Breast Pathology Flashcards
describe the glandular tissue of the breast
consists of breast ducts and lobules
surrounded by fibrous tissue and a peripheral layer of myoepithelial cells
describe breast composition in different ages
older; more fatty tissue
younger; more glandular tissue
describe the lobules of the breast
main secretory component
lined by epithelial cells
produce milk products under appropriate stimulation
what is the function of myoepithelial cells of the breast?
contractile; move the secretions along the lobules
where does most secretion take place in the breast?
the lobules
describe the movement of secretions within the lobules
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
what are the most common breast symptoms?
pain; often cyclical, varying with the menstrual cycle
lump
discharge; clear, coloured, blood stained, almost constantly or at irregular times
describe cyclical mastalgia
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
describe nipple discharge
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
describe mammary duct ectasia
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
what are the causes of opaque discharge from a single duct?
papilloma
papillary lesion
rarely underlying malignancy; ductal carcinoma-in-situ
what is the management of mammary duct ectasia?
usually not necessary
unless the discharge is causing particular problems or prone to superinfection
may require duct excision
describe intraductal papilloma
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
what questions should be asked in a history of a breast lump?
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
what investigations should be performed for a breast lump?
mammography; older women
USS; younger women
needle biopsy; FNA or core needle biopsy
what are the symptoms and signs of a non-pathological breast lump?
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
what are the symptoms and signs of a malignant breast lump?
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
describe mammography in breast pathology
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
what can be seen on mammography?
breast tumour; spiculation, contraction and fibrosis
skin dimpling
pectoralis major muscle
metastatic lymph nodes; not confirmed until examined pathologically
describe the use of USS and its advantages in breast pathology
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
what are the causes of benign breast lumps?
simple cysts fibrocystic change fibroepithelial lesions papilloma fat necrosis
describe breast cysts
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
describe epidermal inclusion cysts
can arise anywhere in the skin
fired by an in-folding of squamous epithelium that contains trapped keratin
usually near the skins surface
describe fibrocystic change
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
describe the histology of fibrocystic change
cyst formation, fibrosis and adenosis
a form of non-proliferative abnormality
calcification can occur in the area of cyst formation or adenosis
describe breast cyst rupture
chronic inflammatory response in the surrounding tissue, leading to adjacent fibrosis
define adenosis
an increase in the number of acini or glands in a lobule without any proliferation of the epithelium in each acinus
what are the types of fibroepithelial lesions?
fibroadenoma; completely benign
benign phyllodes tumour
malignant phyllodes tumour
describe fibroadenoma
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
describe the clinical features of fibroadenomas
usually multiple and bilateral
painless, palpable mass which is very mobile; breast mouse
can fluctuate with the menstrual cycle and pregnancy
well circumscribed
describe the diagnosis and treatment of fibroadenomas
needle core biopsy
surgical excision; curative
many do not opt for treatment once they discover it is benign
describe the histology of fibroadenomas
obvious biphasic pattern
epithelial lined spaces surrounded by loose fibrous stroma
no nuclear pleomorphism, increased cellularity, mitotic activity and necrosis
what is the difference between fibroadenomas and phyllodes tumours?
fibroadenoma; balanced proliferation of benign epithelial and stromal tissue
phyllodes; stromal component proliferates out of proportion of the epithelial component resulting in stromal overgrowth
describe benign and malignant phyllodes tumours
benign stroma overgrowth which has a tendency for local recurrence
or
frankly malignant and sarcomatous
describe papillomas in breast
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
what are the clinical features of breast papilloma?
lump
nipple discharge; can be blood stained
what is the difference between solitary and multiple papillomas?
solitary; in large ducts near the nipple, can produce discharge easily
multiple; occur further from the nipple, more deep Ito the breast parenchyma
what features of a papilloma suggest malignancy?
epithelial atypia on core biopsy
multiple
describe fat necrosis
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
describe the histology of fat necrosis
large coalescing globules of fat
surrounded by foamy macrophages
multinuclear giant cells
what are the risk factors for breast cancer?
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
describe the clinical presentation of breast cancer
symptomatic or screening pathway lump skin tethering rash; especially around nipple nipple discharge mass lesion on x-ray cluster of calcifications on x-ray
what is the triple assessment of breast cancer?
clinical, radiological and pathological assessment
describe the clinical assessment of breast cancer
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
describe the radiological assessment of breast cancer
mammography
USS
MRI; difficult cases, certain age groups, dense lesion
biopsy of lesion
describe the pathological assessment of breast cancer
fine needly aspirate
core biopsy
what are the advantages and disadvantages of fine needle aspirate of breast cancer?
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
describe a benign breast FNA
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
describe a malignant breast FNA
larger cells much more pleomorphic; nuclei different shapes and sizes more discohesive no formation of well-defined groups necrotic material in the background
what are the advantages and disadvantages of core biopsy of breast cancer?
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
describe a core biopsy histology of DCIS (malignant)
basement membrane surrounding pleomorphic malignant cells
calcification
area of necrosis
describe a core biopsy of an invasive carcinoma
dark purple malignant cells infiltrating the light pink fibrosis tissue
infiltration of fatty breast tissue
