Breast Pathology 2 Flashcards
Name miscellaneous malignant tumors
Malignant phyllodes tumor
Angiosarcoma
Lymphoma
Metastatic tumors
What is the tumorous version of the fibroadenoma?
Malignant phyllodes tumor - has sacromatous stromal component
Which organ does the phyllodes tumor generally metastasize to?
Lung
Which malignant tumor usually occurs post radiotherapy?
Angiosarcoma
Which metastatic tumors usually spread to the breast?
Carcinoma : Bronchial / ovarian serous/ clear cell ca of kidney
Malignant Melanoma
Soft Tissue tumors ( leiomyosarcoma)
Where does breast cancer arise from?
The glandular epithelium of the TDLU
—an adenocarcinoma
What are the ductal precursor lesions?
- epithelial hyperplasia type
- columnar cell change (+/- atypia)
- atypical ductal hyperplasia
- ductal carcinoma in situ???
Name lobular precursor lesions.
Lobular in situ neoplasia
- atypical lobular hyperplasia
- lobular CA in situ
What is seen histologically with in situ carcinoma ?
Confined within BM of acini and ducts
- cytologically appear MALIGNANT but non invasive
Can in situ carcinoma still progress to invasive ca?
Yes.
if High Grade In situ carcinoma
What are 2 types of Lobular In situ hyperplasia ?
ALH ( atypical lobular hyperplasia) …<50% of lobulee involved
LCIS (lobular ca in situ)…>50% of lobule
What is characteristic of the cells proliferating in lobular in situ neoplasia?
- ER positive
- E-cadherin Negative (d/t mutation and deletion of CDH1 gene) `
- small intermediate sized nuclei
- —small, rounded, loosely cohesive cells fill and expand the acini
What is e-cadherin?
- a surface protein responsible for the cohesion of NORMAL breast epithelial cells
What are the key fts of the LCIS?
- FREQ. Multifocal and bilateral
- incidence decreases after menopause and is 0.4-4% present in benign biopsies
Gross and imaging ft of LCIS?
- GROSS= not palpable or visible
- may calcify (seen on mammography)
What is the significance of Lobular in situ neoplasia?
- marker of subsequent risk
- TRUE precursor lesion
How to manage Lobular in situ neoplasia?
And why is it done this way?
- vacuum/ excision biopsy
> do follow-ups
> clinical trials
—-as lobular in situ neoplasia is multifocal; there is no point to perform a multiple lumpectomy
What is the risk of developing ductal carcinoma from A LOW gr. DCIS?
10x the risk
What are the fts of DCIS?
- 15-20% OF BREAST malignancies are DCIS
- arises in TDLU
- unicentric
What are the histological fts of DCIS?
- malignant looking cells confined within the BM of the duct
- may involve the lobules (cancerisation) and nipple skin (Paget’s)
What is Paget’s disease? Is it invasive?
- high gr. DCIS extending along the ducts REACH the epidermis of the nipple
- —still in situ carcinoma (not invasive)
How is DCIS classified?
- cytological type
- histological grade
- presence of necrosis (COMEDO)
What is the risk of ductal ca in situ progressing into an INVASIVE CA?
- true precursor to invasive carcinoma
- 75% progress to INVASION following incisional biopsy
How to manage DCIS?
- dx> Surgery
( mammographic follow-up in LOW risk DCIS pts) - Adjuvant radiotherapy
- Chemoprevention (endocrine therapy)
What is a key ft of Micro-invasive Carcinoma?
- basically DCIS that extends <1mm past the BM
= treat as HIGH grade DCIS
When is a tumour deemed to be invasive?
- when the malignant epithelial cells have BREACHED the Bm
- infiltration of normal tissues
- risk of death and metastasis
What is said to be the primary risk factor of developing CA of the breast?
-the more estrogen in your life; the greater the chance of you to develop INVASIVE breast cancer
What should be explored with the pt for risk factors?
- age at menarche
- age at first birth
- parity
- breastfeeding
- age at menopause
- exogenous/endogenous hormones ( OCP/HRT)
- previous breast disease
- genetics
- lifestyle
IS there greater risk of breast cancer with estrogen-only HRT or estrogen-progesterone HRT?
- greater risk with estrogen and progesterone HRT
What factors of lifestyle predisposes one to carcinoma of the breast?
- body weight
- alcohol consumptiom
- food types (smoked food)
- smoking
- inactivity
- NSAID (lowers risk)
2 MAJOR gene mutations a.w breast cancer?
- BRCA 1 and BRCA 2
(but only 1 in 450 people carry the mutation) - 45-64% LIFE-time risk
How does invasive carcinoma usually arise?
- genes along with external factors may further predispose on to the cancer
- —lifestyle and hormones
What are the stats like with breast cancer incidence and mortality?
- Incidence is risng
- Mortality is falling
Name the MOST common female cancer!
- invasive breast carcinoma—– 1 in 8! may develop
2nd most common cause of cancer death
How may the breast cancer be staged?
TNM
1. Local invasion of the tumor (stroma/ skin/ muscles of chest wall)
- Lymphatics (regional draining LN)
- Blood-borne (M) —> bone/ liver/ brain/ lungs/ abd. viscera/ female genital tract
Where are the possible nodes for the cancer to spread to?
- internal mammary and intra-mammary nodes
- supra-/ infra-clavicular nodes
- apical and AXILLARY nodes
- cervical nodes
What are the 3 things invasive breast cancer is classified by?
- Morphology (type and grade)
- Gene Expression Profiling (intrinsic sub-types)
- Hormone Receptor Expression (ER/ PR/ HER2)
What are the diff. types of invasive breast CA?
- ductal/ lobular/ mucinous/ medullary/ tubular/ cribriform/ papillary/ mixed
What is meant by tumour grade?
- MEASURE of tumour differentiation
a) well differentiated= low grade= GOOD PROGNOSIS
b) poorly differentiated= high grade= POOR prog.
What is the tumor grading based on?
- tubular differentiation (1-3)
- nuclear pleomorphism (1-3)
- mitotic activity (1-3)
Survival rate reduces with _____
higher tumor grade
What hormone receptors may be found on malignant cells of the breast?
- ER
- PgR
- HER2
Significance of knowing which receptor is predominantly found on the tumor cells?
- ER expression indicates response to anti-estrogen therapy
What is invovlved in anti-estrogen therapy?
- oophorectomy
- Tamoxifen
- Aromatase Inhibitors
(Letrozole) - GnRH antagonists (Zoladex)
WHich tumor is likely have better prognosis, er +/-?
- ER +
same with PR
What is HER2?
- Human epidermal growth factor receptor 2
- —-amplification seen in 15%
Which drug is responsive to HER2 + tumor?
Trastuzumab
Which poses as having poor prognosis, HER2 +/- ?
HER2 -
Which breast tumor has the worst prognosis?
being triple negative
What TNM hold worst prognosis?
- bigger tumors
- -more than 1 LN metastasis
- -presence of lymphovascular invasion
What prognostic indices are used for breast cancer?
- Nottingham Prognostic Index (histopathology only)
- Adjuvant online (ER+ Clinical factors+ histopathology)
- NHS predict (ER+ clinical factors+ HER2+ histopathology+ mode of detection)
