Breast

Question 1

Name the components of the standard ‘triple assessment’ for breast pathology.

Answer 1

• clinical (history and exam)
• imaging (USS, MRI, mammogram [ages 50-70])
• pathology (cyto- or histopathology)

Question 2

Describe the options for breast cytopathology and the C classification.

Answer 2

• note histopathology is preferred over cytopathology
• options: FNA, fluid, nipple discharge, nipple scrape
• C classification used for FNA. C1 = unsatisfactory sample, C2 = benign, C3 = atypia (probably benign), C4 = suspicious of malignancy, C5 = malignant

Question 3

Describe the options for breast histopathology and the B classification.

Answer 3

• two main options are core biopsy and vacuum assisted biopsy.
• others: skin biopsy, incisional biopsy of a mass
• a needle with a closed compartment is inserted into the mass. the lid is opened inside the mass, allowing the compartment to be filled. the lid is then closed.
• histology allows us to determine invasive status, ductal / lobular, degree of differentiation, receptor status
• B1 = unsatisfactory sample, B2 = benign, B3 = atypia (likely benign), B4 = suspicious of malignant, B5a = carcinoma in situ, B5b = invasive carcinoma

Question 4

Name the developmental anomalies of the breast.

Answer 4

hypoplasia, accessory breast tissue, juvenile hypertrophy, accessory nipple

Question 5

Name the causes of gynaecomastia.

Answer 5

• physiological (puberty, old age)
• disease: chronic liver disease, Klinefelter’s, adrenal tumours, thyrotoxicosis
• drugs: cannabis, methadone, prostate cancer drugs, spironolactone, digoxin

Question 6

Describe the pathological findings of fibrocystic change.

Answer 6

• common in women 20-50 [peak 40-50]
• relates to early menarche, late menopause
• can present asymptomatic, as smooth discrete lumps, sudden pain, cyclical pain, lumpiness etc.
• cysts mm-cm with blue dome filled with pale fluid. intervening fibrosis, apocrine metaplasia

Question 7

Describe the pathological findings of sclerosing lesions.

Answer 7

• benign, proliferations of acini and stroma which can cause a mass or calcification
• sclerosing adenitis 20-70, neg risk of carcinoma
• radial scar <10mm, complex sclerosing lesion >10mm. fibroelastic core, radiating fibrosis, and distorted ductules. may mimic carcinoma.

Question 8

Describe the benign inflammatory pathologies that may affect the breast.

Answer 8

• fat necrosis: occurs with local trauma (e.g. seatbelt injury) or warfarin therapy.
• duct ectasia: pain, acute episodic inflammatory changes, bloody/purulent discharge. associated with smoking.
• treat infections, exclude malignancy, stop smoking, and excise

Question 9

Describe the pathological findings of Phyllodes tumour.

Answer 9

• slow growing mass unilaterally in 40-50
• tumours are prone to local recurrence if not adequately excised. unlikely to metastasise unless a fibroblastoma.
• fibroblasts and stroma grow in a ‘leaf-like’ pattern with stromal overgrowth.

Question 10

Describe the pathological findings of intraduct papilloma.

Answer 10

• nipple discharge/blood, may be asymptomatic, may present with calcification/nodules
• age 35-60, tends to affect subareolar ducts
• benign IDP -> IDP with ADH -> DCIS with ADH -> papillary DCIS
• fibrovascular core, fine pink collagenous stroma in papilla, increased MEp

Question 11

Describe the progression pathway of lobular and ductal precursor lesions.

Answer 11

• hyperplasia usual type > atypical ductal hyperplasia > DCIS > invasive ductal carcinoma
• normal lobule > atypical lobular hyperplasia (ALH) > LCIS

Question 12

Describe the localisation of ductal and lobular carcinomas in the breast.

Answer 12

• ductal is usually unilateral

- lobular is usually bilateral/multifocal, meaning they cannot normally be excised.

Question 13

Define ‘invasive breast carcinoma’ and describe its epidemiology.

Answer 13

• malignant epithelial cells breach the BASEMENT MEMBRANE and have infiltrated normal tissues
• commonest female cancer, second highest cancer death rate [after lung]
• with an aging population, incidence is increasing (1/7 > 1/6), however, mortality is decreasing.

Question 14

Give the risk factors for breast carcinoma

Answer 14

• uncontrollable: age, previous breast disease, family history (1st degree relative confers double risk), genetic cancer syndromes, BRCA 1/2
• reproductive: age at menarche, age at first birth + parity + breastfeeding, age at menopause, denser breasts (4-5x)
• lifestyle: weight, alcohol, smoking, [NSAIDs lower risk]
• hormones - OCP, HCT
• [lower risk with higher deprivation]

Question 15

Name the histopathologic subtypes of breast cancer, and their proportions.

Answer 15

• ductal/no specific type 70%
• lobular 10%
• mucinous 2%
• medullary 3%
• tubular, papillary, cribriform = 4%
• others 10%

Question 16

Name the genetic subtypes of breast cancer, their receptor status, and management.

Answer 16

ET = endocrine therapy. CT = chemotherapy

• luminal A: ER+, low proliferation, best prognosis. ET [+ CT if high tumour burden]
• luminal B, C: ER+, high proliferation. CT -> ET
• HER2 enriched: HER2+, ER-. Anti-HER2
• normal-like: ER-, non-epithelial
• basal-like: ER-, HER2- PR-, basal CK+, worst prognosis. Treated with CT.

Question 17

Name the receptors associated with breast cancer and their prognostic significance.

Answer 17

• ER [oestrogen receptor], PR / PgR [progesterone receptor]: positivity is a good prognostic factor.
• HER2 [human epidermal growth factor receptor 2]: positivity is a negative prognostic factor.

Question 18

Describe the traditional grading system and TNM grading system of breast cancer.

Answer 18

• traditional gives a score of 1-3 in three factors: tubular differentiation, nuclear pleomorphism, mitotic activity. grade 1 = 3-5pts, 2 = 6-7, and 3 = 8-9
• T 1-4: 0.1-2cm [1a-c], -5, >5, invades chest wall
• N 1-3: 1-3nodes, 4-9, >10
• M0, M1: not present, present

Question 19

Describe the presentation of breast malignancy.

Answer 19

• 50% is asymptomatic via screening (e.g. mammogram program for those 50-70)
• 50% are symptomatic (lump, altered shape/contour or skin change [e.g. peau d’orange] , lumpiness, nodularity, discharge, puckering/dimpling, pain in breast or axilla)

Question 20

Describe the options, indications, and side-effects of chemotherapy in breast cancer.

Answer 20

• FEC and taxane, +/- herceptin (HER2+)
• NACT: downsizing a tumour (mastectomy -> lumpectomy), enrol patients into clinical trials, allow operation in locally advanced cancers, better cosmetic results
• adjuvant: risk of relapse, tumour extent, grade, proliferation, vascular invasion, patient preference
• acute s/e: fatigue, myelosuppression, N&V, anorexia, mucositis, diarrhoea, constipation, renal symptoms, neurotoxicity, infertility
• late s/e: cardiac, infertility, neuropathy, renal impairment, osteoporosis, small risk carcinogenesis

Question 21

Name the main options for mammography and give the main indications for each.

Answer 21

• standard mammography: good for showing calcification (vascular, oil cyst eggshell, plasma cell mastitis, dystrophic). Used in screening programme.
• tomosynthesis: removes overlap. good for further assessing mammographic abnormalities (not in very dense breasts)
• contrast enhanced: produces an additional (‘subtracted’) image, which enhances lesions by vascularity

Question 22

Name and describe the main options for ultrasound and the main indications for each.

Answer 22

• targets breast and axilla if suspicion, targeted assessment, pregnancy problems, monitoring response to systemic treatment, followup of occult lesions, image guided procedures etc.
• elastography: measures tissue stiffness (probe - shear wave; strain - palpation). adjuvant, for fibroadenoma
• contrast-enhanced uses microbubbles. assessing response to NACT, axillary node characterisation
• ABUS automatically acquires information, availability is poor

Question 23

What are the two main categories of breast surgery? Compare their efficacy.

Answer 23

• BCT (breast conservation therapy), and mastectomy.
• some believe mastectomy is the overall ‘safer’ option, although clinical trials from 1995 and 2013 have proven this is just as effective, if not worse, than BCT.

Question 24

Describe the principles of BCT (breast conservation surgery).

Answer 24

• if palpable: wide local excision from the pectoralis fascia to the skin (leaving both intact)
• if impalpable, metal wires, radioactive seeds, or radiofrequency are used to help locate the area for excision
• oncoplastic surgery uses the principles of both oncotic (safe) and plastic (cosmetic) surgery to improve outcomes

Question 25

Describe how axillary lymph nodes are assessed in breast cancer.

Answer 25

• axillary USS
• normal nodes, or no micrometastases after core biopsy: sentinel node biopsy
• abnormal nodes: core biopsy
• micrometastesis: axillary node clearance (s/e lymphoedema)

Question 26

Describe the principles of mastectomy.

Answer 26

• takes tissue from elsewhere in the body and uses it to reconstruct the breast (TDAP, latissimus dorsi, etc.)
• complications: loss of implant, capsular contracture, rippling, migration, requiring revision surgery (40%),
• extremely rare chance of ALC lymphopaenia (1:25,000)