Breast Pathology

Question 1

describe the glandular tissue of the breast

Answer 1

consists of breast ducts and lobules

surrounded by fibrous tissue and a peripheral layer of myoepithelial cells

Question 2

describe breast composition in different ages

Answer 2

older; more fatty tissue

younger; more glandular tissue

Question 3

describe the lobules of the breast

Answer 3

main secretory component
lined by epithelial cells
produce milk products under appropriate stimulation

Question 4

what is the function of myoepithelial cells of the breast?

Answer 4

contractile; move the secretions along the lobules

Question 5

where does most secretion take place in the breast?

Answer 5

the lobules

Question 6

describe the movement of secretions within the lobules

Answer 6

the secretions move into the intralobular duct
one duct supplies each lobular unit
this moves to the extralobular ducts, the larger lactiferous ducts and the lactiferous sinuses

Question 7

what are the most common breast symptoms?

Answer 7

pain; often cyclical, varying with the menstrual cycle
lump
discharge; clear, coloured, blood stained, almost constantly or at irregular times

Question 8

describe cyclical mastalgia

Answer 8

usually greatest in the premenstrual phase
usually relieved once menstruation begins
sometimes improved by evening primrose oil and simple analgesics
may require mastectomy; relatively uncommon
very low risk for malignancy

Question 9

describe nipple discharge

Answer 9

single duct; accentuated by pressing on one area
multiple ducts; expressed by pressing anywhere around the nipple
clear; usually physiological, may be a prolactin-secreting tumour of the pituitary gland
opaque
blood stained

Question 10

describe mammary duct ectasia

Answer 10

opaque discharge from multiple ducts
commonly in women 35-45
almost always in smokers
defect in the elastic tissue surrounding the larger ducts causing secretions to pool and an inflammatory response
not associated with risk of underlying malignancy

Question 11

what are the causes of opaque discharge from a single duct?

Answer 11

papilloma
papillary lesion
rarely underlying malignancy; ductal carcinoma-in-situ

Question 12

what is the management of mammary duct ectasia?

Answer 12

usually not necessary
unless the discharge is causing particular problems or prone to superinfection
may require duct excision

Question 13

describe intraductal papilloma

Answer 13

usually single duct
may be bloodstained; papilloma will twist, undergo partial infarction and break off or the surface will ulcerate
rarely malignancy arises within central fibrovascular core
covered by multi-layered epithelial cells
mixture of epithelial and contractile myoepithelial cells expected in any benign condition

Question 14

what questions should be asked in a history of a breast lump?

Answer 14

when it was first noticed
if it comes and goes with their menstrual cycle
associated with pain
if they've had lumps before
increasing/decreasing size
FHx of breast cancer

Question 15

what investigations should be performed for a breast lump?

Answer 15

mammography; older women
USS; younger women
needle biopsy; FNA or core needle biopsy

Question 16

what are the symptoms and signs of a non-pathological breast lump?

Answer 16

decreasing in size
appears just before menstruation or diminishes significantly after it
associated with pain
upper outer quadrant
fatty and soft on examination
firm; fibroadenomas
firm/hard depending on the pressure of fluid; cysts
vague and poorly defined; normal benign changes
smooth outline; benign

Question 17

what are the symptoms and signs of a malignant breast lump?

Answer 17

overlying skin changes; inflammation
tethered skin causing a dimple
medial
hard consistency
focal
very irregular edge; malignant
large fixed mass in the axilla; axillary nodal metastases

Question 18

describe mammography in breast pathology

Answer 18

the breast is placed between 2 plates and the beam is shone from above to below
2 angles; craniocaudal and oblique
something real will appear on both views
composite shadowing will appear on one view
medial part is not shown well
particularly effective in older patients; more fatty and less glandular breast tissue

Question 19

what can be seen on mammography?

Answer 19

breast tumour; spiculation, contraction and fibrosis
skin dimpling
pectoralis major muscle
metastatic lymph nodes; not confirmed until examined pathologically

Question 20

describe the use of USS and its advantages in breast pathology

Answer 20

not useful as a screening tool; very labour intestine and get a lot of false positives
can tell if a lesion is cystic (almost always benign) or solid
can show the outline of the lesion; smooth (reassuring)
can see needles; useful for image-guided biopsy

Question 21

what are the causes of benign breast lumps?

Answer 21

simple cysts
fibrocystic change
fibroepithelial lesions
papilloma
fat necrosis

Question 22

describe breast cysts

Answer 22

usually deep-seated
mostly arise in a dilated duct or lobule which is either developed abnormally or contains entrapped secretions
often lined by apocrine epithelium; metaplastic process
epithelium usually attenuated due to the pressure of the secretion

Question 23

describe epidermal inclusion cysts

Answer 23

can arise anywhere in the skin
fired by an in-folding of squamous epithelium that contains trapped keratin
usually near the skins surface

Question 24

describe fibrocystic change

Answer 24

usually doesn’t produce signs or symptoms
present in about 50% of women
clinical presentation; lumps, bumps, vague thickening
can calcify; usually picked up on mammogram screening
form as lobules unfold and coalesce
can be caused by duct blockages leading to a holdup of secretions

Question 25

describe the histology of fibrocystic change

Answer 25

cyst formation, fibrosis and adenosis a form of non-proliferative abnormality calcification can occur in the area of cyst formation or adenosis

Question 26

describe breast cyst rupture

Answer 26

chronic inflammatory response in the surrounding tissue, leading to adjacent fibrosis

Question 27

define adenosis

Answer 27

an increase in the number of acini or glands in a lobule without any proliferation of the epithelium in each acinus

Question 28

what are the types of fibroepithelial lesions?

Answer 28

fibroadenoma; completely benign benign phyllodes tumour malignant phyllodes tumour

Question 29

describe fibroadenoma

Answer 29

a very common cause of breast lumps most common benign breast tumour usually in women <30yrs contains dense interlobular stroma and looser intralobular stroma rarely contains fat, smooth muscle or bone

Question 30

describe the clinical features of fibroadenomas

Answer 30

usually multiple and bilateral painless, palpable mass which is very mobile; breast mouse can fluctuate with the menstrual cycle and pregnancy well circumscribed

Question 31

describe the diagnosis and treatment of fibroadenomas

Answer 31

needle core biopsy surgical excision; curative many do not opt for treatment once they discover it is benign

Question 32

describe the histology of fibroadenomas

Answer 32

obvious biphasic pattern epithelial lined spaces surrounded by loose fibrous stroma no nuclear pleomorphism, increased cellularity, mitotic activity and necrosis

Question 33

what is the difference between fibroadenomas and phyllodes tumours?

Answer 33

fibroadenoma; balanced proliferation of benign epithelial and stromal tissue phyllodes; stromal component proliferates out of proportion of the epithelial component resulting in stromal overgrowth

Question 34

describe benign and malignant phyllodes tumours

Answer 34

benign stroma overgrowth which has a tendency for local recurrence or frankly malignant and sarcomatous

Question 35

describe papillomas in breast

Answer 35

a lesion composed of fibroascular cores lined by benign epithelium arise within the wall of a breast duct usually cause blockage and duct widening/dilation richly vascular

Question 36

what are the clinical features of breast papilloma?

Answer 36

lump | nipple discharge; can be blood stained

Question 37

what is the difference between solitary and multiple papillomas?

Answer 37

solitary; in large ducts near the nipple, can produce discharge easily multiple; occur further from the nipple, more deep Ito the breast parenchyma

Question 38

what features of a papilloma suggest malignancy?

Answer 38

epithelial atypia on core biopsy | multiple

Question 39

describe fat necrosis

Answer 39

well circumscribed and discrete to a diffuse area of vague thickening usually caused by trauma; can be minor damage to the fatty tissue of the breast with an inflammatory response infiltration of macrophages which take on a foamy appearance can form an oily cyst or can calcify

Question 40

describe the histology of fat necrosis

Answer 40

large coalescing globules of fat surrounded by foamy macrophages multinuclear giant cells

Question 41

what are the risk factors for breast cancer?

Answer 41

``` FHx; BRCA1 and BRCA2 PMHx increased breast density; increased proportion of glandular tissue, more difficult to detect subtle abnormalities (more negative screening) increased levels of oestrogen and progesterone early age at menarche late menopause age at first childbirth OCP use lack of breastfeeding obesity alcohol smoking ionising radiation; ipsilateral or contralateral ```

Question 42

describe the clinical presentation of breast cancer

Answer 42

``` symptomatic or screening pathway lump skin tethering rash; especially around nipple nipple discharge mass lesion on x-ray cluster of calcifications on x-ray ```

Question 43

what is the triple assessment of breast cancer?

Answer 43

clinical, radiological and pathological assessment

Question 44

describe the clinical assessment of breast cancer

Answer 44

``` Hx; lumps or bumps skin changes nipple discharge systemic symptoms; weight loss, fatigue, lethargy, anaemia FHx of breast cancer; very important risk factors ``` ``` examination; overall physical condition lumps tethering appears fixed or free to move within the breast skin and nipple changes metastatic spread within the axilla ```

Question 45

describe the radiological assessment of breast cancer

Answer 45

mammography USS MRI; difficult cases, certain age groups, dense lesion biopsy of lesion

Question 46

describe the pathological assessment of breast cancer

Answer 46

fine needly aspirate | core biopsy

Question 47

what are the advantages and disadvantages of fine needle aspirate of breast cancer?

Answer 47

advantages; quick, minimal technical difficulty, cheap equipment, relatively painless, few complications disadvantages; difficult to subtype benign or malignant lesions, cannot give a position benign diagnosis, cannot differentiate between invasive and in-situ carcinoma

Question 48

describe a benign breast FNA

Answer 48

cells forming cohesive groups well-defined outlines dark-coloured dots; myoepithelial cells that line the ducts look like bare nuclei as they lose their cytoplasm

Question 49

describe a malignant breast FNA

Answer 49

``` larger cells much more pleomorphic; nuclei different shapes and sizes more discohesive no formation of well-defined groups necrotic material in the background ```

Question 50

what are the advantages and disadvantages of core biopsy of breast cancer?

Answer 50

advantages; can make a specific benign diagnosis, low false positive rate, can distinguish in-situ from invasive carcinomas, can identify invasive subtypes, can provide hormone receptor status and HER2 status disadvantages; more technically complex, requires a radiologist, local anaesthetic required, more complications (haematoma), expensive

Question 51

describe a core biopsy histology of DCIS (malignant)

Answer 51

basement membrane surrounding pleomorphic malignant cells calcification area of necrosis

Question 52

describe a core biopsy of an invasive carcinoma

Answer 52

dark purple malignant cells infiltrating the light pink fibrosis tissue infiltration of fatty breast tissue