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Breast Pathology Flashcards

1
Q

What imaging is used in the assessment of breast disease?

A

Mammography
US
MRI

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2
Q

What pathology testing is carried out in breast disease assessment?

A

Cytopathology

Histopathology

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3
Q

How are samples taken for breast cytopathology?

A

FNA
Fluid
Nipple discharge
Nipple scrape

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4
Q

What are the categories in breast FNA cytology?

A 
C1- Unsatisfactory
C2- Benign
C3- Atypia, probably benign
C4- Suspicious of malignancy
C5- Malignant
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5
Q

What Ix are carried out in breast histopathology?

A

(Needle) core biopsy
Vacuum assisted biopsy (large volume, mammotome)
Skin biopsy
Incisional biopsy of mass

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6
Q

What therapeutic interventions are carried out in breast histopathology?

A

Excisional biopsy of mass

Resection of cancer- wide local excision/mastectomy

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7
Q

What are the categories in breast needle core biopsy?

A 
B1 - Unsatisfactory / normal
B2 - Benign
B3 - Atypia, probably benign
B4 - Suspicious of malignancy
B5 - Malignant
B5a - carcinoma in situ
B5b - invasive carcinoma
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8
Q

What are some developmental anomalies in breast growth?

A

Hypoplasia
Juvenile hypertrophy
Accessory breast tissue
Accessory nipple

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9
Q

What are some non-neoplastic breast diseases?

A 
Gynaecomastia
Fibrocystic disease
Hamartoma
Fibroadenoma
Sclerosing lesions- sclerosing adenosis, radial scar/complex sclerosing lesions
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10
Q

What are some inflammatory benign breast diseases?

A

Fat necrosis
Duct ectasia
Acute mastitis/abscess

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11
Q

What are some benign tumours of the breast?

A

Phyllodes tumour

Intraduct papilloma

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12
Q

What is gynaecomastia?

A

Breast developmental in the male

Ductal growth without lobular development

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13
Q

What are some causes of gynaecomastia?

A

Exogenous/endogenous hormones
Cannabis
Prescription drugs
Liver disease

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14
Q

When do fibrocystic changes usually occur?

A

20-50yo, majority 40-50

Very common

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15
Q

What are the clinical features of fibrocystic change?

A

Menstrual abnormalities
Early menarche
Late menopause
Often resolve or diminish after menopause

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16
Q

How do fibrocystic changes present?

A 
Smooth discrete lumps
Sudden pain
Cyclical pain
Lumpiness
Incidental finding
Screening
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17
Q

What is the usual appearance of cysts related to fibrocystic changes?

A

1mm to several cm
Blue domed with pale fluid
Usually multiple
Associated with other benign changes

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18
Q

How do cysts related to fibrocystic changes appear microscopically?

A

Thin walled, but may have fibrotic wall

Lined by apocrine epithelium

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19
Q

How are cysts managed?

A

Exclude malignancy
Reassure
Excise if necessary

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20
Q

What is a hamartoma?

A

Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution

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21
Q

How do fibroadenomas usually present?

A

Common- found through screening
Usually solitary (10% multiple)
Commoner in African women

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22
Q

When is the peak incidence of fibroadenomas?

A

3rd decade

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23
Q

How will fibroadenomas feel?

A 
Painless
Firm
Descrete
Mobile mass
'Breast mouse'
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24
Q

How will fibroadenomas appear on US?

A

Solid

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25
Q

How will fibroadenomas appear grossly and microscopically?

A

Circumscribed
Rubbery
Grey-white
Biphasic tumour/lesion- epithelium/stroma

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26
Q

How is fibroadenoma managed?

A

Diagnose
Reassure
Excise

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27
Q

Describe sclerosing lesions

A

Benign, disorderly proliferation of acini and stroma
Can cause a mass or calcification
May mimic carcinoma

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28
Q

How will sclerosing adenosis present?

A

Pain, tenderness of lumpiness/thickening
Asymptomatic
Usually 20-70yo

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29
Q

How will radial scar present?

A

Wide age range
Common- 67% multicentric, 43% bilateral
Incidental finding
Mammographically detected

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30
Q

How is a radial scar and complex sclerosing lesion differentiated?

A

RS 1-9mm

CSL >10mm

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31
Q

Describe the appearance of a radial scar

A

Stellate architecture
Central puckering
Radiating fibrosis

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32
Q

What are the histological characteristics of a radial scar?

A

Fibroelastotic core
Radiating fibrosis containing distorted ductules
Fibrocystic change
Epithelial proliferation

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33
Q

Are radial scars malignant?

A

Usually no
Mimic carcinoma radiologically
Likely not premalignant
In situ or invasive carcinoma may occur within lesion

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34
Q

What can cause fat necrosis?

A

Local trauma- seat belt trauma, frequently no Hx

Warfarin therapy

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35
Q

What occurs in fat necrosis?

A

Damage and disruption of adipocytes
Infiltration by acute inflammatory cells
Foamy macrophages
Subsequent fibrosis and scarring

36
Q

How is fat necrosis managed?

A

Confirm diagnosis

Exclude malignancy

37
Q

What are the clinical features of duct ectasia?

A 
Affects sub-areolar ducts
Pain
Acute episodic inflammatory changes
Bloody and/or purulent D/C
Fistulation
Nipple retraction and distortion
38
Q

What is duct ectasia associated with?

A

Smoking

39
Q

Does fibrosis occur in duct ectasia?

A

Yes- Periductal fibrosis

40
Q

How is duct ectasia managed?

A

Treat acute infections
Exclude malignancy
Stop smoking
Excise ducts

41
Q

What are the 2 main causes of acute mastitis/abscess?

A

Duct ectasia- mixed organisms, anaerobes

Lactation- staph aureus, strep pyogenes

42
Q

How is acute mastitis/abscess managed?

A

Antibiotics
Percutaneous drainage
Incision & drainage
Treat underlying cause

43
Q

What are the clinical features of phyllodes tumour?

A

40-50yo

Slow growing unilateral breast mass

44
Q

Describe the growth of phyllodes tumour

A

Biphasic
Stromal overgrowth
Behaviour depends on stromal features
Benign, borderline, malignant (sarcomatous)

45
Q

What is the behaviour of phyllodes tumour?

A

Pathology helps to predict
Prone to local recurrence if not adequately excised
Rarely metastasise

46
Q

What are the papillary lesions of the breast?

A

Intraduct papilloma
Nipple adenoma
Encysted papillary carcinoma

47
Q

What are the symptoms and signs of intraduct papilloma?

A

Nipple discharge +- blood

Asymptomatic at screening- nodules, calcification

48
Q

What age group is effected by intraduct papilloma?

A

35-60yo

49
Q

What are the pathological and clinical features of intraduct papilloma?

A

Sub-areolar ducts
2-20mm diameter
Papillary fronds contained a fibrovascular core, covered by myoepithelium and epithelium
Epithelium may show proliferate activity

50
Q

What are the categories of epithelial proliferation in intraduct papilloma?

A

None-benign
Usual type hyperplasia-benign
Atypical ductal hyperplasia
Ductal carcinoma in situ

51
Q

What tumours often metastasise to the breast?

A

Carcinoma- bronchial, ovarian serous carcinoma, clear cell carcinoma of kidney
Malignant melanoma
Soft tissue tumours- leiomysarcoma

52
Q

Where does breast carcinoma arise from?

A

Glandular epithelium of the terminal duct lobular unit (TDLU)
Technically adenocarcinoma

53
Q

What are some ductal precursor lesions of breast carcinoma?

A

Epithelial hyperplasia of usual type
Columnar cell change
Atypical ductal hyperplasia
Ductal carcinoma in situ

54
Q

What are some lobular precursor lesions of breast carcinoma?

A

Lobular in situ neoplasia- atypical lobular hyperplasia, lobular carcinoma in situ

55
Q

Where is in situ carcinoma confined within?

A

Basement membrane of acini and ducts

56
Q

What is in situ carcinoma on cytologically?

A

Malignant but non-invasive

57
Q

What is the difference between atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS?

A

ALH <50% of lobule involved

LCIS >50% of lobule involved

58
Q

What are the pathological findings in lobular in situ neoplasia?

A 
Small-intermediate sized nuclei
Solid proliferation
Intra-cytoplasmic lumens/vacuoles
ER +ve
E-cadherin -ve (deletion &amp; mutation of CDH1 on Ch 16)
59
Q

What are the clinical 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
60
Q

What is the management of lobular in situ neoplasia?

A

LN on core biopsy- proceed to excision or vacuum biopsy to exclude higher grade lesion
LN on vacuum or excision biopsy- follow up, clinical trials

61
Q

What is the risk of progression to invasive carcinoma of epithelial hyperplasia of usual type?

A

2x RR

62
Q

What is the risk of progression to invasive carcinoma of atypical ductal hyperplasia?

A

4x RR

63
Q

What is the risk of progression to invasive carcinoma of ductal carcinoma in situ (low grade)?

A

10x RR (25% over following 10y)

64
Q

What % of breast malignancies are DCIS?

A

15-20%

65
Q

Where does DCIS arise?

A

TDLU

66
Q

What is characteristic about DCIS?

A

Unicentric (single duct system)

67
Q

What are the pathological features of DCIS?

A

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

68
Q

What is Paget’s disease of the nipple?

A

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

69
Q

What is used to classify DCIS?

A

Cytological grade
Histological type
Presence of necrosis (comedo)

70
Q

Describe microinvasive carcinoma

A

Rare
DCIS (high grade) with invasion of <1mm
Treat as high grade DCIS

71
Q

Why is DCIS significant?

A

RF for development of invasive carcinoma
True precursor lesion
75% progress to invasion following incisional biopsy only

72
Q

How is DCIS managed?

A

Diagnosis
Surgery- trials of mammographic follow-up in low risk DCIS
Radiotherapy
Chemoprevention (trial)

73
Q

What is the definition of an invasive carcinoma?

A

Malignant epithelial cells which have breached the BM

74
Q

What are the RFs for breast carcinoma?

A

Age
Reproductive history- age at menarche/first birth/menopause, parity, breast feeding
Hormones- endogenous, exogenous- OCP, HRT
Oral contraception
Previous breast Hx
Geography
Lifestyle- bodyweight, physical activity, alcohol, diet, NSAID (lower risk), smoking
Genetics

75
Q

By how much is the RR increased if a first degree relative is affected by breast cancer?

A

2x

76
Q

Describe the incidence and risk of BRCA 1/2

A

Each present in 0.1% of population (approx 1 in 450 carry mutation in one of these genes)
2% of all breast cancers
45-64% lifetime risk

77
Q

What is the 1,5,10,20y survival rate for breast cancer?

A
  1. 8%
  2. 1%
  3. 0%
  4. 5%
78
Q

How can invasive breast carcinoma be classified histologically?

A 
Ductal (NST)
Lobular
Mucinous
Medullary
Tubular
Cribriform
Papillary
Mixed
79
Q

What is tumour grade a measure of?

A

Differentiation

80
Q

If a tumour is very similar to the parent tissue, is it well or poorly differentiated, and thus a good or poor prognosis?

A

Well differentiated, therefore good prognosis

81
Q

What is assessed in breast carcinoma grading?

A 
Tubular differentiation (1-3)
Nuclear pleomorphism (1-3)
Mitotic activity (1-3)
82
Q

How is tumour grade scored from it’s assessment?

A

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

83
Q

What does ER expression in invasive carcinoma predict?

A

Response to anti-oestrogen therapy: oophorectomy, tamoxifen, aromatase inhibitors, GnRG antagonists

84
Q

What does HER2 overexpression or amplification in invasive carcinoma predict?

A

Response to trastuzamad (Herceptin)

Seen in ~15%

85
Q

What hormone receptors will usually be +ve in invasive carcinoma?

A

80% ER
67% PgR
14% HER2

86
Q

What is the Nottingham Prognostic Index?

A

Histopathology based (grade and stage)

87
Q

How is the NPI calculated?

A 
0.2 x tumour diameter (cm)
Tumour grade (1-3)
LN status (1-3)

Reproduction (40 decks)

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