Breast Pathology Flashcards
Outline the epidemiology of breast disease generally
Breast disease is a common clinical problem
The majority of breast diseases are benign
(include the majority of breast masses)
But 1-in-8 women will be diagnosed with breast cancer before the age of 85
What is the general clinical presentation of breast disease?
Lump / Palpable mass
General lumpiness
Discomfort/Pain
Nipple changes
Nipple discharge
Change in the shape of breast
Skin changes
Mammographic screening detected abnormality
What investigations are undertaken when breast disease is suspected?
Thorough clinical history and physical examination
Radiology: ultrasound / mammography
Biopsy
- To make sure a tumour is malignant/not malignant, you must take a biopsy for the pathology lab to make a diagnosis
- Sucks up cells through needle to smear on slide and provides a cytological slide of random cells with no architecture
- Now take a biopsy with a larger needle that can take a piece of tissue with architecture - better for assessment
Name and describe two benign diseases of the breast
There are many benign conditions of the breast that may present similarly to malignant pathology - clinicians must differentiate benign and malignant pathologies
In MD1, benign pathologies requiring knowledge are:
- Fibrocystic change
- Fibroadenoma
Characterise **Fibrocystic change **of the breast
**Fibrocystic change **is a common breast condition that occurs in females of middle to late reproductive age
It involves variable duct dilation - which may or may not induce cyst formation - that leads to significant fibrosis of the breast tissue. Adenosis and metaplasia may occur in some cases.
The condition is bilateral and multifocal
It is largely asymptomatic but can produce lumps and discomfort that can be confused with breast cancer
Characterise fibroadenoma
**Fibroadenoma **is most common in younger women
It refers to a neoplastic or hyperplastic stromal tumour with epithelial components - results from over proliferating fibroblasts which trigger epithelial proliferation concurrently
Is benign
Presents with a solitary well circumscribed benign mass in a single breast
Outline the epidemiology of breast carcinoma
**Breast carcinomas are the most common cancer and 2nd most common cause of cancer-related death in women **
1-in-8 women are diagnosed with breast cancer before the age of 85
The average age of first diagnosis is 85 y.o
With new drugs and management, the five year survival rate has increased from 70.9-86.6% from 1983-2004
Discuss the predisposing factors to breast cancer
Age
70% of women diagnosed with breast cancer are over 50 years old
- likely to be a result of increased time for mutation to accumulate
Genetic Factors
Sporadic Mutations
- Somatic **p53 mutations **
-
HER2 mutations
- Some patients have amplification of the HER2 gene -> leading to more protein expression of the HER2 receptor
- HER2 is a epidermal growth factor receptor -> with more of the receptors, get more proliferative signalling to the breast cells
Familial Cases
- 15-20% of all breast cancer cases are the result of interactions between multiple low-risk susceptibility genes and environmental factors
- tend to have one or more affected first degree relatives
- 5-10% specific germline mutations in BRCA1, BRCA2 or p53
- Autosomal dominant mutations to these tumour suppressor genes which are important in cell cycle arrest and DNA repair
- Earlier onset cancer
- May also develop other tumours -especially ovarian cancer with BRCA1 mutations
Oestrogen
Oestrogen increases the proliferation and development of mammary glands; more oestrogen exposure over the life time associated with greater cancer risk:
- Occurs via early age of menarche, late age of menopause, late age of first birth / nulliparous (no offspring), use of HRT or postmenopausal obesity
- Breast feeding appears to be protective - lactation suppresses ovulation
Environmental
There is a greater incidence of breast cancer associated with developed nations, obesity, alcohol and less pregnancies/breast feeding
Past history of certain breast diseases
Atypical hyperplasia, in situ carcinoma and invasive carcinomas
What is the significance of discovering breast hyperplasia in association with benign pathologies?
Hyperplasia of breast tissues is a non-neoplastic incidental finding that often occurs alongside other benign pathologies.
The hyperplasia may be with or without atypia -> the more atypia, the greater the risk of cancer development in time
Discuss the two main types of breast in situ carcinoma
Breast in situ carcinomas arise when malignant populations of tumour cells are confined to wither the ducts or acini of the breast - with no basement membrane invasion demonstratable.
I.S carcinomas carry an increased risk of developing invasive tumours if left untreated over time
Ductal Carcinoma in situ
- Most common
- Frequently associated with calcification that is seen on mammogram
- Malignant cells may extend up the ducts to the nipple to cause Paget’s disease of the nipple
Lobular carcinoma in situ
- Tend to be incidental finding on biopsy
Note: these in situ carcinomas tend to be asymptomatic
How do invasive carcinomas of the breast spread?
Local Spread via:
- Skin
- Nipple
- Underlying muscle/chest wall
- pleura
Metastatic **Spread **via:
- Lymphatics
- axillary node most common
- Blood
What are the two main types of invasive breast carcinoma?
Invasive ductal carcinoma
Is the most common type = 70-80%
Involves the infiltration of duct forming epithelium into the parenchyma of the breast
Typically leads to the formation of a ‘schirrous’ firm stellate mass
50% of masses are in the upper-outer quadrant of the breast
_Invasive lobular carcinoma _
There are various subtypes
What is standard management of breast cancer?
Always investigation and diagnosis by radiology and biopsy
Depending on the characteristics of the primary tumour and cancer stage; any variable combination of:
- Surgery
- Radiotherapy
- Chemotherapy
- Anti-oestrogen drugs
- Herceptin / transtuzumab
In breast cancer surgery, do surgeons remove the whole breast?
Are all lymph nodes within the distribution of the breast cancer site removed?
Generally surgery of the breast is conducted in a manner that is breast conserving - performing a quadranectomy of the mass site; rather than a mastecomy of the whole breast.
Masetectomies are required in some circumstances - but this is less often done.
Surgeons sample lymph nodes for the presence of malignancy; rather than removing all of them. It is important not to remove them if not necessary because doing so leads to tissue oedema due to reduced lymphatinc drainage
How are breast cancers graded?
The Elston and Ellis modification of the Bloom and Richardson grading system is used to grade breast cancers
It incorporates scores for acinar/tubule formation, **nuclear pleomorphism **and mitotic index
These scores are then graded as low, intermediate or high grade breast cancers
The is increasing emphasis towards classifying (not grading) tumours by molecular markers
