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Breast Pathology 2 Flashcards

1
Q

What are the miscellaneous malignant tumours?

A

Malignant Phyllodes tumour - sarcomatous stromal component

Angiosarcoma - post XRT

Lymphoma - breast and/or lymph nodes

Metastatic tumours

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2
Q

Phyllodes tumour is at risk of metastasis to which part of the body?

A

Lungs

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3
Q

What are the metastatic tumours to breast?

A

Carcinoma:
Bronchial
Ovarian serous carcinoma
Clear cell carcinoma of kidney

Malignant melanoma

Soft tissue tumours:
Leiomysarcoma

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4
Q

Define breast carcinoma

A

A malignant tumour of breast epithelial cells

Arises in the glandular epithelium of the terminal duct lobular unit (TDLU)
It is an adenocarcinoma but is usually just referred to as “breast carcinoma

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5
Q

What are the precursor lesions for breast carcinoma?

A 
Ductal:
Epithelial hyperplasia of usual type
Columnar cell change (+/- atypia)
Atypical Ductal Hyperplasia
Ductal Carcinoma in situ

Lobular:
Lobular in situ neoplasia
Atypical lobular hyperplasia
Lobular carcinoma in situ

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6
Q

What is in-situ carcinoma?

A

Confined within basement membrane of acini & ducts

Cytologically appear malignant but non - invasive

Non-obligate precursor of invasive carcinoma

Classification:
Lobular
Ductal

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7
Q

Name the two types of IN SITU neoplasia

A

Atypical Lobular hyperplasia (ALH)
<50% of lobule involved

Lobular Carcinoma in situ (LCIS)
>50% of lobule involved

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8
Q

What are the histological features of lobular in-situ neoplasia?

A 
Intra-lobular proliferation of characteristic cells: 
Small-intermediate sized nuclei
Solid proliferation
Intra-cytoplasmic lumens/vacuoles
ER positive
E-cadherin negative 
Dyscohesive cells
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9
Q

What are the general features of lobular in situ neoplasia?

A 
Frequently multifocal and bilateral
Incidence 0.5-4% in benign biopsies
Incidence decreases after menopause
Not palpable, not visible grossly
May calcify – mammography
Usually an incidental finding
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10
Q

What is the significance of lobular in situ neoplasia?

A

Marker of subsequent risk

Also a true precursor lesion

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11
Q

Management of lobular in situ neoplasia

A

LN discovered on core biopsy:
Proceed to excision or vacuum biopsy to exclude higher grade lesion

LN discovered on vacuum or excision biopsy:
Follow up
Clinical trials
Tamoxifen

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12
Q

What are the features of ductal carcinoma in situ

A 
Arises in TDLU
Characteristically unicentric (single duct system)
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13
Q

What is ductal carcinoma in situ (DCIS)?

A

Cytologically malignant epithelial cells
Confined within basement membrane of duct
May involve lobules (cancerisation)
May involve nipple skin (Paget’s)

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14
Q

What is Paget’s disease of the Nipple?

A

High grade DCIS extending along ducts to reach the epidermis of the nipple
Still in situ carcinoma (ie non-invasive)

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15
Q

How is DCIS classified?

A

Based on

a) cytological grade - most important in terms of risk of progression
b) Histological type
c) Presence of nerosis (comedo)

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16
Q

What is the significance of DCIS?

A

Risk factor for development of invasive carcinoma
True precursor lesion for invasive carcinoma
75% progress to invasion following incisional biopsy only (1938)

17
Q

Management of DCIS

A 
Diagnosis
Surgery
(Trials of mammographic follow-up in low risk DCIS)
Adjuvant radiotherapy
Chemoprevention - Endocrine therapy
18
Q

What is microinvasive carcinoma?

A

DCIS (high grade) with invasion of <1mm

Treat as high grade DCIS

19
Q

What is invasive breast carcinoma?

A

Malignant epithelial cells which have breached the BM

Infiltration of normal tissues

Risk of metastasis and death

20
Q

Risk factors for invasive breast carcinoma

A

Age

Reproductive history:
Age at menarche
Age at first birth
Parity
Breastfeeding
Age at menopause

Hormones:
Endogenous
Exogenous (OCP, HRT)

Previous breast disease - increases risk of reoccurence

Geography - highest in western world

Lifestyle:
Bodyweight
BMI
Physica activity (protective) 
Alcohol
Diet 
NSAID (lowers risk)
Smoking

Genetic:
Family history - affected first degree relatives DOUBLES risk
Cancer syndromes - see slife 45

21
Q

Which mutations involved in breast Ca?

A

BRCA1 and BRCA2 mutations

22
Q

What is the aetiology of invasive Ca?

A

Genetics
Lifestyle/environment
Hormones

23
Q

What is the natural history/progression of invasive breast Ca?

A

Local invasion (T):
Stroma of breast
Skin
Muscles of chest wall

Lymphatics (N):
Regional draining lymph nodes

Blood-borne (M):
Bone, liver, brain, lungs, abdominal viscera, female genital tract

24
Q

Common lymph nodes involved in invasive Ca

A 
Cervical
Supraclav
Infraclav
Apical
Axillary
Sentinel
Intramammary
Internal Mammary
25
Q

Types of invasive breast Ca classification

A

Morphological:
Type
Grade

Gene expression profiling:
Intrinsic sub-types

Hormone receptor expression:
Oestrogen receptor (ER)
Progesterone receptor (PR)
HER2

26
Q

Breast carcinoma grading

A 
Objective assessment of:
Tubular differentiation (1-3)
Nuclear pleomorphism (1-3)
Mitotic activity (1-3)

Score 3,4 or 5 = Grade 1
Score 6 or 7 = Grade 2
Score 8 or 9 = Grade 3

27
Q

Oestrogen receptor expression type of breast Ca

A

ER expression predicts response to anti-oestrogen therapy

Oophorectomy
Tamoxifen
Aromatase inhibitors (Letrozole)
GnRH antagonists - (Goserilin [Zoladex])

28
Q

Types of hormone receptors

A

80% ER positive
67% PgR positive
14% HER2 positive (trastuzamab)

29
Q

What are the prognostic indices in breast cancer?

A
  1. Hormone receptor status - ER PR. Predicts behaviour and sensitivity to hormonal treatments
  2. HER 2 status - Her 2 amplification generally predicts poorer prognosis but will allow treatment with Herceptin and Trastuzumab
  3. Stage - How far has the tumour spread? (TNM)
  4. Grade - How aggressive is the tumour? Differentiation?
  5. Nottingham Prognostic Index
30
Q

What does staging of breast cancer tell us?

A

How far the tumour has spread
T - how far the tumour has spread in mm
N - if spread to lymph nodes has occured and how many are involved
M .- Metastasis - Present or not?

31
Q

What are the grades of breast cancer?

A

Grade 1 - well differentiated - slow growing
Grade 2 - moderate differentiation - intermediate growth
Grade 3 - poor differentiation - fast growing

32
Q

What is the Nottingham Prognostic Index?

A

Is a way of combining grade and stage together into a single number that can be used as a shorthand to stratify prognosis

[0.2xS(mm)] + N + G

33
Q

Clinical presentation of breast cancer

A

In the breast:

  • Pain (rare)
  • Lump
  • Skin changes - dimpling, puckering, peau d’orange, redness

In the nipple:

  • Discharge - if cancer is close to nipple and invades the duct
  • redness, rash - Paget’s disease of the nipple

At the axilla:
- lump

Reproduction (32 decks)

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