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Cellular pathology > Breast > Flashcards

Breast Flashcards

1
Q

Describe the anatomy of the breast

A

The breast is a large sweat gland modified to produce milk (instead of sweat).
The female breast is made up of approximately 15-25 lobes - each composed of groups of lobules.

COOPER’S DROOPERS = cooper’s ligaments hold up the breast

The entire duct + lobular system is lined by epithelium surrounded by a basement membrane

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2
Q

What is the functional unit of the breast

A

The Terminal Duct Lobular Unit (TDLU)

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3
Q

Explain the production of milk

A

The lobule (TDLU) is composed of multiple acini (glands) and it is within the acini that the milk is produced. The milk drains via the terminal ducts into the main duct system of the breast - eventually opening out at the nipple where the baby suckles.

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4
Q

What is the most likely cause of a breast lump in a young woman

A
  • Fibroadenoma
  • Fibrocystic change

Cancer is much less common

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5
Q

What is the most likely cause of a breast lump in an older woman

A
  • cancer is an important cause
  • fibroadenoma
  • fibrocystic changes
    can both still occur
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6
Q

How would you investigate a breast lump

A

Triple assessment

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7
Q

What is triple assessment

A
  • Clinical = history + examination
  • Radiological = <35 years undergo ultrasound (breast tissue much denser) >35 years undergo mammogram (identifies micro calcifications and densities)
  • Pathological - FNA / core biopsy
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8
Q

How do you interpret FNA/core biospy

A

C = FNA cytology; B = biopsy

C1/B1 = inadequate or not diagnostic
C2/B2 = benign eg. fibroadenoma, fibrocystic change
C3/B3 = equivocal, favour benign
C4/B4 = equivocal, favour malignant
C5/B5 = malignant - although this category also includes DCIS
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9
Q

What is a fibroadenoma

A

The commonest benign tumour of the breast.

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10
Q

Who gets fibroadenomas

A

Typically women under the age of 30

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11
Q

How does fibroadenoma present

A

Firm, mobile, painless lump.
May be multiple.

The tumour is well circumscribed and composed of well differentiated glands embedded in a well differentiated connective tissue stroma

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12
Q

How are fibroadenomas managed

A

Reassurance and discharge

Excision

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13
Q

What is fibrocystic change

A

A variety of benign, non-neoplastic changes in the breast which are the result of minor aberrations in the normal response to cyclical hormonal changes.

The changes affect the TDLU (functional unit of the breast) - which is characterised by fibrosis (scarring) and cyst formation

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14
Q

Who gets fibrocystic change

A

Typically seen in women 25 - 45

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15
Q

How does fibrocystic change present

A
  • Breast pain
  • Tenderness
  • Lumps/cysts (“lumpy bumpy breasts”)
    This is especially likely during the second half of the menstrual cycle
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16
Q

What is the management of fibrocystic change

A

Treatment options include: reassurance; analgesics; cyst aspiration; excision (rare)

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17
Q

What is the most common cancer in the UK

A

Breast cancer

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18
Q

Who gets breast cancer

A

Women (>99% of cases)
Rare before 25
Most common between 40 and 70 (80% diagnosed in >50yrs)

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19
Q

What are major risk factors for breast cancer

A

(1) Increasing lifetime oestrogen exposure
(2) FHx
(3) Alcohol consumption

20
Q

What increases lifetime oestrogen exposure

A 
(A) female sex
(B) increasing age
(C) obesity (fat makes oestrogen)
(D) early menarche
(E) late menopause
(F) long term COCP
(G) HRT > 10 years
21
Q

What genes are associated with breast cancer

A

(A) BRCA1 + BRCA2 (TSGs; autosomal dominant; lifetime risk of breast cancer 85-100%; high risk of ovarian cancer; may be offered propylactic surgery)
(B) Li-Fraumeni syndrome - P53 germ line mutation

22
Q

What is the most common site of breast cancer

A

Upper outer quadrant of the breast - as this is where there is the greatest proportion of breast parenchymal tissue

23
Q

What features on examination make you suspect breast cancer

A
  • Hard, painless lump (may be fixed to chest wall or overlying skin)
  • Nipple inversion
  • Skin dimpling
  • Ulceration/fungation
  • Peau d’orange - cutaneous oedema secondary to dermal lymphatic obstruction = the dimples are where the hair follicles are and the breast is swollen around them
  • Nipple eczema (in pagets)
  • Palpable auxiliary nodes - suggests tumour has spread here
  • Metastatic disease (weight loss/pleural effusion)
24
Q

How would you investigate breast cancer

A

Triple assessment
Grade - via biopsy
Stage

25
Q

How is breast cancer managed

A

Discussed in an MDT meeting

  • surgeon
  • oncologist
  • radiologist
  • pathologist
  • specialist nurse

Treatment plan is agreed - depends on tumour type, grade, stage, patient fitness, patient choice

26
Q

What is the most common type of breast cancer

A 
Invasive adenocarcinoma - the most common types are:
Ductal carcinoma (75%)
Lobular carcinoma (15%)
27
Q

What is an adenocarcinoma

A

Malignant tumour of the glandular epithelium (the breast is a gland!)

28
Q

What is DCIS

A

Ductal carcinoma in situ. This is where epithelial cells showing cytological signs of malignancy are present in the TDLU.

However, the basement membrane is intact - they have not invaded into the surrounded tissue.

  • Pre-cancer
  • Confined by BM
29
Q

What is invasive ductal carcinoma

A

The tumour cells have invaded through the basement membrane into the adjacent fatty tissue. Invasive ductal carcinoma invades into adjacent breast tissue and it has the ability to metastasise.

30
Q

What types of ductal carcinoma are malignant

A

IDC fulfils the two criteria for a malignant tumour - invasive with the ability to metastasise

DCIS has not invaded into the adjacent breast tissue - and it has not invaded through the BM therefore does not have the ability to metastasise. This is not malignant. However it should be noted that DCIS if left untreated can progress to IDC (DCIS = pre-cancerous).

31
Q

How does DCIS present and what would you see on investigation

A
  • Does not usually form a mass
  • Often associated with micro calcifications - may be detected on mammography
  • Usually a unifocal lesion concentrated in one area of the breast
32
Q

How is DCIS treated

A

Unifocal and many progress to IDC so it is surgically excised.

33
Q

How does IDC present

A

Palpable breast mass

34
Q

What is Paget’s disease of the nipple

A

It affects the skin of the nipple and areola. It is due to the presence of DCIS cells in the epidermis (they extend all the way along the duct system to react the skin surface) - the affected skin “reacts” to the presence of the DCIS cells = characteristic eczematous clinical appearance

35
Q

How is Paget’s disease of the nipple investigated

A

Biopsy

36
Q

How is DCIS graded

A

FNA/biopsy will show it as C5/B5 - although it is not malignant

37
Q

What is ILC

A

Tumour cells which infiltrate the normal breast tissue in a linear (single-file) pattern OR as single cells that appear to be separate

This is due to a loss of function of E-cadherin-catenin cell adhesion system

38
Q

What is the most important prognostic factor in invasive breast cancer

A

Tumour stage (TNM) - particularly lymph node status

39
Q

List prognostic factors in invasive breast cancer

A

(1) tumour stage - spread
(2) tumour grade - how differentiated and thereby aggressive
(3) Histological subtype
(4) Vascular invasion
(5) Excision margin
(6) Oestrogen receptor / HER2 status

40
Q

Is is a good or bad prognostic factor to have a ER (oestrogen receptor) positive breast tumour?

A

Postive prognostic factor as they tend to be lower grade and less aggressive and are likely to respond to hormonal therapy.

41
Q

What is the HER gene

A

An oncogene that encodes a transmembrane tyrosine kinase receptor.

HER2 over expression is associated with poor prognosis, however good response to perception (a monoclonal antibody against the HER2 receptor)

42
Q

What is the setinel lymph node

A

The first lymph node draining a cancer

43
Q

What is the clinical significance if the setinel lymph node does not contain cancer

A

There would be a very high likelihood of the cancer spreading to other nodes or elsewhere (since the cancer has to pass through the sentinel node first)

44
Q

How is the setinel node used in determining management of breast cancer

A

Sentinel node +ve (contains cancer) = axiliary clearance - removal of all axilliary nodes

Sentinel node -ve (no cancer) = no further surgery in axilla is required

45
Q

What are advantages of setinel node technique

A
  • Important prognostic information

- Negative sentinel node are spared an unnecessary ax node clearance

46
Q

How is the setinel node identified

A
  • Dye and / or isotope injected into the tissue around the tumour
  • Assess which lymph nodes that have taken up the dye
  • Remove them
  • Pathologist examines for signs of cancer
47
Q

What is the NHS breast screening programme

A

Aim is to identify DCIS and small invasive carcinomas at early stage before S+Sx develop

Women 47-73 invited for a mammogram every 3 years

Cellular pathology (8 decks)

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