Practice question answers Pathology of breast I
Practice question answers
Pathology of breast I
© Jun Wang, MD, PhD
1. C. The clinical
presentations of pain, erythematous and edematous changes are supportive of
inflammatory process. Although she has a family history of cancer, no other
evidence of neoplasm is noted. The post-partum status and presence of nipple
crackers are more commonly associated with acute
mastitis. The axillary lymphadenopathy is most likely reactive. The
most characteristic pathological findings of any acute inflammation is diffuse
neutrophilic infiltrate. Atypical cell forming single files are seen in invasive
lobular carcinoma. Calcifications are nonspecific degenerative
changes that can be seen in fibrocystic
changes, inflammations, and carcinomas.
Finger like projects with normal appearing cells are seen in benign papillary
lesions, including usual
ductal hyperplasia and intraductal
papilloma. Irregular glands infiltrating stroma is characteristic
for adenocarcinoma, including invasive
carcinoma of breast with ductal differentiation.
2. A. Acute
mastitis is most commonly caused by bacterial infection. BRCA
mutation is associated with various malignancies, especially breast
and ovarian
carcinomas. Glucose intolerance is seen in diabetes and diabetic
mastopathy. High level of testosterone is seen in polycystic
ovary disease, stromal
hyperthecosis and certain ovarian sertoli-Leydig
cell tumor. Elevated estrogen effect is associated with ductal
hyperplasia and some breast
cancer, but not acute
mastitis.
3. A. See discussion in question 1. Inflammatory
carcinoma is caused by lymphatic vessel blockade by tumor cells. It usually
has signs or radiologic findings of a underlying malignancy.
4. D. Dense lymphocytic infiltration
surrounding normal appearing ducts is consistent with diabetic
mastopathy, especially in a patient with type I diabetes. Acute
mastitis is characterized by neutrophilic infiltration. Ductal
ectasia has dilated ducts with fibrotic wall, benign epithelial
lining, proteinaceous contents and foamy macrophages, but dense lymphocytic
infiltration is uncommon. Chronic
lymphocytic leukemia/Small lymphocytic lymphoma is characterized by
monotonous small lymphocytic proliferation.
5. E. Lymphocytic
mastopathy is associated with diabetes, especially type 1 diabetes.
Other conditions may be associated with neoplasms.
6. A. Ductal
ectasia has dilated ducts with fibrotic wall, benign epithelial
lining, proteinaceous contents and foamy macrophages, but dense lymphocytic infiltration
is uncommon. Fat
necrosis is commonly associated with trauma, and morphologically has
multinucleated giant cells and necrotic adipose tissue, but not ductal
dilation. Intraductal
papilloma usually located at retreareolar area, and has papillary
growth with fibrovascular core covered by benign ductal cells. Lobular
carcinoma in situ is characterized by dilated terminal ducts filled
with E-cadherin negative, loosely cohesive cells. Lymphocytic
mastopathy has dense lymphocytic infiltration surrounding normal
appearing ducts and is associated with diabetes.
7. C. Although the patient has a history of
cancer, and recurrence definitely need to be ruled out, the lack of cytokeratin
positive epithelial suggest no carcinoma components are present. The history of
trauma (surgery) and the presence of foamy histiocytes and multinucleated giant
cells are more compatible with fat
necrosis. Angiosarcoma
is characterized by complex vascular growth with atypical endothelial cells. Ductal
ectasia has dilated ducts with fibrotic wall, benign epithelial
lining, proteinaceous contents and foamy macrophages. Intraductal
papilloma usually located at retreareolar area, and has papillary
growth with fibrovascular core covered by benign ductal cells. Inflammatory
carcinoma is caused by lymphatic vessel blockade by tumor cells. It usually
has signs or radiologic findings of an underlying malignancy.
8. C. Although the clinical information and
family history are suggestive of malignancy, biopsy findings of
lymphoplasmacytic infiltrate with multinucleated giant cells are compatible
with a granulomatous inflammatory process. Once fungal and AFB infections are
ruled out, it is most likely idiopathic
granulomatous mastitis. Acid-fast bacilli infection usually can be detected
by special stain and other microbiology studies. Inflammatory
carcinoma is caused by lymphatic vessel blockade by tumor cells. It usually
has signs or radiologic findings of an underlying malignancy. Zuska’s
disease is a periareolar absecess.
9. B. Fibrocystic
changes is a group of pathological processes including stromal
fibrosis and cyst formation. Usual
ductal hyperplasia has increased layers of ductal epithelial cells. Intraductal
papilloma usually located at retroareolar area, and has papillary
growth with fibrovascular core covered by benign ductal cells. Invasive
ductal carcinoma has ducts with irregular shape and irregular arrangement,
suggestive of stromal invasion. Lymphocytic
mastopathy has dense lymphocytic infiltration surrounding normal
appearing ducts and is associated with diabetes.
10. B. A retroareolar mass in male is most
commonly gynecomastia,
unless evidence of other abnormalities are seen. It is characterized by stromal
hypertrophy with scattered ducts, with or without ductal hyperplasia. Ductal
ectasia has dilated ducts with fibrotic wall, benign epithelial
lining, proteinaceous contents and foamy macrophages. Invasive
ductal carcinoma has ducts with irregular shape and irregular arrangement,
suggestive of stromal invasion. Invasive
lobular carcinoma has atypical epithelial cells forming single files
in stroma. Tubular
carcinoma is a very well differentiated invasive cancer with
irregular ducts lined by normal appearing ductal cells.
11. E. This is a case of florid type usual
ductal hyperplasia with increased ductal epithelial cells almost filled
ductal lumen, and irregular spaces at periphery, as confirmed by
immunohistochemistry studies of positive reactivity to keratin 903. Atypical
ductal hyperplasia has more monotonous cells with or without REGULAR
spaces, usually cribriform appearance. Ductal
carcinoma in situ has relatively monotonous cells in low grade, and mark
pleomorphic ductal cells in high grade groups. Both atypical
ductal hyperplasia and ductal
carcinoma in situ are negative for keratin 903. Fibrocystic
changes is a group of pathological processes including stromal
fibrosis and cyst formation. Invasive
lobular carcinoma has E-cadherin negative atypical epithelial cells forming single files in stroma.
In addition, presence of intact myoepithelial layers, as shown by positive
reactivity to CD10 and p63, rules out invasion.
12. D. No treatment is needed for usual
ductal hyperplasia. Hormonal therapy, mastectomy and radiation therapy are
for malignancies. Excisional biopsy is recommended for atypical
ductal hyperplasia or intraductal
papilloma found in core biopsies, to rule out accompanied
malignancies that are not sampled during core biopsy process.
13. A. The picture of a few ducts filled with
monotonous cells with cribriform appearance, positive reactivity to E-cadherin
and negative reactivity to keratin 903 is most compatible with atypical
ductal hyperplasia. It will be named ductal
carcinoma in situ if more ducts are involved, or the area is larger. Fibrocystic
changes is a group of pathological processes including stromal
fibrosis and cyst formation. Invasive
ductal carcinoma has ducts with irregular shape and irregular arrangement,
suggestive of stromal invasion. Invasive
lobular carcinoma has E-cadherin negative atypical epithelial cells forming single files in stroma.
In addition, presence of intact myoepithelial layers, as shown by positive
reactivity to CD10 and p63, rules out invasion. Usual
ductal hyperplasia has increased ductal epithelial cells that may fill
ductal lumen, and irregular spaces at periphery, as well as positive reactivity
to keratin 903.
14. A. See discussion in question 12.
15. A. See discussion in question 13.
16. D. Increased small ducts with intact
myoepithelial layer in a fibrotic background is most likely sclerosing
adenosis. Fibroadenoma
has ductal proliferation and the ducts are usually compressed in a markedly
proliferated fibrous background. Invasive
ductal carcinoma has ducts with irregular shape and irregular arrangement,
suggestive of stromal invasion. Radial
scar is characterized by a central fibrous core with normal ducts regularly
radiating toward periphery. Tubular
carcinoma is a very well differentiated invasive cancer with
irregular ducts lined by normal appearing ductal cells.
17. D. See discussion in question 12.
18. C. Radial
scar is characterized by a central fibrous core with normal ducts regularly
radiating toward periphery. They have intact myoepithelial layers that can be
seen by CD10 or p63 stain. Fibroadenoma
has ductal proliferation and the ducts are usually compressed in a markedly
proliferated fibrous background. Invasive
ductal carcinoma has ducts with irregular shape and irregular arrangement,
suggestive of stromal invasion. Sclerosing
adenosis has increased small normal ducts with intact myoepithelial layer
in a fibrotic background. Tubular
carcinoma is a very well differentiated invasive cancer with
irregular ducts lined by normal appearing ductal cells.
19. A. Biopsy finding of radial
scar usually do not need any treatment, unless it is big or malignancy is a
concern. Lumpectomy with axillary lymph node dissection is for invasive cancers.
See discussion in question 12 as well.
20. B. Bloody nipple discharge is indicative
for intraductal
papilloma, that usually located at retreareolar area, and has
papillary growth with fibrovascular core covered by benign ductal cells. Fibrocystic
changes is a group of pathological processes including stromal
fibrosis and cyst formation. Lobular
carcinoma in situ is characterized by dilated terminal ducts filled
with E-cadherin negative, loosely cohesive cells.
21. A. See discussion in question 12.
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