Breast Lecture 3 - Pathology of Breast Disease Flashcards
what si the normal strucutre of the breast?
Epithelial - ducts and lobules ( glandular )
Mesenchymal-fat and fibrous tissue
Hormone dependent - ER , PR
Physiological changes with age and pregnancy
Structure of the breast:
Each breast has _ __ __ sections (lobes) arranged like the petals of a daisy
Inside each lobe are many smaller structures called _________
At the end of each lobule are tiny sacs (_____) that can produce ____
8 to 10
lobules
bulbs
milk
normal anatomy:
before puberty – breasts in both sexes – _____
variable degrees of branching, lack _______
15 to 25 _________ ______
start in the nipple – branch - __________ _______ _______ _____
hormonally __________
ducts
lobules
lactiferous ducts
temrinal ductal lobular unit
responsive
what is shown here?
normal histology of the breast
lymphatics of the breast:
Lymph ducts: Drain fluid that carries white blood cells from the breast tissues into lymph nodes in the _____ and behind the _______
Lymph nodes: Filter harmful bacteria and play a key role in fighting off _______
axilla
sternum
infection
what are some benign breats conditions?
FIBROCYSTIC CHANGE - fibrosis, adenosis, cysts, apocrine metaplasia, ductal epithelial hyperplasia (usual type, atypical) - Fibrocystic breast changes happen when women develop fluid-filled cysts along with areas of fibrosis in one or both breasts
FIBROADENOMA - circumscribed mobile nodule in reproductive age
INTRADUCT PAPILLOMA - lactiferous ducts, nipple discharge
FAT NECROSIS - traumatic
DUCT ECTASIA – nipple discharge
what is a fibroadenoma?
proliferation of _______ and _______ elements
most common breast tumor in adolescent and _____ adult women (peak age = _____ decade)
well-circumscribed, freely ______, ________ mass
may ______ with age if left untreated
ducts distorted elongated - slit-like structures ___________ ______, ducts not compressed - ___________ ______ pattern
proliferation of epithelial and stromal elements
most common breast tumor in adolescent and young adult women (peak age = third decade)
well-circumscribed, freely mobile, nonpainful mass
may regress with age if left untreated
ducts distorted elongated - slit-like structures intracanalicular pattern, ducts not compressed - pericanalicular growth pattern
what are some other adenomas?
Tubular adenoma:
- far less common than fibroadenomas
- young women, discrete, freely movable masses
- uniform sized ducts
Lactating Adenoma:
- enlarging masses during lactation or pregnancy
- prominent secretory change
what is an intraduct papilloma
Usually middle aged women
Nipple discharge
Can show epithelial hyperplasia, which might be atypical
An intraductal papilloma is a wart-like lump that develops in one or more of the milk ducts in the breast. It’s usually close to the nipple, but can sometimes be found elsewhere in the breast. Intraductal papilloma is a benign (not cancer) breast condition
what is fat necrosis?
can simulate carcinoma clinically and mammographically
history of antecedent trauma, prior surgical intervention
histiocytes with foamy cytoplasm
lipid-filled cysts
fibrosis, calcifications, egg shell on mammography
what is shown here?
Duct ectasia
Duct ectasia, also known as mammary duct ectasia, is a benign (non-cancerous) breast condition that occurs when a milk duct in the breast widens and its walls thicken. This can cause the duct to become blocked and lead to fluid build-up. It’s more common in women who are getting close to menopause
what is a phyllodes tumour?
Fleshy tumor, leaf-like pattern and cysts on cut surface
circumscribed, connective tissue and epithelial elements, 1-15 cm
less than 1 % of breast tumors
benign, borderline, malignant
metastases are hematogenous
how common is breast cancer?
Affects one in 8 females :22% of all female cancers
1 in 870 men
Commonest cause of female cancer death (1/3 of affected women will die from disease)
how does breast cancer present on a mammogram and macrospoically
Mammogram- soft tissue opacity, microcalcification
Macroscopic- hard lump, fixed mass, tethering to skin, peau d’orange dimpling of skin
what is the epidemiology of breast cancer?
1.7 million new cases in 2012
Incidence increasing in most countries
470,000 deaths
Half of the global burden in low- and medium-resourced countries
In Europe breast cancer affected 464,000 women in 2012 and was responsible for the death of 131,000
55,000 new cases of breast cancer each year in the UK, including around 4700 in Scotland
350 male breast cancer yearly in the UK, including around 30 in Scotland
what are the risk factors for breast cancer?
gender
age
menstrual history
age at first pregnancy
radiation
family history
personal history
hormonal treatment
genetic factors
Other factors - obesity, lack of physical activity, alcohol
what is the risk of different breast lesions leading to cancer?
Epithelial proliferation without atypia – Relative risk 1.5-2x
With atypia ductal or lobular – Relative risk 4-5x
Lobular carcinoma in situ (LCIS) – Relative risk 8-10x
Ductal carcinoma in situ (DCIS) – Relative risk 8-10x
5 to 10% of breast cancers can be attributed to inherited factors
what genes may be responsible for inherited breast cancer?
what are some non-invasive carcinomas?
Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (LCIS/ LISN)
what are osme invasive carcinomas?
Invasive ductal carcinoma, NST (~75%)
Invasive lobular carcinoma and its variants (5-15%)
Special types (rest)
In situ carcinoma:
preinvasive - does not form a ________ tumor
not detected clinically (only _____ in DCIS-screening)
multicentricity and bilaterality (____)
no ________ spread (basement membrane)
risk of invasion depending on _____
palpable
X-ray
LCIS
metastatic
grade
what is shown here?
DCSI
what is shown here?
low grade DCIS
what is shown here?
LCIS
in situ cancer - what is the risk of DCIS and LCIS risk of progression?
Low grade DCIS - 30% in 15 years
High grade DCIS - 50% in 8 years
LCIS - 19% in 25 years and bilaterality
what is shown here?
invasive ductal carcinoma (IDC)
NST
what is shown here?
IDC
grade 3
what is hsown here?
invasive lobular carcinoma (ILC)
histological classification - what are some special types?
Tubular carcinoma
Mucinous carcinoma
Carcinoma with medullary features
Metaplastic carcinoma
others
what is shown here?
tubular carcinoma
what is shown here?
left - Mucinous
right - Medullary
what arre diagnostic procedures for breast cancer?
Clinical examination
Radiology (Mammogram, ultrasound, MRI)
Fine needle aspiration cytology FNA
Needle core biopsy
Wide local excision with adequate margins
how is screening for breast cancer done?
30 % reduction in mortality
Mammogram every 3 years
Women 50 - 70 years old
Approximately 1,700 cases of screen detected breast cancer were diagnosed in women of all ages in 2011- 2012
Over 80% (1,406 cases) of cancers detected were invasive, of which over half were less than 15mm in size
what are microcalcifications, who has them and are they harmful?
Tiny deposits of calcium can appear anywhere in the breast and often show up on a mammogram
Most women have one or more areas of microcalcifications of various sizes
Majority of calcium deposits are harmless
A small percentage may be in precancerous or cancerous tissue
Two of the most important mammographic indicators of breast cancer are what?
- Masses
- Microcalcifications: Tiny flecks of calcium – like grains of salt – in the soft tissue of the breast that can sometimes indicate an early cancer
pictures showing some cancers
on a histology report, what different information will be given about findings?
Invasive vs. Non-invasive
Histological Type-Ductal (85%) vs. Lobular
Grade (estimate of the aggressiveness under microscope)
Size
Margins
Lymph Nodes
Estrogen/Progesterone Receptor (2/3 positive)
HER-2/ neu
whre does breast cancer spread locally?
skin
pectoral msucles
where does breast cancer spread in the lymphatics?
axillary and internal mammary nodes
where does breast cancer spread in the blood to?
bone
lungs
liver
brain
what is shown here?
Lymph-vascular space invasion (LVSI)
what is shown here?
Lymph node metastasis
what is the prognosis of breast cancer and what is it based on?
Patient related and tumour related
Node status (best prognostic indicator)
Tumour size ( < 2cm )
Type
Grade (1,2,3 )
Age
Lymphovascular space invasion
Oestrogen receptors ( ER )
Progesterone receptors ( PR )
HER-2
Proliferative rate of tumour
Gene expression profiling
Nottingham Prognostic Index (NPI) based on tumour size, grade and nodal status
Overall 64 % five year survival
what are molecular markers?
ER /PR strong predictors of response to hormonal therapies
ER/PR negative tumours do not respond
HER-2 : about 20-30% positive - predicts response to trastuzumab ( Herceptin )
what is molecular classification?
Gene expression technology
5 subtypes: ER + luminal A, luminal B, Basal, Her 2+ and normal breast-like
Biologically diverse disease
Predictive gene signatures/potential to improve therapy
Complement current clinicopathological features
what is the management of breast cancer?
Staging
surgery (mastectomy, breast conserving surgery -WLE) +/- lymph nodes
radiotherapy
antihormonal therapy (Tamoxifen)
chemotherapy
what is pagets disease of the nipple?
result of intraepithelial spread of intraductal carcinoma
large pale-staining cells within the epidermis of the nipple
limited to the nipple or extend to the areola
pain or itching, scaling and redness, mistaken for eczema
ulceration, crusting, and serous or bloody discharge
what is gynecomastia?
- most common clinical and pathologic abnormality of the male breast
- increase in subareolar tissue
- in 30 to 40 percent of adult males, both breasts are affected in many cases
- associated with hyperthyroidism, cirrhosis of the liver, chronic renal failure, chronic pulmonary disease, and hypogonadism, use of hormones - estrogens, androgens, and other drugs (digitalis, cimetidine, spironolactone, marihuana, and tricyclic antidepressants)
carcinoma of the male breast, how common is it?
uncommon < 1 % of all breast cancers
