USMLE Presentation: Pathology of Breasts and Hearts Monday

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USMLE PresentationPathology ofBreasts and
Hearts

• Monday, February 27th, 2006
• Jou Jou Hanna

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Breast Diseases

• A. Fibrocystic Disease
• B. Benign Tumors
• C. Malignant Tumors
• (Risk Factors)

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A. Fibrocystic Disease

• Presents normally with
• - diffuse breast pain
• - multiple lesions, often bilateral
• Four Histologic Types
• Fibrosis (stroma)
• Cystic (fluid)
• Sclerosing (? acini intralobular fibrosis)
• Epithelial Hyperplasia (? risk of carcinoma with
  atypical cells)

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Mostly benign and common change within the
breast. May need mammogram or biopsy to rule out
other diseases
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Epithelial Hyperplasia

• Is there risk of carcinoma here?
• YES!!!!!

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B. Benign Tumors

• Fibroadenoma
• -most common tumor lt 25 y/o, usually seen in
  pregnancy
• -small, moble, firm mass
• -NOT a precursor to breast cancer
• Cystosarcoma Phy LL odes
• -Large, Leaflike projections
• Intraductal Papilloma
• -tumor of lactiferous ducts, presents with
  nIpple discharge.

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• usually benign and typically stop growing after
  only reaching a few centimeters in diameter
  fibroadenomas are often left alone after they are
  diagnosed. Even without treatment, approximately
  10 fully recede each year .

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Which do you think is cystosarcoma phyllode,
which is intraductal papilloma?
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C. Malignant Tumors (carcinoma)

• Risk Factors?
• -Gender.so it would affect ME, more than Levi!

?
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Risk Factors cont

• Age
• Early 1st menarche (lt 12 y/o)
• Delayed 1st pregnancy (gt 30 y/o)
• Late menopause (gt 50 y/o)
• Fm Hx of 1st-degree relative with breast cancer
  at a young age
• Is risk ? or ? with fibroadenoma or
  nonhyperplastic cysts???
• NOOOOO!!!! Risk is not increased.

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Malignant Tumors cont

• Common Postmenopause
• Arises from mammary duct epithelium or lobular
  glands
• Overexpression of estrogen/progesterone receptors
  or erb-B2 (HER-2, an EGF receptor)
• Women have 2 Breasts

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Malignant Tumors cont

• Histologic Types
• Ductal Carcinoma In Situ (DCIS)
• Invasive ductal (MOST COMMON)
• Comedocarcinoma
• Inflammatory
• Invasive lobular
• Medullary
• Pagets Disease of the Breast
• (eczematous patches on nipple,
• not common, usually unilateral)

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II. Cardiovascular Pathology

• A. Hypertension
• B. Arteriosclerosis
• C. Ischemic Heart Disease
• D. Infarcts red vs. pale

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II. Cardiovascular Pathology

• A. Hypertension
• 1. Definition - high blood pressure with
  guidelines of gt 140 mmHg systolic gt 90 mmHg
  diastolic
• Normal??
• lt 120 lt 80 mmHg
• Prehypertensive??
• 120-139/80-89 mmHg

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II. Cardiovascular Pathology

• 2. Risk Factors
• ? age, diabetes, smoking, genetics,
• gt gt
• Blacks gt White
  gt Asians

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II. Cardiovascular Pathology

• A. Hypertension
• 3. Features
• 90 of HTN is primary - ? CO or ? TPR
• 10 of HTN is secondary - due to renal disease
• Predisposes to Atherosclerosis, stroke, CHF,
  renal failure, retinopathy, and aortic dissection
• Malignant HTN is severe, rapidly progresses,
• and causes fibrinoid necrosis
• of small arteries
• ?

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II. Cardiovascular Pathology

• B. Arteriosclerosis ( 3 types)
• 1.) Monckeberg usually benign, calcification
  of only the Media in the arteries
• esp radial or ulnar

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II. Cardiovascular Pathology

• 2.) Arteriolosclerosis
• Hyaline thickening of small arteries in essential
  (primary) HTN
• Hyperplastic onion skinning in malignant HTN

• 3.) Atherosclerosis
• - Thickening and hardening of arteries, that
  usually affects the intima of large and
  medium-sized arteries

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II. Cardiovascular Pathology

• 3. Atherosclerosis cont
• Risk Factors smoking, HTN, diabetes mellitus,
  hyperlipidemia, Fm Hx
• Progression
• ? Proliferative ?
• Plaque
• Fatty Streaks
  ? Atheroma
• Think of your blood vessels as pipes carrying
  essential water to your house. The walls of the
  pipes over time may become rusty, eventually
  leading to the pipe becoming blocked and your
  water supply being cut offie eventually the
  Atheroma!!

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II. Cardiovascular Pathology

• 3. Atherosclerosis cont
• Symptoms Doesn't produce symptoms
• until the artery is severely restricted
• or obstructed.
• Chest pain, Leg cramps
• Complications Aneurysms, ischemia, thrombus,
  emboli, peripheral vascular disease, and infarcts
• Location Abdominal Aorta gt Coronary artery gt
  Popliteal artery gt Carotid artery (A. C. P. C.)

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II. Cardiovascular Pathology

• C. Ischemic Heart Disease Manifestations
• 1. Angina (CAD narrowing gt 75)
• a.) Stable mostly 2º to atherosclerosis,
  episodic retrosternal chest pain with exertion
• b.) Unstable thrombosis but no necrosis,
• worsening chest pain, ie. increase in
• frequency (crescendo)
• c.) Prinzsmetals Variant Prinzes are Prissy
• so lazy, even occurs at rest!

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II. Cardiovascular Pathology

• C. Ischemic Heart Disease Manifestations
• 2. Chronic IHD (progressive onset of CHF over
  many years due to myocardial damage)
• 3. Myocardial Infarction (most often acute
  thrombosis due to coronary artery
  atherosclerosis)
• 4. Sudden Cardiac Death ( death within 1 hour of
  onset of symptoms, most commonly due to lethal
  arrhythmia)

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II. Cardiovascular Pathology

• D. Infarcts
• Red vs. Pale
• -Color red is seductive - Pale
  is a Prude therefore
• So, more loose (tissues)
  keeps things tight solid
• with collaterals
  (tissues), ie. those w/Single Blood supply
• - Lungs, Liver, Intestines
  - Brain, Heart, Kidney, Spleen -
  REd REperfusion

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III Evolution of MI

• A. Time Frame Histologic Picture
• B. Diagnosis
• C. Complications

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III Evolution of MI
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III Evolution of MI
Hey, I want to hear a Bandcontraction band
that is!

• Such a long line to
• get intook 4 hours
• before he saw the
• BANDand then he EMIGRATED in!
• ?
• Mr. neutroPHIL

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III Evolution of MI

• Concert lasted 2-4 days.really Woodstock!
• Finally within that time, the rest of his family,
  
• The Neutrophils were extensively infiltrated
• extensive Coagulative Necrosis

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III Evolution of MI
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III Evolution of MI

• Now 5-10 days after the band concert, and its
  time to clean up!
• Police Macrophages
• were tired of the Neutrophils
• hangin around, so they attacked!
• (phagocytosis)

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III Evolution of MI

• 7 10 weeks have gone by
• Neutrophils were so badly beaten up by the
  police Macrophageshad a lot of SCARS and
  Fibrosis

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III Evolution of MI

• B. Diagnosis of MI
• What is the Gold Standard??
• EKG in the 1st 6 hours
• - ST Elevation (Transmural Infarct)
• Vs.
• - ST Depression (SubenDocardial Infarct)
• Cardiac Troponin I rises after 4 hours is
  elevated for 7-10 dys
• CK-MB is test of choice in 1st 24 hours post-MI
• LDH1 (former test of choice)
• AST are Asses b/c it is nonspecific, so not
  helpful b/c can be found in cardiac, liver,
  skeletal muscle cells.

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III Evolution of MI

• C. MI Complications
• Cardiac Arrythmias
• LV failure Pulmonary Edema
• Thromboembolism
• Cardiogenic Shock
• Rupture of Ventricular free wall, papillary mm,
  interventricular septum, cardiac tamponade
• Fibrinous Pericarditis friction rub
• Dresslers Syndrome autoimmune resulting in
  Fibrinous Percarditis

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IV Cardiomyopathies

• A. Dilated
• -Large, globulated
• -Most common (90)
• -Systolic Dysfunction
• -Etiologies
• Alcohol abuse Looks like a
• Beriberi Balloon on Chest X-ray
• C? Coxsackie, Chronic Cocaine, Chagas ?
• Doxorubicin toxicity
• pEripartum
• Hemochromatosis

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IV Cardiomyopathies

• B. Hypertrophic
• -LV walls are thickened
• -Often Asymmetric involves
• intraventricular septum ?
• -50 familial A.Dominant
• - Hyper High Jump therefore,
• cause of sudden death in athletes
• -Diastolic Dysfunction
• Chamber becomes
• Banana Shaped on Echo ?

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IV Cardiomyopathies

• C. Restrictive/obliterative
• -heart is restricted in its ability to contract
  because the inner lining of the heart becomes
  stiff
• -does not expand properly when filling
• -Major Causes Restrictive APE²S
• Amyloidosis
• Postradiation fibrosis
• Endocardial fibroelastosis
• Endomyocardial fibrosis (Lofflers)
• Sarcoidosis

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IV Cardiomyopathies

• A. Dilated - fundamental defect is INEFFECTIVE
  CONTRACTION (smaller ejection fractions)
• B. Hypertrophic - fundamental defect is
  INABILITY to FILL a hypertrophic LV during
  DIASTOLE. Ejection is forceful here, but
  ineffective b/c amt. of blood is ?.
• C. Restrictive fundamental defect is a STIFF
  Inelastic ventricle that can be filled ONLY with
  GREAT EFFORT

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Practice Questions

• 1.) 52 y/o woman noticed a lump in her left
  breast 3 months ago, after extensive work-up
  decides to undergo surgery. A surgical specimen
  is sent to a pathologist. Their report states,
  small, glandular structures, lined by poorly
  differentiated cells. Based on the hx, path
  report, and incidence of different types of
  breast cancers, which is the following carcinomas
  does this px most likely have?
• Colloid (mucous)
• Invasive ductal
• Invasive lobular
• Medullary
• Metastatic bronchogenic

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Practice Questions

• Answer
• B. Invasive Ductal Carcinoma
• Its the most common 75-80
• Develops from epithelial cells of the terminal
  duct
• Histo presentation is same
• Most common mode of presentation is a palpable
  mass in the breast

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Practice Questions

• 2.) 17 y/o MALE develops a painless, firm mass
  beneath the nipple of his left breast. Right
  breast is normal upon examination. Which of the
  following is conditions does this mass most
  likely represent?
• Fibrocystic changes
• Gynecomastia
• Intraductal papilloma
• Invasive duct carcinoma
• Invasive lobular carcinoma

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Practice Questions

• Answer
• B. Gynecomastia
• Most common breast mass in men, esp. under 25
  yrs/o
• Benign proliferation of ductal stromal elements
  of the breast
• Generally idiopathic, may be due to hormonal
  changes

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Practice Questions

• 3.) 53 y/o man complains of progressive weakness
  and inability to exercise. Its been getting
  worse over the last 2 years. He also notes his
  ankles have been getting bigger. He DENIES any
  episodes of chest pain, arm pain, or jaw pain
  either at rest or when exercising. Hes not
  diabetic, but admits to having high cholesterol.
  What is the most likely etiology of his
  progressive symptoms?
• Chronic Ischemic Heart Disease
• Myocardial Infarction
• Prinzmetal Angina
• Stable Angina
• Unstable Angina

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Practice Questions

• Answer
• A. Chronic Ischemic Heart Disease
• Atherosclerosis of coronary arteries is the
  underlying pathologic change in the majority of
  ischemic heart disease
• States that it is progressive

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THE END!!!!

• Thank you very much
• Any questions?????