Breast Flashcards
Explain the general structure of the breast
The breast parenchyma is made up of 10–20 lobes with interlobar stroma in between
Each lobe is made up of multiple lobules, which are drained by a single lactiferous duct that opens onto the surface of the nipple
The lactiferous sinus is the terminal dilation of the lactiferous duct
What are the components of a triple asessment of a breast lesions?
- Clinical exam
- Imaging (USS or Mammogram depending on age)
- Cytology (FNA) or Histology (core biopsy)
What is the gold-standard for diagnosing breast cancer?
Core biopsy histology
Then graded via cellular detail and code
B1 (normal)
B2 (benign)
B3 (uncertain)
B4 (suspicious) to
B5 (malignant).
* B5a = DCIS,
* B5b = invasive carcinoma
Name 2 common inflammatory diseases of the breast
- Acute Mastitis
- Fat necrosis
What is the aetiology of Acute mastitis?
Lactational: Milk stasis lead to infection with S.aureus
Non-lactational: keratinising squamous metaplasia block
lactiferous ducts leading to peri-ductal inflammation and rupture
What does FNA cytology show in acute mastitis?
shows an abundance of neutrophils
What is Fat necrosis of the breast?
What is its typical clinical presentation?
Inflammatory reaction to damaged adipose tissue
Typical presentation in
- obese, middle aged women presenting with
- painless breas mass, mammographic lesion
- (can mimic carcinoma with skin tethering, nipple retraction)
What are causes of Fat necrosis of the breast?
Causes – trauma, radiotherapy, surgery, nodular panniculitis
What are histological findings of fat necrosis on cytology?
Cytology – empty fat spaces , histiocytes and giant cells
What is a Fibroadenoma?
What are the cytological and histological finding?
Most common cause of breast lump, especially in young women
Benign condition arising from fibro (stromal) and glandular (adenomal) epithelium
On Cyology
* FNA cytology – branching sheets of epithelium (green overla)
* Multinodular mass of expanded intralobular stroma (red overlay)
What is the clinical appearance of a fibroadenoma on examination?
Usually singls, unilateral 1-5cm mass
Solitary, well-defined, nontender, rubbery, and mobile mass
Can change size with menstrual cycle
What is the most common clinical presentation of a breast cyst?
Breast mass presenting in peri-menopausal women (singls or mutliple, unilateral or bilateral)
Might change during menstrual cycle
O/E
- well demarcated
- painless
- fluctuant/mobile masss + painless transillumniable
- +/- clear nipple discharge
What is breast duct ectasia?
Chronic inflammatory process leading to dilation of terminal (subarolar) lacifrous ducts due to stasis of secretions (blockage)
What is a common presentation of duct ectasia?
Peri- or postmenopausal smoking woman presents with
1. Tender, fixed (subareolar) mass
2. Nipple inversion
3. Firm, thick yellow- green-white nipple discharge (+/- local abscess)
What are the cytolgical and histological findings of breast duct ectasia?
Cytology of nipple discharge: proteinaceous material and macrophages (buzzword)
Histology
Duct dilatation, periductal inflammation, proteinaceous material in side the duct
What is the most common breast lesion with nipple discharge?
What is it?
Intaductal Papilloma
Benign papillary tumour arising within the duct system of the breast (from the laciferous ducts)
What is the clinical presentation of an intraductal papilloma?
Clinically presents with a sub-areolar mass +/- bloody nipple discharge
What are the
1. Radiological findings of Mammogram
2. Cytology and
3. histology
of intraductal papilloma?
- Not seen on mammogram.
- Cytology of nipple discharge – branching papillary groups of epithelium
- Histology – papillary mass within a dilated duct lined by epithelium
What is a radial scar?
What is the apearance on mammogrphy and histological findings?
Benign sclerosing lesion – central scarring surrounded by proliferating glandular tissue in stellate pattern
- Usually presents as a stellate mass on mammography, closely mimicking carcinoma
- Lesions >1 cm are sometimes called “complex sclerosing lesions”
- Histology – central, fibrous, stellate area [BUZZWORDS]
What are fibrocystic chages of the breast? What is the epidemiology, clinical presentation and histology?
Presentation: changes according to menstrual cycle (hormone responsive), lumpiness in breasts
- Occurs in 1/3rd of pre-menopausal women
Histology – dilated large ducts which may become calcified
What is Usual epithelial hyperplasia of the breast?
What is the risk of progression to a carcinoma?
Not formally considered a precursor lesion to invasive breast carcinoma
although slightly 1-2% increased risk of carcinoma
What is Flat epithelial atypia a.k.a. atypical ductal carcinoma?
What is the risk of developing breast cancer?
4x risk of developing carcinoma
Histology: Multiple layers of epithelial cells and lumens moreregular and round with punched out areas
What is a phylloids tumor?
How does it present and how should it generally be managed?
Arise from interlobular stroma (like fibroadenomas – can arise within existing
fibroadenomas) with increased cellularity and mitoses
- Present >50yrs as palpable mass
- Low grade or high grade lesions. Mostly relatively benign, but can be locally aggressive therefore –>
excised with wide local excision/mastectomy to limit local recurrence. - Histology: “branching”/”leaf-like fronds”/”artichoke appearance”
What is the normal screening programme for breast cancer in the UK?
Screening: 47 to 73yr old women invited every 3 years for mammography (looks for
abnormal areas of calcification or a mass within the breast)
What is the most common breast cancer?
80% of Breast cancers are Invasive
20% are Ductal carcinoma in situ
Out fo the invasieve cancers
1. Invasive ductal carcinoma (80%)
2. Invasive lobular carcinoma (10%)
What are the characteristics of Breast Carcinoma in situ?
How are most of them detected?
Neoplastic epithelial proliferation limitedt to ducts/ lobules by basement membrane
Ductal: detected on Mammogram with microcalcification
Lobular: incidental findings as no changes on mammography
What is the risk of ductal carcinoma in situ to progress to invasive breast carcinoma?
Up to 40 % of DCIS can progress to invasive breast cancer if left untreated
What are histological findngs of DCIS?
Ducts filled with atypical epithelial cells
What are typical hisoligcal findings of DCIS?
- Enlarged ducts lined with atypical epithelium
- Neoplastic cells within ductal lumen
- Intact basal membrane
Microcalcifications
How are the invasive breast carcinomas classified?
Generally classified into different sub-groups
- Invasive ductal: 80% of cancers, no further sub-classification possible
Other subgroups if they are possible
1. Invasive lobular: 10% of all breast cancers, less agressive than invasive ductal
2. Tubular carcinoma: less common, well-formed tubules on
What is a common histological findinsg of invasice ductal carcinoma?
Big, pleiomorphic cells [BUZZWORD] – invasive cells move intro stroma
No further differentiation possible
What are histological characteristics of invasive tubular carcinoma?
cells aligned insingle file chains/ strands
How does receptor testing in breast cancer is relevant?
What receptor positivity is associated with
- good progonsis
- bad prognosis?
ER/PR (Estrogen / Progesterone receptors): good prognosis because can respond to tamoxifen
HER2 positive: might be possible for targeted therapy, but still worse prognosis
Triple negative (ER/PR and HER2) associated with bad prognosis
What is he msot important factor in prognosis of breast cancer?
status of the axillary lymph nodes
What receptor status do most
1. low-grade
2. High-grade
breast cancers usually have?
How does that change treatment
Low grade: usually ER/PR +ve, HER2- –> Tamoxifen
High grade: usually ER/PR-ve, HER2 +ve: Herceptin
Triple negative: 10-15% of cancers, usually more agressive
What is Herceptin/trastuzumab?
Targeted therapy for HER2 positive breast cacncer
:
monoclonal Ig to Her2 (direct toxic effect on myocardium, must monitor LVEF)
What is the MOA of tamoxifen?
mixed agonist/antagonists of oestrogen at its receptor
After what 3 criteria are breast cancers graded?
Nuclear pleomorphism
Tubule formation
Mitotic activity
What are BRCA genes?
What is the inheritence?
What are the clinical characteristics?
TSG –> can be mutated with autosomal dominant inheritence
Increased risk of
- breast, ovarian and prostate cancers (5-10% of breast cancers are BRCA +ve)
- risk of developing breast cancer if BRCA +ve up to 85%
What is pagets disease of the nipple?
a rare type of breast cancer that affects the lactiferous ducts and the skin of the nipple and areola
Proliferation of malignant glandular epithelial cells (in situ carcinoma) in the nipple areolar epidermis.
