Breast pathology

Question 1

Normal Breast anatomy

Answer 1

Mainly fatty tissue above pec major. Skin is attached to the fascia by cooper’s ligaments. Multiple breast lobules connect in lactoferrous ducts into lactoferrous sinuses–> these then open in the areola

Question 2

Malignant Pre-cursor lesions

Answer 2

Malignant but pre-full cancers. Ductal carcinoma in situ (DCIS) –>arise from the lining of ducts. Lobular carcinoma in situ (LCIS) –>arise from terminal ducts of lobules. These will progress to full invasive cancer

Question 3

Prognostic factors for breast cancer

Answer 3

Tumour–> Size, grade, multifocality,
Vascular invasion
Lymph node spread
Receptor studies (Her 2 estrogen receptor)

Question 4

Fibrocystic breast change

Answer 4

A common condition effecting up to 50% of women of childbearing age which is characterized by one or more non-cancerous breast lumps which vary with hormonal status and can cause discomfort–> can be proliferative or non-proliferative, proliferative increased Ca risk

Question 5

Epithelial hyperplasia

Answer 5

Due to increased mitotic rate, no increased Ca risk if mild, but if moderate (>4 layers) then 2x risk

Question 6

Ductal carcinoma in situ (DCIS)

Answer 6

15-30% of all carcinomas–>90% unilateral. Classified by cytology (low,intermediate or high) & architecture(cribiform, solid, micropapillary/papillary). 8-10x risk of developing invasive carcinoma, 10% of low grade progress while 40% of high grades do

Question 7

Lobular carcinoma in situ (LCIS)

Answer 7

Found in as incidental in 8% of breast biopsies
30-70% bilateral and 75% multicentric
8-10x risk of invasive Ca in either breast

Question 8

Paget’s disease of the nipple

Answer 8

A DCIS within the sub-areolar ducts which extends into the epidermis–> 2% of pts with breast cancer
35-50% have associated invasion
Presents with itching or ‘ezcema’

Question 9

Risk factors for invasive Carcinoma - genetic

Answer 9

Affects 1 in 9 women in Britain. One 1st degree relative (1.5-3x risk), Two (4-6x) and the BRCA1/2 (5% of cases).

Question 10

Features of breast carcinoma

Answer 10

Macroscopic–> firm, white irregular tumour (scirrhous), often with necrosis and calcification
Microscopic–> Grade 1-3 on cytology and tubule formation, pleomorphism and mitotic activity

Question 11

Nottingham Prognostic Index (NPI)

Answer 11

0. 2 x tumour size(cm) + node stage(1,2,3) + tumour grade (1,2,3)
1. 4 – poor prognosis, requires aggressive adjuvant treatment

Question 12

Biologic therapies

Answer 12

C-erbB2 –> Herceptin

ER —-> Tamoxifen

Question 13

Immunohistochemical markers - cell types

Answer 13

Cytokeratin –> epithelial cells–> carcinoma. Leucocyte common a/g–>leucocytes–>lymphoma. Vimentin–>mesenchymal –>melanoma/lymphoma. Desmin–>Muscle –> sarcoma. HMB45–> Melanoma

Question 14

Immunohistochemical markers - prognosis

Answer 14

Cytokeratin CAM 5.2 –> lymph node metastasis

K-67/cyclin D1/p27Kip1–> cell cycle related

Question 15

Immunohistochemical markers - response to treatment

Answer 15

Oestrogen receptor (ER)--> sensitive to anti-oestrogens
Progesterone receptor (PR)--> functionally and ER, sensitive to anti-oestrogens
c-erbB2/Her2/neu--> sensitivity to herceptin

Question 16

Risk factors for invasive Carcinoma - hormonal

Answer 16

prolonged oestrogen exposure (early menache, late menopause, nulliparity).

Question 16

Risk factors for invasive Carcinoma - environmental

Answer 16

US and N europe are high risk, also previous radiotherapy