Breast Pathology Flashcards
Presentation of breast disease (3)
o Breast lump
o Abnormal screening mammogram
o Nipple discharge
Ix for breast (TRIPLE TEST)
- Clinical examination
- Imaging (sonography, mammography, MRI)
MRI tends to only be used for very small lesions that may be missed by US or mammography
- Pathology (cytopathology and/or histopathology) – either FNA or core biopsy
- aspiration by 16/18 gauge needle
Screening is 50-70 years of age
Cytopathology
- Cell are aspirated, spread across a slide and stained
- Good cellular detail and quick to prepare but does NOT show the tissue architecture
- Used in the investigation of nipple discharge and palpable lumps
- Aspirates are coded C1-5
- C1 = inadequate
- C2 = benign
- C3 = atypia, probably benign
- C4 = atypia, probably malignant
- C5 = malignant
Histopathology
- Intact tissue is removed, fixed in formalin, embedded in paraffin wax, thinly sliced, stained with H&E (haematoxylin and eosin)
- Either core biopsies or surgical excisions
- Takes 24 hours to process
- Shows architectural and cellular detail
- This is the GOLD STANDARD for the diagnosis of breast cancer
Example stain to the right:
- Stained purple is the breast’s glandular tissue
- Pink area around the glands is the stroma
- Large pink circle in the middle of the top left image is the duct with the acini around the duct
- This unit is called the terminal duct lobular unit (TDLU)
- Blue arrows are pointing towards myoepithelial cells (this helps to pump milk)
- Epithelial (luminal) cells are on the inside of myoepithelial cells
What are the three inflammatory breast diseases?
Duct ectasia = inflammation and dilatation of large breast ducts:
Acute mastitis = acute inflammation in the breast:
Fat necrosis = an inflammatory reaction to damaged adipose tissue
Duct ectasia
- Aetiology is unclear
- Usually presents with nipple discharge
- May cause breast pain, breast mass and nipple retraction
- Cytology: proteinaceous material and neutrophils ONLY
-
Histology:
- Duct distension with proteinaceous material in it
- Foamy macrophages
Acute mastitis
- Often seen in lactating women due to cracked skin and stasis of milk
- May complicate duct ectasia
- Usual organism: staphylococci
- Presentation: painful (tender), red breast
- Treatment: drainage and antibiotics
- Cytology: neutrophils
Fat necrosis
- Causes = Trauma, surgery, radiotherapy
- Presentation: breast mass BENIGN
Cytology → fat cells surrounded by macrophages
5 examples of benign breast conditions
Fibrocystic disease – group of alterations which reflect normal, albeit exaggerated, responses to hormonal influences
Fibroadenoma – benign fibroepithelial neoplasm of breast
Phyllodes (‘leaf-like’) tumour – a group of potentially aggressive fibroepithelial neoplasms of the breast
Intraductal papilloma – a benign papillary tumour arising within the duct system of the breast
Radial scar – benign sclerosing lesion characterised by a central zone of scarring surrounded by a radiating zone of proliferating glandular tissue
Fibrocystic disease group of alterations which reflect normal, albeit exaggerated, responses to hormonal influences
- Very common
- Presentation: breast lumps
- No increased risk for subsequent breast carcinoma
- Histology → ducts dilated; ducts calcified (seen on mammogram)
Fibroadenoma benign fibroepithelial neoplasm of breast
- Common
- Presentation: well circumscribed mobile breast lump [young women; 20-30yo]
- Treatment: ‘shell out’
- Histology → glandular and stromal cells
Phyllodes (‘leaf-like’) tumour – a group of potentially aggressive fibroepithelial neoplasms of the breast
- UNCOMMON
- Presentation: enlarging mass in women >50 years
- Some may arise within pre-existing fibroadenomas
- Vast MAJORITY are BENIGN (but a small proportion can behave aggressively (malignant phyllodes))
-
Histology overlapping cell layers, cellularity
- Level of malignancy determined on cellularity of the stroma
- High cellularity + stromal overgrowth malignant
Intraductal papilloma – a benign papillary tumour arising within the duct system of the breast
Arises within the:
- Small terminal ductules (peripheral papilloma)
- Large lactiferous ductules (central papilloma)
COMMON (mainly in 40-60 years)
Central papillomas present with bloody nipple discharge
Peripheral papillomas may remain clinically silent
Treatment: excision of duct
Cytology → clusters of cells, potential increased risk with multiple papillomas of carcinoma
Histology → dilated ducts; polypoid mass in the middle
- Fibrovascular core (which nourished the polyp)
- blood vessels within the stroma
Radial scar – benign sclerosing lesion characterised by a central zone of scarring surrounded by a radiating zone of proliferating glandular tissue
- MIMICS BREAST CANCER ON RADIOLOGY
- Range in size from microscopic to large / clinically apparent
- Lesions >1 cm = complex sclerosing lesions
- Thought to be due to exuberant reparative phenomenon in response to areas of tissue damage in the breast
- Presentation: stellate masses on screening mammograms (may closely resemble carcinoma)
- Excision is curative
-
Histology → two distinct areas:
- Central stellate area
- Peripheral proliferation of ducts and acini
Proliferative breast diseases definition
a diverse group of microscopic intraductal proliferative lesions of the breast associated with an increased risk of subsequent development of invasive breast carcinoma → produce no symptoms (found on biopsy)
Proliferative Breast Diseases (3 types)
1) Usual epithelial hyperplasia [LEFT] – not a true pre-malignant change
- Marker of slightly increased risk of breast cancer
- The lumens are quite irregular (but this is a benign feature)
(2) Flat epithelial atypia/atypical ductal carcinoma [MIDDLE] – the first likely low-grade malignant change
- FEA may represent the earliest morphological precursor to low grade ductal carcinoma in situ
- 4 x increased risk of developing cancer
- There are multiple layers of epithelial cells and the lumens are becoming more regular
(3) In situ lobular neoplasia [RIGHT]
- Associated with an increased risk of invasive breast carcinoma
- It occurs within the acinar unit of the breast
- You get a very solid proliferation of cells within the acinus
3 types of malignant breast disease
Ductal Carcinoma in situ (DCIS) – neoplastic intraductal epithelial proliferation with risk of progression to breast cancer
Invasive breast carcinomas – a group of malignant epithelial tumours which infiltrate within the breast and have the capacity to spread to distant sites
Basal-like carcinoma – carcinoma type discovered following genetic analysis of breast carcinomas
Ductal Carcinoma in Situ (DCIS) neoplastic intraductal epithelial proliferation with risk of progression to breast cancer
- COMMON (Incidence has INCREASED since screening programmes came into effect)
- 85% are detected on mammography (areas of microcalcification)
- 10% will produce clinical features (lump, Paget’s disease); 5% diagnosed incidentally
- Histological classification: low, intermediate or high grade
Histology (LOW) → “cribriform / punched-out DCIS”
- Lumens compact/regular
- Calcification (cells are rapidly dying and rapidly regenerating)
- Overlapping cells
Histology (HIGH):
- Central lumen necrotic material Large cells
- Pleiomorphic cells occlude the duct Few lumens
Treatment: surgical excision (chemotherapy is hardly ever given)
Recurrence is more likely with high grade or extensive disease
Invasive breast carcinomasa group of malignant epithelial tumours which infiltrate within the breast and have the capacity to spread to distant sites
Invasive breast carcinomas: cytology
Invasive ductal carcinoma → pleiomorphic cells with large nuclei
- AKA: Non-specific type
- E-cadherin +ve
Invasive lobular carcinoma [LEFT] → linear (‘Indian File’ pattern), monomorphic (look similar)
Invasive tubular carcinoma [MIDDLE] → elongated tubules invading the stroma
Invasive mucinous carcinoma [RIGHT] → empty spaces contain lots of mucin
Basal-like carcinoma carcinoma type discovered following genetic analysis of breast carcinomas
- Histology → sheets of markedly atypical cells, prominent lymphocytic infiltrate, central necrosis
- Immunohistochemistry → +ve for “basal” cytokeratins CK5/6 and CK14
- Associated with BRCA mutations
- Propensity to… vascular invasion and metastasis
Histological grading of invasive breast carcinomas
Nottingham Modification of Bloom-Richardson System
Invasive breast carcinomas: receptor status (which 3 receptors)
Invasive breast carcinomas: prognosis
- The status of the axillary lymph nodes is the MOST IMPORTANT PROGNOSTIC FACTOR
- Other factors: size, histological type, histological grade
NHS Breast Screening Programme
aim to pick up DCIS and early invasive carcinomas
NHS Breast Screening Programme
aim to pick up DCIS and early invasive carcinomas
Male breast disease (2 conditions)
