Breast path

Question 1

Acute mastitis: symptoms (3), cause (1), what is the involved breast tissue full of?

Answer 1

Red, painful breast + fever
Almost always a staph invasion in breast feeding/ lactating mothers via cracks in the skin
Involved breast tissue is necrotic and full of neutrophils

Question 2

Treatment of acute mastitis? (3)

Answer 2

Continued expression of milk
+ antibiotics
+/- surgical drainage

Question 3

Periductal mastitis: association (2), Histology

Answer 3

Mostly in SMOKERS & NOT associated with lactation

Histology - keratinizing squamous epithelium extends deep into nipple duct orifices

Question 4

Mammary duct ectasia: epidemiology (2), what is it? Cause? what does it mimic on mammography? Cytology? (2)

Answer 4

Multiparous 40-60 yr olds
Poorly defined palpable periareolar mass wit THICK, WHITE NIPPLE SECRETIONS
Caused by granulomatous inflammation of large breast ducts
Mimics mammography of cancer
Cytology - proteinaecous material, inflammatory cells

Question 5

Fat necrosis what is it? presentation (3), causes (all traumatic - 3)

Answer 5

Inflammatory rxc to damaged adipose tissue
presents as PAINLESS breast mass/ skin thickening/ mammographic lesion
Cause - trauma, surgery, radiotherapy

Question 6

Fibrocystic disease/ fibroadenosis (breast lumpiness): what is it? Cystic change. Fibrosis. Adenosis

Answer 6

Group of changes caused by exaggerated normal response to hormones
Cystic change - small cysts from due to dilation of lobules; contain fluid +/- calcified
Fibrosis - inflammation + fibrosis occurs secondary to cyst rupture
Adenosis - increased number of acini per lobule (normal in pregnancy)

Question 7

Gynaecomastia: what is it? indicator of what? Histology (2)

Answer 7

Breast enlargement in males
Indicates HYPEROESTRINISM - alcohol, age, liver cirrosis, functioning testicular tumour
Histology - epithelial hyperplasia, finger like projections into ducts

Question 8

Fibroadenoma (breast mouse - moves): what is it? age group? describe lumps (4). Cure?

Answer 8

Most common benign tumour, from stroma, usually multiple
Ocurrs in any age group of reproductive age 20-30 most common
Epithelium responsive to hormones - enlarges during preg, calcifies in menopause
Lumps - firm, spherical, mobile, rubbery
Overgrowth of collagenous mesenchyme
‘shelling out’ is curative

Question 9

Duct papillomas are benign or malignant? Arise from where? (2) Discharge? Ix (1)

Answer 9

Benign papillary tumours, arising from duct system:
small terminal ductules - peripheral papilloma. Large lacterferous ducts - central papilloma.
Bloody discharge
Ix - galactogram (not seen on mammogram)

Question 10

Radial scar - what is it? Significance?

Answer 10

Benign sclerosing lesion - central scarring surrounded by proliferating glandular issue in stellate pattern.
Resembles carcinoma on mammogram

Question 11

Breast carcinoma epidemiology: (3)

Answer 11

most common cancer in women
1:8 lifetime risk
99% in women

Question 12

Breast carcinoma risk factors (6)

Answer 12

Susceptibility genes - BRCA1/2; cause lifetime risk to go up to 85% (they also increase risk of ovarian, prostate & pancreatic cancer)
Hormone exposure - anything to do with high oestrogen; remember also pregnancy results in terminal differentiation of milk-producing cells, removing them from pool of potential cancer precursors
Age
FH
Race: caucasian>afro-carribean>asian>hispanic
Obesity/alcohol/tobacco

Question 13

Presentation of breast carcinoma (4)

Answer 13

Hard fixed lump
Paget’s disease
Peau d’orange
nipple retracation

Question 14

Screening programme for breast cancer

Answer 14

47-73 yr olds invited every 3 yrs for mammography - which looks for abnormal areas of calcification in the breast

Question 15

Carcinoma in situ (30%) what is it? types? (2)

Answer 15

Neoplastic epithelial proliferation LIMITED to ducts/lobules by BM
DCIS or LCIS

Question 16

LCIS characteristics (3)

Answer 16

ALWAYS an incidental finding on biopsy as no microcalcifications or stromal rxns.
Cells lack adhesion protein E-cadherin
F for subsequent invasive breast carcinoma

Question 17

DCIS characteristics ( (3)

Answer 17

Dramatically increased incidence following development of mammography
Appear as areas of microcalcifications
10% present with clinical symptoms
Much increased risk of progressing to invasive breast CA

Question 18

Invasive breast CA (80%) what are they? what are the 4 subtypes?

Answer 18

Malignant epithelial tumours that infiltrate within breast and can spread to distant sites
Histologically classified into:
Ductal
Lobular
Mucinous
Tubular

Question 19

Invasive ductal carcinoma is the most common - T or F?

Answer 19

T

Question 20

Invasive lobular carcinoma characteristics

Answer 20

Cells aligned in single file chains/strands

Question 21

Invasive tubular carcinoma characteristics (2)

Answer 21

Well formed tubules with low grade nuclei. Rarely palpable as

Question 22

Mucinous carcinoma characteristic

Answer 22

Produces excess EV mucin which dissects into surrounding stroma

Question 23

Triple assessment

Answer 23

Examination
Radiology - mammography/ USS
FNA & cytology

Question 24

Function of core biopsy, what it assesses (3) grading

Answer 24

Neoplastic lesions are biopsied to check histological subtype + grading
Assess nuclear pleomorphism, tubule formation & mitotic activity
Each gets a score out of 3 (max 9): 3-5 = grade 1, 6-7 = grade 2, 8-9 = grade 3

Question 25

What receptors are checked for in neoplastic lesions? (3)

Answer 25

ER
PR
HER2 (EGFR family - overexpressed oncogene)
ER/PR associated with good prognosis (because tamoxifen will work)
HER2 bad prognosis

Question 26

What is Tamoxifen?

Answer 26

SERM

Question 27

What is herceptin/ trastuzumab?

Answer 27

monoclonal Ig to Her2

NB - has direct toxic effect on myocardium so must monitor LVEF

Question 28

Basal-like carcinoma stains positive for what?

Answer 28

Sheets of atypical cells with lymphocyte infiltrates stain positive for CK 5/6/14

Question 29

Phyllodes tumour

Answer 29

Arise from interlobular stroma with increased cellularity and mitoses
present > 50 yrs with palpable mass
mostly relatively benign, but can be aggressive so excised with wide local excision/ mastectomy