Breast Pathology 1 Flashcards by Aliya Hussain

What does triple assessment of a patient with breast disease involve?

Clinical:
• History
• Examination

Imaging:
• Mammography
• USS
• MRI

Pathology:
• Cytopathology
• Histopathology

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Methods of undertaking breast cytopathology?

Fine Needle Aspiration (FNA)

Fluid

Nipple discharge

Nipple scrape

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Results of breast FNA cytology?

C1 - unsatisfactory

C2 - benign

C3 - atypia, probably benign

C4 - suspicious of malignancy

C5 - malignant

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Methods of undertaking breast histopathology?

Diagnostic:
• (Needle) core biopsy
• Vacuum assisted biopsy (large volume / mammotome) 
• Skin biopsy
• Incisional biopsy of mass

Therapeutic:
• Excisional biopsy of mass
• Resection of cancer (wide local excision or mastectomy)

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Results of needle core biopsy?

B1 - unsatisfactory / normal

B2 - benign

B3 - atypia, probably benign

B4 - suspicious of malignancy

B5 - malignant:
• B5a - carcinoma-in-situ
• B5b - invasive carcinoma

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Broad classifications of benign breast disease?

Developmental anomalies
Non-neoplastic
Inflammatory
Tumours

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Types of developmental anomalies affecting the breast?

Hypoplasia

Juvenile hypertrophy

Accessory breast tissue

Accessory nipple

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Non-neoplastic issues affecting the breast?

Gynaecomastia

Fibrocystic change

Hamartoma

Fibroadenoma

Sclerosing lesions:
• Sclerosing adenosis
• Radial scar / complex sclerosing lesions (same pathology but size determines the name)

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Inflammatory issues affecting the breast?

Fat necrosis

Duct ectasia

Acute mastitis / abscess

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Benign tumours of breast?

Phyllodes tumour

Intraduct papilloma

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What is gynaecomastia?

Breast development in the male; there is ductal growth WITHOUT lobular development

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Causes of gynaecomastia?

Exogenous / endogenous hormones

Cannabis use

Prescription drugs

Liver disease (higher levels of circulating oestrogen)

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Occurrence of fibrocystic changes?

Very common

Women aged 20-50 years (mostly 40-50 years of age)

Most common in women with:
• Menstrual abnormalities,
• Early menarche
• Late menopause, etc

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Treatment of fibrocystic changes?

Often resolve or diminish after menopause

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PC of fibrocystic changes?

Smooth discrete lumps

Sudden pain

Cyclical pain

Lumpiness

Could be an incidental finding or picked up at screening

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Gross pathology of fibrocystic change?

Cysts and intervening fibrosis

Cysts vary from 1mm to several cm in size; they are blue-domed and filled with fluid

NOTE - fibrocystic changes are often assoc. with other benign changes, e.g: sclerosing adenosis

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Microscopic pathology of fibrocystic change?

Cysts - thin-walled but may have fibrotic wall it is lined by apocrine epithelium

There is intervening fibrosis

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Define metaplasia?

Change from 1 fully differentiated cell type to another fully differentiated cell type

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Management of fibrocystic change?

Exclude malignancy and then reassure

Only excise if necessary, e.g: symptomatic

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Define a hamartoma?

Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution, e.g: mammary hamartoma

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Occurrence of fibroadenomas?

Common and usually solitary (10% multiple)

More common in African women

Peak incidence in the 3rd decade of life

Symptoms of fibroadenoma?

Painless, firm, discrete, mobile mass

“breast mouse” - mobile and not fixed

Can be picked up at screening

USS appearance of fibroadenoma?

Solid on USS

Wider than they are deep

Gross pathology of fibroadenoma?

Circumscribed, rubbery and grey-white in colour

2 components of a fibroadenoma?

A biphasic tumour/lesion, i.e: there are 2 elements, of epithelium and stroma

Treatment of a fibroadenoma?

Diagnose and reassure Only excise if necessary

What are sclerosing lesions?

Benign, disorderly proliferation of acini and stroma May present as a mass or calcification and so it may mimic carcinoma

Types of sclerosing lesions?

1. Sclerosing adenosis - occurs between ages of 20-70 years; it is benign and there is negligible risk of subsequent carcinoma 2. Radial scar / complex sclerosing lesion - affect a wide age range and are common, although often an incidental finding or detected on mammogram (mimic carcinoma); possess stellate architecture, with a central puckering and radiating fibrosis: • Radial scar if 1-9mm in size • Complex Sclerosing Lesion (CSL) if >10mm

Symptoms of sclerosing adenosis?

Pain, tenderness or lumpiness/thickening Can be asymptomatic

Histology of a radial scar?

Fibroelastic core with radiating fibrosis, containing distorted ductules Fibrocystic changes Often show epithelial proliferation, although they are probably not pre-malignant NOTE - in-situ or invasive carcinoma may occur within these lesions

Radiological appearance of radial scar?

Mimic carcinoma NOTE - as they look malignant on radiology, biopsy is required for diagnosis

Treatment of radial scar?

Excise or sample extensively by vacuum biopsy

Inflammatory issues of the breast?

Fat necrosis Duct ectasia Acute mastitis / abscess

Causes of fat necrosis?

Local trauma, e.g: seat belt injury, although there is frequently no history Warfarin therapy

Histology of fat necrosis?

Damage and disruption of adipocytes Infiltration by acute inflammatory cells "Foamy" macrophages Subsequent fibrosis and scarring

Management of fat necrosis?

Confirm diagnosis and exclude malignancy

What is duct ectasia?

Sub-areolar duct dilatation, with periductal inflammation and fibrosis, leading to scarring and distortion

Occurrence of duct ectasia?

ASSOC. WITH SMOKING

Clinical features of duct ectasia?

Pain Acute, episodic inflammatory changes Bloody and/or purulent discharge Fistulation Nipple retraction and distortion

Management of duct ectasia?

Treat acute infections Exclude malignancy Smoking cessation Excise ducts

2 main aetiologies of mastitis / abscess?

Duct ectasia (assoc. with smoking) - mixed organisms and anaerobes Lactating mastitis - mainly Staph. aureus and Strep. pyogenes

Management of mastitis / abscess?

Antibiotics +/- drainage (if there is an abscess), e.g: percutaneous drainage or incision drainage Treat underlying cause

Benign tumours of breast?

Phyllodes tumour (cystosarcoma phyllodes) - biphasic tumour with stromal overgrowth; its behaviour depends on the stromal features. Can be benign, borderline or malignant (sarcomatous) Intraduct papilloma

Occurrence of Phyllodes tumour?

Ages 40-50 years

PC of Phyllodes tumour?

Slow-growing unilateral breast mass

Behaviour of Phyllodes tumour?

Pathology helps to predict this If not adequately excised, often recur Rarely metastasise

Papillary lesions of the breast?

Intraduct papilloma - occurs at ages 35-60 years; affects the sub-areolar ducts and are 2-20mm in diameter Nipple adenoma Encysted papillary carcinoma

PC of intraduct papilloma?

Nipple discharge +/- blood Often asymptomatic at screening, where nodules or calcification are found

Structure of intraduct papillomas?

Papillary fronds containing a fibrovascular core Covered with myoepithelium and epithelium; the epithelium may show proliferative activity

Types of epithelial proliferation with intraduct papillomas (IDP)?

1. None = benign IDP 2. Usual type hyperplasia = benign IDP 3. Atypical ductal hyperplasia = IDP with ADH 4. Ductal carcinoma-in-situ (DCIS): • IDP with DCIS • Papillary DCIS

Do IDPs require treatment?

Yes