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Breast Path Flashcards

1
Q

Composition of glandular tissue

A

Ducts

Lobules

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2
Q

Function of Ducts

A

Excretion of milk

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3
Q

Function of lobules

A

Secretion of milk

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4
Q

Most common cause of breast pain

A

Cyclical mastalgia

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5
Q

Rx cyclical mastalgia

A

Primrose oil in the evening

Simple analgesia

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6
Q

Cycle of cyclical mastalgia

A

Worse before period

Better after period

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7
Q

Causes of clear discharge

A

Physiological

Prolactinoma (rare)

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8
Q

Cause of Nipple discharge from multiple ducts

A

Mammary duct ectasia

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9
Q

Cause of nipple discharge from a single duct

A

Papilloma

Ductal ca in sitiu (rare)

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10
Q

Epi of duct ectasia

A

35-45 y/o

Smokers

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11
Q

Rx duct ectasia

A

Nothing

Excision

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12
Q

Path of duct ectasia

A

Defective elastic tissue around the duct

Ineffective excretion of milk

Milk pools in sinus and inflammation ensues

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13
Q

Presentation of intraductal papilloma

A

Single duct discharge

Blood stained

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14
Q

Histology of Intraductal papilloma

A

Fibrovascular core surrounded by epithelial and myoepithelial cells

Inside a duct

Attached to wall

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15
Q

How is a breast lump assessed?

A

Triple assessment:

  1. Clinical (Hx, Examination)
  2. Radiological (Mammography, USS)
  3. Biopsy (FNA/ CB)
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16
Q

Breast Lump Hx

A

S= Site (medial = not good)

O= Onset (duration, getting worse better)

C= Character/Consistency (focal, vague, smooth, irregular, soft, firm, tethered)

R= Radiation (Skin / axilla)

A= Associated sx (Pain, discharge)

T= Timing (Cyclical, constant, period, pregnancy, breast feeding)

E =

S= Size (fluctuation, progression?)

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17
Q

What type of radiology is a mammogram?

A

XR

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18
Q

What type of patients benefit from mammogram screening? Why?

A

Older women

Breast tissue is less dense (more fatty)
Masses are more apparent

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19
Q

Mammogram views

A
  1. Cranio-caudal

2. Oblique

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20
Q

Complications of mammogram?

2

A
  • Exposure to radiation (increased risk of ca)

- Often misses medial masses/calcifications

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21
Q

When is a USS used?

3

A
  • To tell if a lump is cystic or solid
  • To tell if a lump is smooth or irregular
  • To guide biopsy
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22
Q

Types of benign breast lumps

5

A
  1. Simple cyst
  2. Fibrocystic change
  3. Fibroadenoma
  4. Papilloma
  5. Fat necrosis
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23
Q

Types of simple cyst

A
  • Epidermal inclusion cyst

- Deep lobular/ductal cyst

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24
Q

What happens to the lobular/ductal epithelium in lobular/ductal cyst formation?

A

Metaplasia to apocrine epithelium

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25
Q

What happens to the epithelium in epidermal inclusion cysts?

A

There is infolding of the squamous epithelium and a keratin inclusion body is formed

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26
Q

How to people present with fibrocystic change?

A
  • Vague, painless lump/bump/thickening

- Asymptomatic: calcification was picked up on a mammogram

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27
Q

Histopathology of fibrocystic change

A
  • Cyst
  • Fibrosis
  • Adenosis
  • Calcification
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28
Q

Presentation of Fibroadenoma

A
  1. Young:
    - Lump: mobile, painless, smooth
    - Hormonally responsive
  2. Old:
    - Asymptomatic but mamographic abnormality
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29
Q

Histopathology of Fibroadenoma

2

A
  • Balanced proliferation of epithelial and stromal elements

- well circumscribed and pale

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30
Q

Transformation of Fibroadenoma

A

Fibroadenoma —>

Benign Phyllodes Tumour—>

Malignant Phyllodes Tumour

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31
Q

Histopathology of benign phyllodes tumour

A

Stromal proliferation > epithelial proliferation

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32
Q

Histopathology of malignant phyllodes tumour

A

Sarcoma

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33
Q

Histopathology of papilloma

3

A
  • Fibrovascular core surrounded by cuboidal epithelium
  • Branching pattern
  • Within ducts
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34
Q

Presentation of Papilloma and associated cancer risk

A

Bloody discharge from a single duct = lower risk of cancer

No discharge but multiple ducts involved = increased risk of ca

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35
Q

Cause of fat necrosis

A

Trauma:

  • seatbelt
  • surgical
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36
Q

Presentation of Fat necrosis

A

Painless, well circumscribed lump

OR

Vague thickening

BOTH WITH

Hx Trauma

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37
Q

Histopathology of Fat necrosis

3

A
  • Multinucleated giant cells
  • Fat / oil droplets
  • Foamy macrophages
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38
Q

What is the most common cancer in women?

A

Breast

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39
Q

What % of cancers in females does Breast ca account for?

A

25%

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40
Q

How many cases of male breast cancer in UK every year?

A

400

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41
Q

What is the most common cause of cancer death in women?

42
Q

How does FmHx of breast cancer affect risk?

2

A
  • 1st degree relative = doubled risk

- 15% of women with 1st degree relative get breast ca

43
Q

Inheritance pattern of BRCA mutations

44
Q

Chance of BRCA +ve patient developing breast ca by 70y/o

A

50%

Range 45%-65%

45
Q

How does increased breast density affect breast ca risk and diagnosis?

2

A
  • Increased risk ca

- Increased risk of false -ve on mammogram

46
Q

Hormonal Risk Factors for Breast ca

6

A

HRT

OCP

Early Menarche

Nulliparity

Late menopause

Never breast fed children

47
Q

Lifestyle Risk factors for breast ca

4

A

Obesity

Smoking

Alcohol

Ionising radiation

48
Q

What do you look for on a mammogram?

2

A

Mass lesion

Calcification

49
Q

What age range is eligible for breast screening in UK?

How often?

A

50-70 y/o

Every 3 years

50
Q

What % of screening participants are recalled?

51
Q

What % of screening participants have breast ca?

A

1%

25% of recalled patients

52
Q

What would you cover in breast cancer HPC?

11

A 
Lumps
Bumps
Thickening
Skin involvement
Axilla involvement

Discharge
Nipple deviation

Fatigue
Lethargy
Weight loss
Anaemia

53
Q

What would you cover in Breast ca Hx (excluding HPC)?

A

FmHx- Breast ca, degree of relative, age of relative, BRCA, Ovarian ca

PmHx- Age of menarche, parity, menopause, any other ca, specifically ovarian ca, BRCA, Breast Trauma

Surgical Hx-

DHx- OCP, HRT

SHx- Alcohol, smoking, BMI, Radiation

54
Q

Describe examination of a lump

A

3S 3T 3C

Site, size, shape

Temperature, Tenderness, Tethering

Colour, Contour, Consistency

55
Q

When would you use MRI as part of tripple assessment?

A

Young patients

Dense breast tissue
Mammography could give false -ve

56
Q

What is test sensitivity?

A

The ability of a test to identify true positives

a sensitive test would have low false +ve rates

57
Q

What is test specificity?

A

The ability of a test to identify true negatives

A specific test would have a low false negative rate

58
Q

Describe the sensitivity and specificity of FNA?

A

FNA is sensitive but not specific

  • Rules in malignancy (Low false +ve rate)
  • Can’t rule out malignancy even if nothing suspicious shows on the slide
    (Low false -ve rate)

Good at identifying true positives, bad at identifying true negatives

59
Q

Advantages of FNA

5

A
  • Quick
  • Easy
  • Cheap
  • Painless
  • Rarely complications
60
Q

Disadvantages of FNA

5

A
  • Can’t give definite benign diagnosis
  • Can’t subtype malignant lesions
  • Can’t differentiate invasive from in sitiu
  • Can’t sample calcifications
  • High equivocal rate (ambiguous)
61
Q

What stain is used for looking at FNA?

A

Giemsa

Blue-purple

62
Q

What does benign FNA aspirate look like on cytology?

3

A

Cohesive groups

Small cells

Background = sparse myoepithelial cells

63
Q

What does malignant FNA aspirate look like on cytology?

4

A

Dis-cohesive

Bigger

Pleomorphic

Necrotic background

64
Q

Advantages of CB

A
  • Very low false +ve (Very sensitive)
  • Can give specific benign dx
  • Can differentiate in situ from invasive
  • Subtypes
  • Can tell receptor status
65
Q

Disadvantages of CB

A

Local anaesthetic needed

Expensive

Complications more frequent

More complex

Requires radiological guidance

66
Q

Subtypes of breast cancer

A

Ductal carcinoma

Lobular carcinoma

67
Q

What would a CB of in situ ca show?

A

Neoplastic cells

Basement membrane intact

68
Q

What would a CB of invasive ca show?

A

Neoplastic cells

Basement membrane breeched

69
Q

Clinical findings of ductal ca

A

Well defined lump

70
Q

Radiological findings of ductal ca

A

Well-circumscribed mass

71
Q

Macroscopic pathological findings of ductal ca

A

Firm, clearly outlined tumour

72
Q

Miscroscopic pathological findings of ductal ca

A

Abnormal glandular structures

Adenocarcinoma

73
Q

Clinical findings of Lobular Ca

A

Vague thickening

74
Q

Radiological findings of Lobular Ca

A

Poorly distinguished mass

75
Q

Which radiological Ix is best in lobular ca?

76
Q

Macroscopic Pathological findings of Lobular Ca

A

Poorly defined mass

77
Q

Macroscopic pathological findings of Lobular Ca

A

Infiltrating single cells

78
Q

Why does lobular ca present as thickening instead of a lump?

A
  • The malignant cells lose e-cadherin

- The cells don’t stick together well

79
Q

How is breast Ca graded?

A

Rate each of these out of 1-3

Tubule formation
Nuclear pleomorphism
Mitotic figures

Add each of these up

Grade 1 : 3-5
Grade 2 : 6-7
Grade 3 : 8-9

80
Q

How is breast ca staged?

81
Q

In TNM staging, what does this mean?:

N0

A

Node negative

82
Q

In TNM staging, what does this mean?:

N1

A

Nodes involved

Mobile

83
Q

In TNM staging, what does this mean?:

N2

A

Nodes involved

Fixed

84
Q

In TNM staging, what does this mean?:

N3

A

Supraclavicular Nodes

OR

Oedema

85
Q

In TNM staging, what does this mean?:

M0

A

No distant mets

86
Q

In TNM staging, what does this mean?:

M1

A

Distant mets

87
Q

In TNM staging, what does this mean?:

T1

A

Tumour sized 20mm or less

88
Q

In TNM staging, what does this mean?:

T2

A

Tumour sized 20-50mm

89
Q

In TNM staging, what does this mean?:

T3

A

Tumour sized 50-100 mm

OR

<50mm with infiltration

90
Q

In TNM staging, what does this mean?:

T4

A

Tumour sized > 100mm

91
Q

Which has a worse prognosis, ductal or lobular ca?

92
Q

What does tubules represent in Breast ca?

A

Ductal ca

adenocarcinoma

93
Q

Location of ERs?

94
Q

Location of HER-2 receptors?

A

Cell membrane

95
Q

What does ER+ve look like on a slide?

A

Dots coloured in brown

96
Q

What does HER-2 +ve look like on a slide?

A

Dots with brown perimetry

97
Q

Prognosis ER +ve

98
Q

Prognosis HER-2 +ve

A

Better in the short term

99
Q

Rx ER +ve tumours (3)

+ MOA

A

Tamoxifen
Anastrozole
Rimidrex

Block oestrogen binding (ER antagonists)

100
Q

Rx HER+ve

Pathology (6 decks)

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