Breast Pathology 1 (Incomplete) Flashcards by Arya Nedungadi

Features of assesment of a ptaient with breast disease

TRIPLE ASSESMENT

Clinical: history and exam
Imaging: Mammography, US, MRI
Pathology: cyto and histopathology

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Methods of breast cytopathology

Fine Needle Aspiration (FNA)
Fluid
Nipple discharge
Nipple scrape

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Slide image 1 (slide 9)

Typiacl benign sample
Apocrine cells
Normal ductal epithelial cells - stuck together to form sheets and tight junction

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Slide 10

Degenerate cells which are falling apart
Malignant aspirate
Diagnosis: carcinoma
Treatment: surgery

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Breast FNA cytology classification

C1 - Unsatisfactory
C2 - Benign
C3 - Atypia, probably benign
C4 - Suspicious of malignancy
C5 - Malignant (doesn't tell us if it is invasive)

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Diagnostic methods of breast histopathology

(Needle) Core biopsy
Vaccum assisted biopsy
Skin biopsy
Incisional biopsy of mass

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Classification of needle core biopsy results

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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List the developmental anomalies of the breast

Hypoplasia
Juvenile hypertrophy
Accessory breast tissue
Accessory nipple

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List non-neoplastic breast diseases

Gynaecomastia
Fibrocystic change
Hamartoma
Fibroadenoma
Sclerosing lesions 
- Sclerosing adenosis
- Radial scar/complex sclerosing lesions

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List inflammatory breast diseases (Benign)

Fat necrosis
Duct ectasia
Acute mastitis

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List benign tumours of the breast

Phyllodes

Intraduct papilloma

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What is Gyanecomastia?

Breast development in the male

Ductal growth without lobular development

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Histology of gynaecomastia

hyperplastic epithelium

small number associated with progression to malignancy

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Causes of gynaecomastia?

Exogenous/endogenous hormones
Cannabis
Prescription drugs
Liver disease - metabolism of cholesterol based hormone is disruptive ending up with an excess of oestrogen and therefore gynaecomastia

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Epidemiology of fibrocystic change

Women aged 20-50
Majority 40-50
Very common

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Risk factors of fibrocystic change

Menstrual abnormalities
Late menopause
Early menarche

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Presentation of fibrocystic change

Smooth discrete lumps
Sudden pain
Cyclical pain
Lumpiness
Incidental finding
Might be picked up during breast screening

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Gross pathology of fibrocystic change

Cysts: 
1mm - several cm
Blue domes with pale fluid
Usually multiple
Associaetd with other benign changes

Intervening fibrosis

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Microscopic appearance of fibrocystic change

Apocrine lining rather than eccrine lining of regular breast
Metaplastic change
Low nuclear cytoplasm ratio

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Management of fibrocystic change

Exclude malignancy
Reassure
Excise if necessary

Define hamartoma

“Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution”

Features of fibroadenoma

Common (17% in autopsy studies)
Usually solitary (10% multiple)
Commoner in African women

Clinical features of fibroadenoma

Peak incidence in 3rd decade
Common in pre-menopausal women
Screening
Painless, firm, discrete, mobile mass
“Breast mouse”- move away from finger when trying to examine
Solid on ultrasound (helps eliminate cyst)

Appearance of fibroadenoma

Circumscribed

Rubbery

Grey-white colour

Biphasic tumour/lesion with 2 components:
Epithelium
Stroma

Treatment of fibroadenoma

Diagnose Reassure Excise

Types of sclerosing lesions

Sclerosing adenosis Radial scar/ complex sclerosing lesion (both feel malignant, essentially the same thing but of different sizes)

What are sclerosing lesions?

Benign, disorderly proliferation of acini and stroma Can cause a mass or calcification May mimic carcinoma

Clinical features of sclerosing adenosis

Pain, tenderness or lumpiness/thickening Asymptomatic Age: 20-70 Benign, negligible risk of subsequent Ca

Features of radial scar

``` Wide age range Common Incidental finding Mammographically detected Mimic carcinoma radiologically Probably not premalignant per se Often show epithelial proliferation In situ or invasive carcinoma may occur within these lesions ```

Pathology of radial scar

``` RS – 1-9mm CSL - >10mm Stellate architecture central puckering Radiating fibrosis ```

Treatment of radial scar

Excise or sample extensively by vacuum biopsy

Causes of fat necrosis

Local trauma - seat belt injury, frequently no history Warfarin therapy

Pathophysiology of fat necrosis

``` Damage and disruption of adipocytes Infiltration by acute inflammatory cells “foamy” macrophages Subsequent fibrosis and scarring CALCIFICATION ON MAMMOGRAM (d/t saponification) ```

Management of fat necrosis

Confirm diagnosis | Exclude malignancy

What is duct ectasia?

Inflammation with dilation of the sub-areolar ducts

Clinical features of duct ectasia

``` Pain Acute episodic inflammatory changes Bloody and/or purulent D/C - green-brown in colour (inflammatory debris) Fistulation Nipple retraction and distortion ```

Risk factors of ductal ectasia

Smoking Perimenopausal Multiparous

Pathology of ductal ectasia

Sub-areolar duct dilatation Periductal inflammation Periductal fibrosis Scarring and distortion

Management of ductal ectasia

Treat acute infections Exclude malignancy Stop smoking Excise ducts

What are the 2 main aetiologies of acute mastitis/abscess?

1. Duct ectasia - mixed organisms, anaerobes | 2. Lactation - staph aureus, strep pyogenes

Management of acute mastitis/breast abscess

Antibiotics Percutaneous drainage Incision and drainage Treat underlying cause

Clinical features of acute mastitis

Erythematous breast with purulent nipple discharge; may progress to abscess formation

What is periductal mastitis?

Inflammation of the sub-areolar ducts, usually seen in smokers

Clinical features of periductal mastitis

Sub-areolar mass with nipple retraction

What are phyllodes tumours?

Fibroadenoma-like tumor with overgrowth of the fibrous component

What are the histologic features of a phyllodes tumour?

Biphasic tumour Stromal overgrowth Behaviour depends on stromal features: - Benign - Borderline - Malignant (sarcomatous)

What is the behaviour of phyllodes tumour?

Pathology helps to predict Prone to local recurrence if not adequately excised Rarely metastasize

Clinical features of phyllodes tumour

40-50 (postmenopausal) | Slow growing unilateral breast mass

Which tumour appears on biopsy with "leaf-like" projections?

Phyllodes tumour