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YR5 Histopathology > Breast > Flashcards

Breast Flashcards

1
Q

What is the rule of 2s for normal breast tissue?

A

2 main structures: large ducts + terminal ductal lobular unit

2 types of epithelial cells: Luminal + Myoepithelial

2 types of stroma: Interlobular + Intralobular

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2
Q

What is the breast composed of?

A

15 – 25 lobes, further subdivided into lobules which are composed of acini + ductules ~30

Each lobe drains through a main lactiferous duct into the nipple.

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3
Q

What are the functional units of the breast?

A

Terminal duct-lobular units (TDLU)

Successive branching of lactiferous ducts distally leads to the terminal duct which proliferates further to give arise to acini (lobules) + ductules

TDLU: Extralobular terminal duct, acini (lobules) + ductules

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4
Q

What are typical presentations of breast disease?

A

Breast lump +/- pain

Abnormal screening mammogram.

Nipple discharge.

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5
Q

On evaluation, what are the most common causes of apparent breast lumps statistically?

A

Fibrocystic change 40%

No disease 30%

Misc. benign 13%

Cancer 10%

Fibroadenoma 7%

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6
Q

What are appropriate investigations for breast disease?

A

Triple assessment:

Physical examination.

Imaging: Sonography, mammography + MRI

Pathology: FNA cytopathology +/- histopathology

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7
Q

How are pathology investigations conducted?

A

Cytopathology + biopsy

Lesion aspirated by a 16/ 18 gauge needle

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8
Q

What is the most common cause of nipple discharge?

A

Papilloma

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9
Q

What are the differences between pathological and physiological nipple discharge?

A

Path: unilateral, single duct, spontaneous, persistent +/- blood/ pain

Phys: bilateral + from multiple ducts

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10
Q

Why is breast FNA cytology useful?

A

Provides good cellular detail

Quick to prepare

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11
Q

What are the disadvantages of breast FNA cytology?

A

Can’t assess architecture

Can’t differentiate atypical ductal hyperplasia from low grade cancer

Can’t differentiate high grade in situ carcinoma from invasive cancer

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12
Q

What is cytopathology? What is it used for in breast disease?

A

Cells spread across a slide + stained.

Investigation of nipple discharge + palpable lumps.

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13
Q

How are breast lump aspirates coded?

A

C1-5:

C1: Inadequate

C2: Benign

C3: Atypical, probably benign

C4: Suspicious of malignancy

C5: Malignant

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14
Q

What is histopathology?

A

Intact tissue removed, fixed in formalin, embedded in paraffin wax, thinly sliced, stained with H+E.

Attained via core biopsies/ surgical excisions.

Takes 24h to process.

Provide architectural + cellular detail.

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15
Q

How are the results of the NHS breast screening programme coded?

A

Core biopsies coded B 1-5.

B1: Normal breast tissue.

B2: Benign abnormality.

B3: Lesion of uncertain malignant potential.

B4: Suspicious of malignancy.

B5: Malignant (B5a: DCIS, B5b: Invasive carcinoma).

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16
Q

What is duct ectasia? What causes it? In which women do we more commonly see it? How does it present?

A

Benign inflammation + dilation of large breast ducts.

Aetiology unclear.

5th-6th decades, multiparous F

No increased risk of malignancy.

Usually presents with nipple discharge. +/- breast pain, mass, nipple retraction.

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17
Q

What is seen on cytology of nipple discharge in duct ectasia?

A

Proteinaceous material + inflammatory cells only.

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18
Q

What is acute mastitis? In which women is it often seen? What causes it? How does it present?

A

Acute inflammation in breast.

Often seen in lactating women due to cracked skin + stasis of milk. May also complicate duct ectasia.

Often Staphylococci.

Painful red breast (usually unilateral)

Drainage + abx usually curative.

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19
Q

What is fat necrosis? What cause it? How does it present?

A

Benign inflammatory reaction to damaged adipose tissue.

Caused by trauma, surgery, radiotherapy.

Breast mass, late stages +/- focal calcification

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20
Q

What is galactocele? How does it present? Any complications?

A

Cystic dilation of a duct during lactation

Usually multiple ducts

Tender palpable nodules

Secondary infection may convert to acute mastitis/ abscess

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21
Q

What is fibrocystic disease? What is the incidence? How does it present?

A

A group of alterations in the breast which reflect normal, albeit exaggerated, responses to hormonal influences.

Very common.

Breast lumpiness.

No increased risk for subsequent breast carcinoma

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22
Q

What is a fibroadenoma? What is the incidence? How does this present?

A

Benign fibroepithelial neoplasm of the breast.

Common.

Young F: 20-30y

Circumscribed mobile breast lump

Simple “shelling out” = curative.

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23
Q

What is a Phyllodes tumour? What is the incidence? How does this present?

A

A group of potentially aggressive fibroepithelial neoplasms of the breast.

Uncommon tumours.

Enlarging masses in > 50s

Some may arise within pre-existing fibroadenomas.

Majority: benign

Small proportion: more aggressive

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24
Q

What is an intraductal papilloma?

A

Benign papillary tumour arising within the duct system of the breast.

Arise within small terminal ductules (peripheral papillomas) or larger lactiferous ducts (central papillomas).

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25
Q

Summarise the epidemiology and presentation of an intraductal papilloma.

A

Common.

Mostly 40-60y

Central: nipple discharge.

Peripheral: may remain clinically silent if small.

Excision of involved duct is curative.

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26
Q

What are radial scars?

A

Benign sclerosing lesion characterised by a central zone of scarring surrounded by a radiating zone of proliferating glandular tissue.

Range in size from tiny microscopic lesions to large clinically apparent masses.

If >1 cm aka “complex sclerosing lesions”.

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27
Q

How do radial scars present? What is the theorised aetiology?

A

Reasonably common.

Thought to represent an exuberant reparative phenomenon

Stellate masses on screening mammograms- may closely resemble a carcinoma.

Excision is curative.

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28
Q

What are proliferative breast diseases? How are these detected?

A

Diverse group of intraductal proliferative lesions associated with an increased risk for development of invasive breast carcinoma.

Microscopic lesions, usually produce no Sx

Diagnosed in breast tissue removed for other reasons or on screening mammograms if they calcify.

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29
Q

What is usual epithelial hyperplasia?

A

Not considered a direct precursor to invasive breast carcinoma

but is a marker for slightly increased risk (relative risk of 1.5-2.0) for subsequent invasive carcinoma.

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30
Q

What is flat epithelial atypia/ atypical ductal carcinoma?

A

May represent earliest morphological precursor to low grade ductal carcinoma in situ.

1.5x relative risk of developing cancer.

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31
Q

How does in situ lobular neoplasia present? What is it considered to be?

A

More common in 50s, does not form palpable mass

Solid: no lumen

RF for subsequent invasive breast carcinoma in either breast in a minority

Relative risk ~8-10x

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32
Q

What is ductal cell carcinoma in situ (DCIS)? What is the incidence?

A

Neoplastic intraductal epithelial proliferation with an inherent (not inevitable) risk of progression to invasive breast carcinoma.

Common.

Incidence markedly increased since introduction of breast screening programmes.

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33
Q

How is DCIS detected?

A

85% on mammography as areas of microcalcification.

10% produce clinical findings: lump, nipple discharge, or eczematous change of the nipple (Paget’s disease of nipple)

5% incidentally in breast specimens removed for other reasons.

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34
Q

What is the treatment of DCIS?

A

Complete surgical excision with clear margins is curative.

Recurrence is more likely with extensive disease + high grade DCIS.

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35
Q

What are invasive breast carcinomas?

A

Malignant epithelial tumours which infiltrate within the breast + have capacity to spread to distant sites.

Most common cancer in F- lifetime risk of 1 in 8.

Incidence rates rise rapidly with increasing age, most cases occur in elder.

36
Q

What are risk factors for invasive breast carcinomas?

A

Early menarche

Late menopause

Increased weight

High alcohol consumption

OCP use

FH

37
Q

What is the clinical presentation of invasive breast carcinomas?

A

Usually present with a breast lump

Some asymptomatic detected on screening mammography

38
Q

What is basal-like carcinoma characterised by histologically, immunohistochemically and in its nature?

A

Histologically: sheets of markedly atypical cells with a prominent lymphocytic infiltrate. Central necrosis is common.

Immunohistochemically: +ve for “basal” cytokeratins CK5/6 + CK14.

Often associated with BRCA mutations.

Propensity to vascular invasion + distant metastatic spread.

39
Q

How is invasive breast cancer histologically graded?

A

By assessing tubule formation, Nuclear pleomorphism + Mitotic activity.

Each parameter scored from 1-3 + values are added together to produce total scores from 3-9.

3-5 : Grade 1 =well differentiated

6-7 : Grade 2 = moderately differentiated

8-9 : Grade 3 = poorly differentiated

40
Q

What is the association between receptor status and prognosis?

A

Low grade: tend to be ER/ PR +ve, Her2 -ve.

High grade: tend to be ER/ PR -ve, Her2 +ve.

Basal-like carcinomas: often ER/ PR/ Her2 -ve (“triple negative”).

41
Q

What is the most important factor for prognosis of breast cancer?

A

Status of axillary lymph nodes.

Other factors: tumour size, histological type, + histological grade.

42
Q

What is the NHS breast screening programme?

A

Aims to detect DCIS or early invasive carcinomas.

F 47-73y screened every 3y

Screening test: mammogram which looks for abnormal areas of calcification or a mass within the breast.

43
Q

What are the results of the NHS breast screening programme? What happens after?

A

~5% have an abnormal mammogram + are recalled to an assessment clinic for further Ix:

more mammograms

US

Core biopsy sample

44
Q

What is gynaecomastia?

A

Enlargement of male breast.

Pubertal boys + > 50s.

Idiopathic, cirrhosis, leydig cell tumours, drugs (therapeutic + recreational).

Benign, no risk of malignancy.

45
Q

Describe the epidemiology, presentation and histology of male breast cancer

A

Rare (0.2% of all cancers).

Median age 65y

Most present with a palpable lump.

Histologically show similar features to female breast cancers.

46
Q

What is this? Describe what can be seen

A

Duct ectasia

Periductal + interstitial inflammation

Dilated duct

47
Q

What is this?

A

Acute mastitis cytology

48
Q

What is this?

A

Fat necrosis cytology

49
Q

What is this? Describe what can be seen

A

Fat necrosis histology

Central focus of necrotic fat cells

Surrounded by lipid filled macrophages + neutrophilic infiltrate

50
Q

What is this? Describe what can be seen

A

Fibrocystic disease histology

FIBRO: loose stroma replaced by compressed fibrous tissue containing CYSTS lined with flattened/ low cuboidal epithelium

Adenosis: increased no. acini

51
Q

What is this?

A

Fibroadenoma cytology

52
Q

What is this?

A

Fibroadenoma histology

53
Q

What is this? Describe what can be seen

A

Phyllodes tumour cytology

Biphasic pattern

Increased stromal epithelial ratio

54
Q

What is this?

A

Phyllodes tumour histology

55
Q

What is this?

A

Phyllodes tumour histology

56
Q

What is this? Describe what can be seen

A

Intraductal papilloma cytology

Large stellate tissue fragments of benign ductal cells in a proteinaceous background

57
Q

What is this?

A

Intraductal papilloma cytology

58
Q

What is this?

A

Intraductal papilloma histology

59
Q

What is this?

A

Radial scar histology

60
Q

What is this?

A

Usual epithelial hyperplasia histology

61
Q

What is this?

A

Flat epithelial atypia/Atypical ductal carcinoma histology

62
Q

What is this?

A

In situ nobular neoplasia

63
Q

What is this?

A

Low grade DCIS histology

64
Q

What is this?

A

High grade DCIS histology

65
Q

What is this?

A

Invasive ductal carcinoma cytology

66
Q

What is this?

A

Invasive ductal carcinoma cytology

67
Q

What is this?

A

Invasive duct carcinoma histology

68
Q

What is this?

A

Invasive lobular carcinoma histology

69
Q

What is this?

A

Invasive tubular carcinoma histology

70
Q

What is this?

A

Invasive mucinous carcinoma histology

71
Q

What is this?

A

Basal-like carcinoma histology

72
Q

What is this?

A

Basal-like carcinoma histology

73
Q

What is this?

A

Basal-like carcinoma histology

74
Q

What is this?

A

Basal-like carcinoma histology

75
Q

What is this?

A

Basal-like carcinoma histology

76
Q

What is this?

A

Gynaecomastia

77
Q

What is Paget disease of the nipple?

A

Proliferation of malignant glandular epithelial cells (in situ carcinoma) in the nipple areolar epidermis

Uncommon

Peak 6-7th decade

78
Q

What are the 2 theories of etiological origin of Paget’s?

A

Epidermotropic: DCIS cells that migrate + break through epidermal membrane

Transformation: Malignant transformation of keratinocytes/ Tower cells

79
Q

What is this?

A

Paget’s disease of nipple

80
Q

Describe the appearance of Paget’s disease of the breast

A

Red-pink crusting lesion/ cracking of skin

Discoloration

Thickening

Ulceration

Exudate

Nipple retraction

81
Q

How is DCIS classified?

A

Subclassified histologically into low, intermediate + high grade

82
Q

What is the inheritability of invasive breast carcinomas?

A

~5% show clear evidence of inheritance. BRCA mutations cause a lifetime risk of invasive breast carcinoma of up to 85%.

83
Q

Describe the male breast

A

Composed of ductal structures only within collagenized stroma, with no / rare acini

84
Q

Describe the histology of gynaecomastia

A

Epithelial hyperplasia of breast ducts with typical finger-like projections extending into the duct lumen.

Periductal stroma often cellular + oedematous.

85
Q

What does cytopathology code C5 denote?

A

Malignant

86
Q

Which benign lesion most commonly mimics breast cancer on radiology?

A

Radial scar

87
Q

What is the most common malignant breast tumour?

A

Ductal carcinoma

YR5 Histopathology (27 decks)

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