Endocrine Overview

I.                     Dispersed Endocrine System

a.        Neuroendocrine Tumors

                                                               i.      Carcinoids

                                                             ii.      Islets of Langerhans

1.        Insulinomas

2.        Gastrinomas

3.        Paraganglion system

b.        Multiple Endocrine Neoplasia Syndromes

                                                               i.      MEN I (Wermer Syndrome)

                                                             ii.      MEN IIA (Sipple Syndrome)

                                                           iii.      MEN IIB (MEN III)

                                                            iv.      Familial Medullary Thyroid Cancer

II.                   Adrenal

a.        Normal

                                                               i.      Cortex

                                                             ii.      Medulla

b.        Adrenocortical Hypofunction

                                                               i.      Primary Acute (Waterhouse-Friderichsen syndrome)

                                                             ii.      Primary Chronic (Addison’s Disease)

                                                           iii.      Secondary Adrenocortical Insufficiency

c.        Adrenocortical Hyperfunction

                                                               i.      ACTH

1.        Cushing’s Syndrome

2.        Cushing’s Disease

3.        ACTH-independent Cushing’s Syndrome

4.        ectopic ACTH production

                                                             ii.      Hyperaldosteronism

1.        Primary (Conn’s syndrome)

2.        Secondary

                                                           iii.      Adrenogenital Syndrome

1.        Congenital Adrenal Hyperplasia

d.        Neoplasms

                                                               i.      Cortical

1.        Adrenocortical Adenoma

2.        Adrenocortical Carcinoma

3.        Myelolipoma

                                                             ii.      Medullary

1.        Pheochromocytoma

a.        sporadic

b.        familial

2.        Paraganglioma

3.        Neuroblastoma

III.                 Diabetes Mellitus

IV.                 Pituitary

a.        Hypofunction

b.        Hyperfunction

                                                               i.      ACTH

                                                             ii.      Growth Hormone

                                                           iii.      Prolactin

                                                            iv.      End-organ dysfunction

c.        Non-functional Pituitary Tumors

V.                   Parathyroid

a.        Hypoparathyroidism

                                                               i.      Pseudohypoparathyroidism

b.        Hyperparathyroidism

                                                               i.      Adenoma

                                                             ii.      Carcinoma

                                                           iii.      Primary Hyperplasia

                                                            iv.      Secondary Hyperplasia

                                                              v.      Tertiary Hyperplasia

VI.                 Thyroid

a.        Normal

b.        Hypothyroidism

                                                               i.      Cretinism

                                                             ii.      Myxedema

1.        Hashimoto’s Thyroiditis

2.        Riedel Thyroiditis

c.        Hyperthyroidism (Thyrotoxicosis)

                                                               i.      Graves Disease

                                                             ii.      Subacute (Granulomatous) Thyroiditis = de Quervain Thyroiditis

d.        Goiter

                                                               i.      Diffuse nontoxic (simple or hyperplastic) goiter

1.        Endemic Goiter

2.        Sporadic Goiter

                                                             ii.      Multinodular Goiter

e.        Thyroid Nodules

                                                               i.      Benign

                                                             ii.      Follicular Adenoma

                                                           iii.      Carcinomas

1.        Papillary Carcinoma

2.        Follicular Carcinoma

3.        Medullary Carcinoma

4.        Anaplastic Carcinoma

VII.               Breast

a.        Benign Breast Disease

                                                               i.      fibrocystic change

                                                             ii.      sclerosing adenosis

                                                           iii.      fat necrosis

                                                            iv.      papillomas

                                                              v.      fibroadenomas

                                                            vi.      duct ectasia

                                                          vii.      phyllodes (leaf-like) tumors

b.        Breast Cancer

                                                               i.      DCIS

                                                             ii.      LCIS

                                                           iii.      Invasive Carcinoma

1.        Ductal

2.        Lobular

3.        Mucinous

4.        Medullary

5.        Tubular

6.        Cribriform

7.        Adenoid Cystic

 

I.                     Dispersed Endocrine System

most usual secretory products are polypeptides (but also include amines)

a.        Neuroendocrine Tumors

APUD (amine, amine precursor uptake, amino acid decarboxylase)

zellballen

amyloid of tumor origin found in medullary carcinoma of thyroid, islet cell tumors of pancreas

 

Neuroendocrine Cells

Tumors

Centrally located Cells (neural tube)

 

hypothalamus

?

posterior pituitary

?

anterior pituitary

adenomas (Cushing’s, acromegaly)

pineal

pinealoma

Neural Crest Derived

 

Thyroid c-cells

medullary carcinoma (?)

adrenal medulla and related paraganglia

- Pheochromocytoma (hypertension)

- Neuroblastoma

Carotid body and related paraganglia

Carotid body tumor

Melanocytes

melanoma

Enteric cells (uncertain origin – not neural crest)

 

lung

carcinoid

oat cell carcinoma (Cushing’s, etc.)

stomach

carcinoid

intestine

carcinoid

large bowel and appendix

carcinoid

pancreatic islets

adenoma or carcinoma (insulinoma, ZE, etc.)

salivary glands

?

 

                                                               i.      Carcinoids

derived from Kultchitsky cells found in deep mucosa of alimentary canal, biliary tract, and bronchus

carcinoid syndrome (5-HT): flushing, diarrhea, asthma, valvular stenosis

liver usually detoxifies released substances (unless carcinoid is large)

                                                             ii.      Islets of Langerhans

1.        Insulinomas

paroxysmal hypoglycemia

usually solitary, tail

2.        Gastrinomas

extreme hyperacidity

Zollinger-Ellison Syndrome: intractable peptic ulcer disease

3.        Paraganglion system

cells of this system migrate from neural cost with autonomic nervous system

distribution: posterior midline, orbit, lung, urinary bladder, great vessels

-          above diaphragm: usually sensory

-          below diaphragm: usually secretory

most common site: adrenal (then organ of Zuckerkandl arising from paraganglia around distal aorta)

most secreting tumors are neuroendocrin (chromaffin): secrete catecholamine

4.        Vipoma

Vasoactive Intestine Poplypeptide (VIP)

watery diarrhea, hypokalemia, achlorhydria (WDHA syndrome = Verner-Morison syndrome)

5.        Glucagonoma

b.        Multiple Endocrine Neoplasia Syndromes

autosomal dominant (characterized by hyperplasias or neoplasms of multiple endocrine organs)

                                                               i.      MEN I (Wermer Syndrome)

chromosome 11

parathyroid, pancreas, pituitary (3P’s)

1.        primary hyperparathyroidism: hyperplasias and adenoma

2.        pancreatic islet cell tumors: wide variety of peptide hormones

3.        anterior pituitary tumors: usually prolactinomas

                                                             ii.      MEN IIA (Sipple Syndrome)

pheochromocytoma, medullary (thyroid) carcinoma, parathyroid hyperplasias

1.        medullary carcinoma: 100%; multifocal, Parafollicular C cell hyperplasia, aggressive

2.        pheochromocytomas: 50%; bilateral and may be extra-adrenal

3.        parathyroid hyperplasia: 10-20%, stones, hypercalcemia, linked to RET proto-oncogene

                                                           iii.      MEN IIB (MEN III)

Clinically similar to MEN IIA (with neuromas involving skin, oral mucosa, eyes, respiratory tract, GI tract)

different RET proto-oncogene

                                                            iv.      Familial Medullary Thyroid Cancer

variant of MEN IIA with strong disposition to medullary thyroid cancer (but other clinical manifestations are absent)

II.                   Adrenal

a.        Normal

                                                               i.      Cortex

Derived from mesenchyme

Regions

1. Zona Glomerulosa

- narrow outer zone

- produces mineralocorticoids (aldosterone under angiotensin stimulation)

2. Zona Fasciculata

                - broad middle zone

                - produces gluocorticoids (cortisol through ACTH stimulation)

3. Zona Reticularis

                - narrow inner zone

                - produces sex steroids (estrogen and androgen via ACTH stimulation)

                                                             ii.      Medulla

Derived from neural crest

Lie bilaterally on superomedial aspect of the kidneys

Neuroendocrine (chromaffin) cells [synthesize and secrete catecholamines: norepinephrine and epinephrine]

- surrounded by sustentacular cells

Ectopic tissue may be found in retroperitoneum, spermatic cord, hernia sacs, under liver capsule

Blood supply: arterial branches of the renal and inferior phrenic arteries

b.        Adrenocortical Hypofunction

                                                               i.      Primary Acute (Waterhouse-Friderichsen syndrome)

uncommon (children)

etiology: DIC with hemorrhage

treatment: antibiotics

massive hemorrhage secondary to bacterial infection (Neisseria meningitides) – death within hours/days

                                                             ii.      Primary Chronic (Addison’s Disease)

etiology: Autoimmune (60-70%) [also: granulomatous disease (Tb, fungus), amyloid, neoplasm]

epidemiology: white women

signs/symptoms (occur after 90% destruction of cortices): weakness, fatigue, anorexia, nausea, vomiting

- mineralocorticoids: hyponatremia, hyperkalemia, hypotension, volume depletion

- glucocorticoids: hypoglycemia

- decreased urinary steroids

- increased ACTH and ACTH precursor hormone (melanocytes stimulation à hyperpigmentation)

                                                           iii.      Secondary Adrenocortical Insufficiency

Any disorder of hypothalamus/pituitary that decreases ACTH (neoplasia, infection)

- no hyperpigmentation

- decreased ACTH à decreased glucocorticoids and androgens

- normal aldosterone (under angiotensin control) so no hyponatremia or hyperkalemia

c.        Adrenocortical Hyperfunction

                                                               i.      ACTH

1.        Cushing’s Syndrome

most common cause of hyperfunction

etiology: iatrogenic administration of glucocorticoids (à atrophy due to ACTH suppression)

produces increased plasma cortical and urinary 17-OH steroids which are not suppressed by low dose dexamethasone

symptoms: moon facies, truncal obesity, DM, hypertension, muscle wasting, osteoporosis, skin changes (easy bruising, striae, acne, virilization, hirsutism – hair growth in women), menstrual changes

diagnose source by determining ACTH levels and response to dexamethasone (inhibits pituitary ACTH production)

a.        Cushing’s Disease

Most common cause of endogenous hypercortisolism

Due to a small ACTH producing pituitary adenoma (or CRF by hypothalamus)

F>M, 20-30

Diffuse hyperplasia of adrenals

increased ACTH

Suppresses with high dose dexamethasone

b.        ACTH-independent Cushing’s Syndrome

hypersecretion of cortisol due to adrenal neoplasia/hyperplasia

low ACTH

nonsuppression with high dose dexamethasone

adjacent cortex (and contralateral gland): atrophic

c.        ectopic ACTH production

small cell carcinoma of lung

carcinoid

medullary thyroid carcinoma

diffuse hyperplasia of adrenals

M>F, 40-50 yo

increased ACTH, nonsuppression with high dose dexamethasone

                                                             ii.      Hyperaldosteronism

1.        Primary (Conn’s syndrome)

small aldosterone producing adenoma

(aldosterone causes sodium retention and potassium loss à hypertension)

suppressed rennin-angiotensin system (decreased plasma renin activity)

hypertension, hypernatremia, hypokalemia, decreased plasma renin

F>M

2.        Secondary

increased plasma renin causes

etiology: CHF, decreased renal perfusion

                                                           iii.      Adrenogenital Syndrome

virilizing syndromes associated with excess androgens

1.        Congenital Adrenal Hyperplasia

- autosomal recessive (lack of secretion of cortisol and/or aldosterone à compensatory overproduction of precursor androgenic steroids)

- due to decreased cortisol, ACTH is increased à adrenal hyperplasia

21-hydroxylase defect

- responsible for 90% of cases

- virilism due to increased androgens

- 30-50% severe salt-losing due to decreased mineralocorticoids (aldosterone)

d.        Neoplasms

                                                               i.      Cortical

1.        Adrenocortical Adenoma

< 50 grams

non-functional

2.        Adrenocortical Carcinoma

> 100 grams

rare; abdominal mass + pain

large, yellow, cystic, hemorrhagic and necrotic

no single parameter short of metastasis can discern benign from malignant

50% are functional

hematogenous spread > lymphatic spread

5-year survival: 20-35%

3.        Myelolipoma

adipose + bone, non-functioning

                                                             ii.      Medullary

1.        Pheochromocytoma

10% tumour (10% bilateral: familial, extraadrenal=paraganglioma, children, malignant)

norepinephrine: hypertension

epinephrine: anxiety, sweating, palpitations, dizziness

increased urinary excretion of free catecholamines and VMA

paroxysmal HTN (some: sustained HTN); flushing, tachycardia, palpitations

well-circumscribed, pinkish-gray (or yellow-tan) with hemorrhage, necrosis, cysts

zellballen (micro-chromaffin cells arranged in nests, surrounded by vascular network)

no morphologic markers other than metastases are indicators of malignancy

S-100 staining

diagnosis: urine, increased catecholamines (don’t press on abdomen)

a.        sporadic

older, women, 10% bilateral

b.        familial

younger, men, 70% are bilateral,

associated with MEN IIA, IIB and Chr. 22 mutations

neurofibromatosis, von Hippel-Lindau disease, Sturge-Weber syndrome

2.        Paraganglioma

an extra-adrenal pheochromocytoma (vagal, carotid, etc.)

10% are non-functional (none produce epinephrine)

most common location: organ of Zuckerkandl (proximal to desc. aortic bifurcation)

most common location above diaphragm: carotid body

younger age, multicentric

more often malignant

3.        Neuroblastoma

childhood: 80% (< 4 yo)

large, soft gray well-circumscribed

small uniform hyperchromatic (blue) cells arranged in nests and rosettes

dystrophic calcification

NSE, chromogranin, synaptophysin

N-myc oncogenes

spread to liver, skeletal system, lymph

good prognosticators: <2 yo, extra-adrenal, stage, absence of N-myc amplification

[small blue cell tumors include: neuroblastoma, Wilm’s tumor, lymphoma, medulloblastoma, Ewing’s sarcoma]

III.                 Diabetes Mellitus

diabetes is a vascular disease; promotes atherosclerosis

have a 2-3X increase in MI, cerebral infarction, sudden death, peripheral vascular disease, ESRD, neuropathy and blindness

microvascular disease à foot disease (neuropathy, retinopathy, nephropathy)

management: 1) glucose control; 2) blood pressure control

other associated killers: ketoacidosis, infection

Type I: B-cell depletion

        - HLA linked

Type II: deranged B-cell secretion and peripheral insulin resistance (no HLA association)

        - linked to obesity and hyperlipidemia

        - Women, Blacks (also ESRD), Pima Indians, Hispanics

Complications

* Atherosclerosis (aorta and muscular arteries)

        - qualitatively similar to non-diabetics (but much more severe)

        - hyperlipidemia, low HDL, increased hypertension, increased platelet adhesion, glycosylation of plasma lipoproteins

        - à gangrene of lower extremities

        - risk is increased in smokers

        - CVA risk (lenticulostriate branches of MCA and perforating branches of basilar a.) à lacunar infarcts

* Microvascular disease (MI: most common cause of death in diabetic patients)

        - AGE (advanced glycation end products) bind to proteins and confer resistance to proteolysis

        - high glucose and altered hormones increase matrix synthesis

        - diffuse thickening of capillary basement membranes (leaky to plasma proteins)

        1. Foot Disease

                        - gangrene

                        - responsible for 1/5 of diabetic hospitalizations

                        - caused by minor breaks, improper nail care, small burns, poorly-fitting footwear

                        - podiatrist on the team decreases need for amputations

                        - neuropathy causes loss of sensation, motor and autonomic functions (pressure sores, burn blisters, ulcerations)

                        - vessel disease causes ischemia and atrophy of skin (small vessel flow compromise)

2. Neuropathy

                - progression is halted by pancreatic transplantation

                - symmetrical sensorimotor > autonomic > mononeuropathy > truncal

                                - sensorimotor: loss of sensation and muscle atrophy (pain in extremities)

                                - autonomic: diarrhea, postural hypotension, gastroparesis, cystopathy, impotence, gastroparesis

                                - mononeuropathy: unilateral foot drop, wrist drop, cranial nerve palsies, etc.

                                - truncal neuropathy: unilateral or bilateral pain (misinterpreted as cardiac or gastrointestinal disease)

                - pathogenesis: microvascular disease and metabolic injury

                - à axonal degeneration and segmental demyelination

3. Eye Disease

                                                - DM: single most common cause of blindness in 30-64 yo

                                                - 10% of blind have diabetes

                                                - cotton wool spots (hypoperfusion à hemorrhages)

                                                - neovascularization (VEGF): vessels extend into vitreous à fibrosis, retinal detachment

                                                - anti-VEGF treatment is promising

4. Kidney Disease

                - major cause of death in diabetics

                - diabetic nephropathy: most common cause of new ESRD

                - symptoms: microalbuminuria à proteinuria (loss of GFR)

                - hyalinization of afferent and efferent arterioles (thickened GBM and mesangial matrix expansion)

                - nodular expansions = Kimmelstiel-Wilson nodules

                        Treatment

                                1. Tight glucose control

                                2. Blood pressure control

                                3. foot care

                                4. pancreas transplant, islet cell transplant (Type I DM)

 

IV.                 Pituitary

anterior pituitary: GH, somatotropin, ACTH

posterior pituitary: ADH

decreased ADH à diabetes insipidus à polyuria (kidney cannot reabsorb water; causes: trauma, tumors, inflammatory, surgery

inappropriate ADH secretion (may be ectopic) à hyponatremic, cerebral edema

a.        Hypofunction

usually from destruction of entire pituitary (infection, infarction, trauma, amyloid, replacement by neoplasm)

Sheehan’s syndrome (rare): post-partum necrosis

children: pituitary dwarfism, failure of sexual activity

b.        Hyperfunction

most common cause: a small tumor (microadenoma)

                                                               i.      ACTH

Cushing’s disease: hypercortisolism from excess ACTH from a pituitary (or hypothalamic) lesion

                                                             ii.      Growth Hormone

effects depend on timing relative to epihphyseal closure (gigantism vs. acromegaly)

GH also affects viscera à cardiomegaly, hepatomegaly (keep proportions)

GH is antagonistic to insulin à DM

                                                           iii.      Prolactin

most common pituitary adenoma; may go undetected in men and post-menopausal women

amenorrhea, galactorrhea

                                                            iv.      End-organ dysfunction

removal of the thyroid, adrenals, gonads, etc à overproduction of corresponding tropic hormone

hyperpigmentation can result from ACTH production (MSH activity)

c.        Non-functional Pituitary Tumors

20% of pituitary tumors

bilateral temporal hemianopsia

V.                   Parathyroid

calcium homeostasis

PTH à release of calcium from bone (bone reabsorption), renal reabsorption of calcium

a.        Hypoparathyroidism

iatrogenic (surgery), idiopathic (autoimmune), DiGeorge syndrome

                                                               i.      Pseudohypoparathyroidism

X-linked

symptoms: facies, hypocalcemia

normal or elevated levels of PTH

b.        Hyperparathyroidism

sporadic (95%) vs. MEN (5%)

nephrolithiasis is a complication

Brown’s tumour

“painful bones (bone pain/fractures), renal stones (nephrolithiasis), abdominal groans (GI motility), psychic moans (neuromuscular disorders)”

 

 

# glands

calcium

adenoma

1

­

primary hyperplasia

4

­

secondary hyperplasia

4

¯

tertiary hyperplasia

4

­

- differential for hypercalcemia: CHIMPS (cancer (bone), hyperparathyroidism, intoxication of Vit D, Milk-Alkali syndrome, Paget’s disease of bone, Sarcoidosis)

                                                               i.      Adenoma

most common form of primary hyperparathyroidism

elevated PTH, bone reabsorption

                                                             ii.      Primary Hyperlasia

autonomous production of PTH

usually chief cell hyperplasia

                                                           iii.      Secondary Hyperplasia

due to chronic renal disease

secondary to low calcium levels (from renal failure, inadequate diet, vitamin D deficiency, steatorrhea)

                                                            iv.      Tertiary Hyperplasia

due to chronic renal disease

autonomous secretion of PTH after correction of renal disease (PTH elevated, calcium elevated)

most common after renal transplant

treatment: removal

                                                              v.      Carcinoma

very rare

VI.                 Thyroid

a.        Normal

develops from evagination of pharyngeal epithelium (too little: lingual thyroid; too far: substernal thyroid)

TRH (hypothalamus) à TSH (anterior pituitary) à T3, T4 (thyroid) à suppression of TRH, TSH

T4 and T3 are bound to circulating plasma proteins (TBG) à upregulate carbohydrate and lipid metabolism

Parafollicular (C Cells) synthesize and secrete calcitonin: calcium bone absorption, osteoclast inhibition

b.        Hypothyroidism

causes:

primary (cretinism, Hasimoto’s, surgery, drug induced);

secondary: TSH deficiency, Sheehan’s syndrome (post-partum pituitary necrosis)

tertiary: TRH deficiency

                                                               i.      Cretinism

develops in infancy or early childhood

causes: iodine deficiency, inborn error of metabolism

symptoms: impaired skeletal, CNS development

                                                             ii.      Myxedema

hypoparathyroidism in later childhood or adult life

1.        Hashimoto’s Thyroiditis

gross: white, gray (lymphocytes)

autoimmune lymphocytic thyroiditis

anti-TSH receptor (blocks TSH action)

decreased T3, T4, increased TSH; diffuse enlargement

lymphocytic inflammation

HLA-DR5

thick, coarse, dry skin; slowing of speech and intellectual functions

Hurthle cell change (pink, enlarged cells)

small risk of subsequent B-Cell lymphoma

2.        Riedel Thyroiditis

unknown etiology

giant cells

replacement of thyroid parenchyma by dense fibrous tissue (penetrates capsule à contiguous neck structures)

glandular atrophy, hypothyroidism

c.        Hyperthyroidism (Thyrotoxicosis)

symptoms: cardiac (increased CO), ocular (Grave’s only), neuromuscular (fine tremor), skin, gastrointestinal (diarrhea)

                                                               i.      Graves Disease

most common cause of endogenous hyperthyroidism

deep red, enlarged thyroid!!!

autoimmune; test: anti-TSH receptor Abs

increased T3, T4

hypertrophy and hyperplasia of follicular epithelium

histology: scalloped-colloid appearance

increased cardiac output, arrhythmias, exophthalmos (eyes bulge), dermatopathy (pretibial myxadema)

20-40 yo women

                                                             ii.      Subacute (Granulomatous) Thyroiditis = de Quervain Thyroiditis

30-50 yo women  (3:1)

pain in the neck (radiates to jaw, throat, ears)

fever, fatigue, anorexia, myalgias

thyroid inflammation à hyperthyroidism à symptoms à hypothyroidism à normal (2-8 weeks)

d.        Goiter

involves follicular epithelium

most patients are euthyroid

problems swallowing

etiology: usually iodine deficiency

evolution has 2 stages: 1) hyperplastic stage; 2) colloid involution

(don’t need to memorize hereditary enzymatic defects)

                                                               i.      Diffuse nontoxic (simple or hyperplastic) goiter

1.        Endemic Goiter

low iodine

2.        Sporadic Goiter

goiterogens

                                                             ii.      Multinodular Goiter

produces most extreme enlargements of the goiter (>2000 grams)

e.        Thyroid Tumors

most are benign

solitary: more likely to be neoplastic

solitary nodules more common in women

younger: more likely to be neoplastic

men: more likely to be neoplastic than those in women

Hx of radiation associated with malignancy

Hot = “functioning” are more likely to be benign; 10% of cold nodules are malignant

                                                               i.      Benign

1.        Follicular Adenoma

most common cause of solitary nodule

usually non-functional

diagnosis of malignant counterpart based on invasion

                                                             ii.      Carcinomas

usually well-differentiated (non-aggressive)

early to middle-aged women

risk factor: exposure to ionizing radiation, Hashimoto’s, multinodular goiter

1.        Papillary Carcinoma

most common (any age)

history of radiation

solitary or multifocal

10-year survival: 98%

metastasize via lymphatics

activation or mutation of RET

overlap of follicular nuclei

Psamomma bodies

2.        Follicular Carcinoma

metastasize hematogenously

second most common

female 40-50 yo

capsular or vascular invasion distinguishes from adenoma

worse prognosis (5-yr: 30%)

3.        Medullary Carcinoma

arise from parafollicular C Cells (à elevated calcitonin)

calcitonin can be used as a tumor marker

amyloid seen in these tumors (calcitonin sheets)

80% sporadic, 20% familial (MEN IIA, IIB)

4.        Anaplastic Carcinoma

dismal prognosis

VII.               Breast

a.        Benign Breast Disease

                                                               i.      fibrocystic change

cyst formation

hyperplasia without atypia

apocrine change

4th and 5th decades (decreased with post-menopausal parenchymal atrophy)

                                                             ii.      sclerosing adenosis

acini (glandular spaces) are increased in number

                                                           iii.      fat necrosis

traumatic etiology

                                                            iv.      papillomas

benign duct lesions

nipple discharge

                                                              v.      fibroadenomas

circumscribed, benign tumors

third decade

                                                            vi.      duct ectasia

plasma cell mastitis

inflammatory condition of major ducts

symptomatic with pain, with or without lump

                                                          vii.      phyllodes (leaf-like) tumors

= benign cystosarcoma phyllodes

closely related to fibroadenomas

large size, dominant stromal component (usually myxoid)

b.        Breast Cancer

risk factors: age, family history, reproductive/hormonal history, prior history for breast cancer, proliferative breast disease

                                                               i.      LCIS

multifocal, bilateral

incidental

later cancer development in either breast

                                                             ii.      DCIS

focal, unilateral

mammogram, nipple discharge, palpable lump

cancer development same area as DCIS (sometimes many years after DCIS)

calcium deposits + caseous necrosis = higher grade (comedo type: likely to recur after mastectomy)

low-grade (non-comedo type: unlikely to recur after mastectomy)

Paget’s disease: DCIS extending to nipple surface (eczematous appearance)

                                                           iii.      Invasive Carcinoma

stage: (“N” of TNM is most important for long-term prognosis) lymph node metastases, size, invasion of skin or fascia, local edema and heat (inflammatory breast cancer)

menopausal status, grade, steroid hormone receptor status (ER and PR) of tumor

growth fraction

Her-2-neu (growth factor) over-expression

1.        Ductal

2.        Lobular

3.        Mucinous

4.        Medullary

5.        Tubular

6.        Cribriform

7.        Adenoid Cystic

                                                            iv.      Primary Sarcoma

rare (prior radiation exposure)

malignant cystosarcoma phyllodes = unique sarcoma of breast

 

Risk factors for breast cancer: age, 1st degree relative, proliferative breast disease, genetic factors: BRCA1, BRCA2

Benign Breast Disease: fibrocystic changes, papillomas (ducts; nipple discharge); fibroadenomas (3rd decade, circumscribed, benign tumors)

Breast Carcinoma:

                DCIS: neoplastic proliferatioin in ducts; not life-threatening; comedo subtype (necrosis in center, high grade, recur) vs. noncomedo subtype (low grade, rarely recur); increased risk for associated or future invasive CA; recurrence related to size and margins; Paget’s disease: DCIS of nipple

                LCIS: lobular (not emphasized for exam)

                Invasive Carcinoma: no special type (ductal, 70%) vs special types (lobular, mucinous, medullary); prognosis related to stage (size; lymph node status single most important prognostic factor)