplasia
Sclerosing adenosis

3. Define the following patterns of fibrocystic

changes, and explain their clinical significance:
Nonproliferative
fibrocystic changes

lumpy bumpy
a dense breast
benign histologic
findings, poorly
defined lump

(1) cystic change,

often apocrine
metaplasia, (2)
fibrosis, and (3)
adenosis.

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)

A normal duct or acinus

Apocrine cysts &

Epithelial hyperplasia

Sclerosing adenosis &

Complex sclerosing lesion

What histologic features distinguish proliferative

from nonproliferative fibrocystic change?
Nonproliferative changes include
o stromal fibrosis and cyst formation;

Proliferative changes include

o The nonproliferative changes plus epithelial hyperplasia and
sclerosing adenosis.

ADH & ALH

4. Compare and contrast the following tumors with

regard to morphology and clinical features:
Fibroadenoma
Phyllodes tumor
Intraductal papilloma

4. Compare and contrast the following tumors with

regard to morphology and clinical features:

Epidemiology

Fibroadenoma

Phyllodes tumor

Intraductal
papilloma

Women in their 20s

and 30s, and they
are frequently
multiple and
bilateral.

Most present in the

sixth decade, 10 to 20
years later than the
peak age for
fibroadenomas

About half of
affected women
have a history of
breast trauma or
prior surgery

Clinical features Young women

Detected as palpable
present w a palp
masses, but a few are
mass and older
found by mammo
women w a mammo
density, calcific

80% of large duct

papillomas
produce a nipple
discharge. Bloody
or serous.

Histopathology

Papillomas grow
within a dilated
duct and are
composed of
multiple branching

myxoid stroma
resembles normal
intralobular stroma.
(pericanicular
pattern) or

like fibroaden, arise

from intralobular
stroma, but are much
less common, with
higher tumor grade

Fibroadenoma &
Phyllodes tumor

Intraductal papilloma

5. Know the incidence of carcinoma of the female

breast
And describe what effect family history of breast
cancer has.
List at least three other risk factors.

6. Compare and contrast the pathologic features,

relative incidence, and prognosis of the following
types of breast carcinoma:

high-grade ductal carcinoma in situ

low-grade ductal carcinoma in situ
lobular carcinoma in situ
infiltrating ductal carcinoma
infiltrating lobular carcinoma.

6. Compare and contrast the pathologic features,

relative incidence, and prognosis of the following
types of breast carcinoma:
Pathologic
features

Relative
incidence

Prognosis

high-grade ductal
carcinoma in situ

Aassoc with large

central zones of
necrosis and calcif
fills several ducts.

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

lobular carcinoma Same as ALH,

in situ
infiltrating ductal
carcinoma
infiltrating lobular

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

DCIS high grade &

low grade

7. Describe how stage and grade of tumor relate to

the clinical course of breast cancer.
List six clinical or pathologic features that predict
poor survival in breast cancer.
Know what molecular marker affects prognosis.

8. Define gynecomastia.

Symptoms of breast disease and

presentation of breast cancer