Breast Pathology Flashcards
Define carcinoma
Malignant tumour of epithelial origin
A subtype of carcinoma depends on the organ or tissue of origin
Define sarcoma
Malignant tumour arising from mesenchymal tissue
Define lymphoma
Malignancy arising in lymphoid tissue
Define leukaemia
Malignancy arising from haematopoietic cells
Define malignant melanoma
Malignant tumour of melanocyte origin
What is an excision biospy
Excise the area of abnormality with clear margins
Different to a diagnostic biospy
What is an adenocarcinoma?
Gland forming/mucin producing tumour
GIT, Breast, endometrium, prostate
What is the relationship between ducts and lobules in the mammillary breast?
Progressively branching ducts leads to terminal ductular lobular units
Terminal ducts branch into lobules
Describe the normal breast histology
Grape like clusters of acini = lobules
Lobules connect into ducts -> more tube-like in structure.
What is the epithelium like in normal breast histology?
Luminal epithelial cells
Overly myoepithelial cells on basement membrane.
What are the key benign pathologies of the breast?
- Epithelial hyperplasia - neoplasia (inc cell mass)
- Papilloma - wart like growth in milk ducts
- Fibroadenoma - neoplastic stromal cells and reactive epithelium
- Hemangioma - of blood vessels
- Fibrocystic disease -
What are the different malignant pathologies can commonly affect the breast?
- Ductal/lobular carcinoma in situ
- Invasive ductal/lobular carcinoma
- Phyllodes tumour - malignant counterpart of fibroadenoma - stromal.
- Angiosarcoma
What is the key feature of an in situ carcinoma?
Not invaded/breached the basement membrane
What are the key inflammatory breast diseases?
Breast abscess/mastitis
What are the key pathological features of a breast abscess?
Usually an infection acquired during breast feeding
Staphylococcus aureus from skin
Formation of a lacatation abscess
What is the recommended treatment for a breast abscess?
Treated with antibiotics, continued expression of milk
Rarely - incision and drainage (can cause misshapen breast)
What are the key histopathological features of fibrocystic breast changes?
Dilated and cystic ducts (large hollow spaces)- lined by single epithelium
Prominent apocrine metaplasia - outgrowths into ducts
No cytological atypia or mitoses
What is the key history of fibrocystic breast disease?
Most common benign breast disease
Common in 30-5oyrs
Benign cystic typically mobile and rubbery on examination
Prone to hormonal alteration
Skin - dimpled or orange appearance, lumpy, thickened
Do fibrocystic changes inc risk of breast cancer?
Not associated with an increased risk of malignancy
What is the relevant histopathology of a fibroadenoma?
Growth of stroma compressing nearby glandular structures
No stromal atypica
Intact myoepithelial cell layer
Well defined/circumsided edge surrounded by background normal breast tissue
What is the relevant history of a fibroadenoma disease?
Most common benign tumour of the female breast
Round, smooth, firm, mobile singular mass
Can occur at any age, most commonly 25yrs
What is the key pathology underpinning a fibroadenoma?
Well-circumscribed, unencapsulated
Biphasic tumour - proliferation of glandular and stromal elements
No risk of malignancy
What is the typical treatment for a fibroadenoma?
mage risk factors, patient preference
Conservative - follow up
Local surgical excision
What are the key risk factors for breast carcinoma?
Age = 75% greater than 50yrs old
FH = up to 10% germline mutation in BRCA1/2
Reproductive history - early menarche, nulliparity, absence of breast feeding
Geographic = Europe and N America (diet, reproductive patterns and attitudes to breast feeding)
What is the most common categoriy of breast malignancy?
Adenocarcinoma
What is the difference between the in situ and invasive carcinoma stage of breast pathology?
In situ - neoplastic proliferation limited to ducts and lobules by basement membrane
Invasive - penetrated the BM into stroma - potential for lymphovascular invasion and metastatic spread
What are the key features of this close up look at normal breast pathology?
Single later of epithelial cells
Basement membrane - pink line underneath - still in tact
What is the key difference between ductal and lobular carcinoma in situ?
Cell of origin - ducts v lobules
Ductal - in expression of e-cadherin, more likely to show calcification on mammography
Lobular - dec expression of e-cadherin, less likely to show calcification on mammography (can still be present)
What are the key features of ductal carcinoma in situ of low grade histopathology?
Atypical epithelium proliferation into the ducts (commonly excludes lumen)
Intact basement membrane
Darker areas of calcification
Pink central areas of comedo necrosis
What are the features of ductal cell carcinoma in situ in high grade histopathology?
Mitoses
Abnormal muclear features
Variation in nuclea shape and size
Overlapping nuclei or cramped appearance
What is the key risk of DCIS breast disease?
Precursor for invasive carcinoma
What is the most common histological classification of breast cancer?
Invasive ductal carcinoma (70-80%)
What are the key pathological features of the pathology of invasive ductal cell carcinoma?
Penetrated though BM and invaded stroma
Can can lymphatic/vascular invasion and metastases
Is an adenocarcinoma - mucin producing
How does invasive ductal carcinoma appear on mammography?
Radiodense mass
What skin changes can indicated invasive ductal carcinoma of the beast?
If central - nipple retraction
Blocked lymphatics - peau d orange
What are the gross histological features of ductal cell carcinoma of the breast?
Haphazard outline - not clear, projecting into nearby tissue
Haphazard malignant glands - infiltrating stroma - different shape and size
May also just have abnormal cells in stroma/adipose tisse as invades - single or indian files (lines of cells with large and darkened, circular nuclei)
What is removed in a radical mastectomy?
What are the consequences of this?
mammary glands
Both pectoral muscles
Entire axillary lymphatic tissue
Causes - permanent disfigurement, shoulders caved, arm swelling (elephantiasis)
What are the different treatment options that exist for breast cancer today?
Surgery - mastectomy, breast conserving (wide local excision)
SLN biopsy - followed by axillary LN if positive
Radiotherapy
Chemotherapt
Endocrine therapy - esotrgen antagonists
Tissue targeted therapy - anti ERBB2 trastuzumab
Who is invited to the NHS Breast Screening Programme?
All women aged 50 to 70 yrs - regerested with a GP every 3 years
What is the role of pathology in breast cancer?
Biospy diagnosis - confirming benign or malignant
Grade tumours - give prognostic value
Identifying surface receptors
What factors contribute to breast cancer tumour grading by Bloom Richardon System?
Tubule Formation (score from 1 -3)
Nuclear Pleomorphism (1-3)
Mitotic Activity(1-3)
Combined 3-5 is grade 1 (well differentiated)
6-7 Grade 2 (moderately differentiated)
8-9 Grade 3 (poorly differentiated)
For what treatments is hormone receptor status important in breast cancer?
Tamoxifen - must be ER or PGR positive
Traztuzumab - targets HER2
How does the receptor status of the tumour affect its prognosis?
Triple negative - more liekly to reoccur early on peak 2 years after diagnosis, risk then decreases
HER2 positive - less risk, bipeak at 2 years and 7 years
Luminal - lowest overall risk, relatively constant with small peak at 3 years
NOT YEAR IMPORTANT
What are the different methods of spread of an invasive carcinoma?
Why are these important?
Direct spread
Lymphocvascular space invasion
Metastasis - locoregional lymph nodes, distant metastasis
These are important prognostic factors
What is the key lymphatic drainage of the breast?
Axillary up to 75/90%
Parasternal lymph nodes
Inferior phrenic lymph nodes
What is the role of pathological sentinel lymph node biopsies?
Between one and 3 lymph nodes are sampled
Axillary lymph node only is sentinel are positive
If positive consider chemotherapy or radiotherapy alongside surgical treatment
What are the TNM stages for breast cancer?
T
1 - less than2cm
2 - less than 5cm
3 - greater than 5cm
4 - skin or chest wall
N
1 - ipsilatareal moveable axillary LN
2 - i fixed axillary or internal mammary LN
3 - infraclavicular, supracilvacule LN
M
1 - distant metastasis
What is the use of personalised medicine in breast pathology?
Oncotype DX - quantifies risk of breast cancer recurrence to give a recurrence score
Low score are unlikely to benefit from additional chemotherapy alongside required hormonal therapy
