(48) Breast pathology Flashcards
The majority of malignancies in the breast arise from which tissue type?
Epithelial cells = CARCINOMAS
Malignant tumours from connective tissue cells rarely occur. What are these called?
Sarcomas
Many tumours have more fibrous tissue which has what characteristics?
Fibrous tissue makes things lumpy/harder and more radio-opaque. (fat is soft and radiolucent)
What are the 3 principal components of the anatomy of the breast?
- fat
- fibrous connective tissue
- epithelial tissue
lobes - ducts - nipple
How is younger breast tissue different?
More glandular and therefore fibrous - more lumpy, even when benign and radio-dense
Why are mammograms less effective in younger people?
As young breast tissue is more lumpy anyway as it is more glandular - USS is better for detecting tumours
What factors increase the risk of breast cancer?
- alcohol
- oestrogen-progesterone contraceptives/menopausal therapy
- x-ray/gamma radiation
- body fat
What factors decrease the risk of breast cancer?
- breastfeeding
- (physical activity)
Who does the NHS breast screening programme target?
- all women aged 50 and over
- free breast screening every 3 years
- for some areas, screening is extended to cover ages 47-73
Has the NHS breast screening programme been effective?
- lowered mortality rates from breast cancer in the 55-69 age group
- benefits of mammographic screening is greater than harm in terms of over diagnosis
- 2-2.5 lives saved for every overdiagnosed case
Is fibrocystic change in the breast always pathological?
So common as to be almost physiological - can mimic cancer both clinically and pathologically
How does breast disease present?
- lumps
- puckered skin/indrawn nipple
- pain
- inflammation/infection
- nipple discharge
- abnormal/sore nipple
- radiology/screening
What is the “triple assessment” of breast abnormality?
- all breast lumps should be considered in 3 parameters
1. clinical (examination and palpation)
2. radiological (look for calcifications)
3. pathological (cytology or histopathology) - the results of all these need to be triangulated at an MDT meeting
If suspicious calcifications or a mass is found, what needs to be done?
It will need to be biopsied to permit the pathologist to make a diagnosis
How can normal breast tissue be described histologically?
Very organised
lots of “little villages” connected by roads
How can invasive breast tumours be described histologically?
Irregular disorganised margins of invasive tumours, high grade tumours might get rounded edge due to fast growth
uncontained, untidy
“urban sprawl”
What procedure should happen in any breast lump?
Triple assessment
What type of genes are BRCA genes?
Tumour suppressor genes - mutation causes lack of function
Biopsies are graded using the “B” grading system. What is this?
B1 = unsatisfactory B2 = benign lesion B3 = atypical probably benign B4 = atypical probably malignant B5a = malignant, in-situ B5b = malignant, invasive
What are fibroadenomas?
Fibroepithelial neoplasms in which there is coordinated growth of the glandular and connective tissue (stromal) element “breast mice” - benign
How do fibroadenomas present?
They are common and present as mobile lumps or radiological masses
- painless
- firm
- solitary
- mobile
- slowly-growing
Are fibroadenomas are cause for concern?
Should be biopsied but if confirmed to be fibroadenoma by biopsy then can be left alone as they are benign
What are phyllodes tumours?
Rare fibroepithelial neoplasm which forms a spectrum of lesions - at one end are lesions very similar to fibroadenomas, other end very aggressive and malignant
What do the more aggressive phyllodes tumours show?
Overgrowth of the stromal element, which in some cases might be frankly sarcomatous
If a tumour is seen histologically to be invading into the fat, is it benign or malignant?
Malignant
If a tumour is seen histologically to have sharp edges and not infiltrating, is it benign or malignant?
Benign
Name some benign reasons for lumps
- physiological
- lipoma
- fibroadenoma
- fibrocystic change
Which type of breast lump may be either benign or malignant?
Phyllodes tumour (rare, extremely rarely they may be malignant)
Malignant breast lumps can exist in which two states?
- in situ
- invasive
What constitutes fibrocystic change?
A constellation of changes - includes usual type ductal hyperplasia, apocrine metaplasia and cysts
How does fibrocystic change present?
- may present as a lump
- may be associated with microcalcifications
- can therefore be tricky for histopathologist to interpret correctly in rare cases and limited samples
If fibrocystic chance a precursor for breast cancer?
May share risk factors e.g. oestrogen exposure, but probably not a precursor
What is the different between benign and malignant breast tumours in terms of macroscopic appearance?
Benign = generally expansile and do not invade, leading to a rounded border
Malignant = typically invasive, irregularly take over adjacent tissues
What causes the puckered skin/indrawn nipple in breast cancer?
- tumour cells interact with carcinoma-associated fibroblasts
- fibroblasts contract = retract the nipple
What causes the Peau d’orange sign?
Caused by a cancer blocking up all the lymphatic capillaries leading to oedema - but tethered where the sweat glands are
What may cause inflammation/infection in the breast?
- mastitis during breast feeding
- breast abscesses and fistulae
- TB
- carcinoma/sarcomas
What may cause nipple discharge or abnormal/sore nipple?
- duct ectasia
- intraductal papilloma
- in-situ papillary carcinoma
- intracystic papillary carcinoma
What is duct ectasia?
A condition in which the lactiferous duct becomes blocked or clogged. This is the most common cause of greenish discharge.
What is a papilloma?
A small wart-like growth on the skin or on a mucous membrane, derived from the epidermis and usually benign
What is Paget’s disease of the nipple?
A malignant condition that outwardly may have the appearance of eczema, with skin changes involving the nipple of the breast - a consequence of cancer cells growing into the skin of the nipple
Pain in the breast is an uncommon way for carcinoma to present and is difficult to treat. It can be cyclical, what does this mean?
Related to the menstrual cycle
How are breast cancers radiologically detected?
- opacities - as for lumps
- calcifications (character indicates specific disease)
Cancers may be associated with formation of calcium crystals. How does this appear?
Reddish-purple coloured on histology
Why is a biopsy of a calcification difficult to take?
As the calcification cannot be felt (especially if detected be breast screening) - a guide wire will need to be inserted to assist the surgeon in removing the right bit
What should a path report tell you about malignancy?
- in-situ or invasive
- type
- grade
- size
- vascular invasion
- nodal status
- relationship to margins
- ER, PR, HER2 status
Can you have in situ carcinoma and invasive cancer at the same time?
Yes
What does DCIS stand for?
Ductal carcinoma in situ
Is there a need to remove lymph nodes in in-situ carcinoma?
No
What are the main recognised types of breast carcinoma?
- ductal (everything else) - 75%
- lobular 12%
- tubular/cribriform 3%
- medullary 3%
- mucoid 2%
- metaplastic 1%
- others 4%
How does mucinous carcinoma appear on histology?
Lots of white bits which is the jelly-like mucin produced by the tumour cells
How does lobular carcinoma appear on histology?
‘Indian files’ of cancer cells
Most cancers don’t fall into a recognisable type. So what is more important?
Grading
Give a main difference between a grade III and a grade I cancer?
More mitotic figures etc.
How does grade (1, 2 or 3) affect survival?
Higher grade, lower survival
How is ‘grade’ different from ‘stage’?
Grade = the intrinsic biology, how quickly it is able to progress potentially
Stage = how far it has got at the time of diagnosis
Nodal status and size of mass is a key indicator of what?
Stage
What is the Nottingham prognostic index?
Grade + nodal status (0 = score 1, 1-3 = score 2, 4 or more = score 3) + 0.2 x tumour size
- 4 or less = good, 80% + 16yr survival
- 41-5.4 = moderate, 46%
- 41+ = poor, 10%
What is important about knowing if a tumour is ER +ve (oestrogen receptor positive)?
It will response to oestrogen-targetting agents eg. Tamoxifen
Which drug will cause a response in cancers that have overexpression of HER2 gene?
Herceptin
