Breast Pathology Flashcards by S B

what is the assessment model for a patient with breast disease

Triple assessment

Clinical
- History and Examination
Imaging
- Mammography
- Ultrasound
- MRI
Pathology
- Cytopathology
- Histopathology

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how is breast cytopathology obtained

fine needle aspiration
fluid
nipple discharge
nipple scrape

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what are the 5 stages of breast FNA cytology

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

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what are the 5 stages of needle core biopsy

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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what are developmental benign breast disease

Hypoplasia (one or both breasts don’t develop during puberty)

Juvenile hypertrophy (breasts continue to grow)

Accessory breast tissue

Accessory nipple

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what are non-neoplastic benign breast disease

Gynaecomastia
Fibrocystic change
Hamartoma
Fibroadenoma
Sclerosing lesions

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what are inflammatory benign breast disease

Fat necrosis
Duct ectasia
Acute mastitis/abscess

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what are benign breast tumours

Phyllodes tumour

Intraduct Papilloma

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what is gynaecomastia

breast development in the male

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what is the pathology of gynaecomastia

Ductal growth without lobular development

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what can cause gynaecomastia

Exogenous/endogenous hormones
Cannabis
Prescription drugs
Liver disease

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who are fibrocystic changes seen in

Women aged 20-50
Majority 40-50

very common

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how does the breast appear with fibrocystic changes

lumpy, cobblestone appear

lumps are smooth with defined edges, and are usually free-moving in regard to adjacent structures

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what is seen with fibrocystic changes of the breast

Menstrual abnormalities
Early menarche
Late menopause

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what happens with fibrocystic changes after menopause

often resolve or diminish

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how do fibrocystic changes often present

Smooth discrete lumps
Sudden pain
Cyclical pain
Lumpiness

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what is the gross pathology of fibrocystic changes

Cysts

1mm – several cm
blue domed with pale fluid
usually multiple
associated w/ other benign changes

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what are the cysts in fibrocystic changes lined with

apocrine epithelium

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Mx of fibrocystic changes

exclude malignancy
reassure
excise if necessary

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what is a hamartoma

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

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what are features of a fibroadenoma

common
usually solitary
commoner in african women
peak incidence in 3rd decade

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presentation of fibroadenoma

Painless, firm, discrete, mobile mass

sometimes called “breast mouse” as they move so freely

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how do fibroadenomas present on USS

solid

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what is the pathology of a fibroadenoma

Circumscribed

Rubbery

Grey-white colour

Biphasic tumour/lesion

Epithelium
Stroma

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Tx of fibroadenoma

diagnose reassure excise

what often co-exists with fibrocystic changes

Sclerosing adenosis

what is Sclerosing adenosis

benign proliferative condition of the terminal duct lobular units characterised by an increased number of the storma, acini and their glands

what can Sclerosing adenosis cause

mass or calcification may mimic carcinoma

presentation of Sclerosing adenosis

Pain, tenderness or lumpiness/thickening Can be Asymptomatic Age 20-70

what can detect a radial scar as they are not usually palpable

mammogram | - incidental finding

pathology of radial scar

central fibrous core with central puckering stellate architecture

histology of radial scar

Fibroelastotic core Radiating fibrosis containing distorted ductules Fibrocystic change Epithelial proliferation

why do radial scars get Ix when found

as they can mimic carcinomas radiologically

what can cause fat necrosis in the breast

Local trauma - e.g. Seat belt injury - Frequently no history Warfarin therapy

what is the pathology of fat necrosis in the breast

Damage and disruption of adipocytes Infiltration by acute inflammatory cells “foamy” macrophages Subsequent fibrosis and scarring

what are clinical features of duct ectasia

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

what is duct ectasia

lactiferous duct becomes blocked or clogged most common cause of greenish discharge

what is duct ectasia associated with

smoking

what is the pathology of duct ectasia

Sub-areolar duct dilatation Periductal inflammation Periductal fibrosis Scarring and distortion

Mx of duct ectasia

Treat acute infections Exclude malignancy Stop smoking Excise ducts

what are the 2 main aetiologies of acute mastitis/abscess and the organisms associated with infection

Duct ectasia - Mixed organisms - Anaerobes Lactation - Staph aureus - Strep pyogenes

Mx of acute mastitis/abscess

Antibiotics Percutaneous drainage Incision & drainage Treat underlying cause

what are the clinical features of a phyllodes tumour

Age 40-50 | Slow growing unilateral breast mass

what are examples of papillary lesions

Intraduct papilloma Nipple adenoma Encysted papillary carcinoma

what are the clinical features of an intraduct papilloma

Age 35-60 | Nipple discharge +/- blood

what are intraduct papillomas

benign breast lesions

how are intraduct papillomas broadly classified

central or peripheral

where are peripheral intraduct papillomas found

terminal duct lobular unit.

what are potential complications of intraduct papillomas

if they are big enough they may block the ducts and causes cysts

what is ductal carcinoma in situ

breast carcinoma limited to the ducts with no extension beyond the basement membrane >> cancer has not infiltrated the parenchyma of the breast + lymphatics >> cannot metastasise

if there is no epithelial proliferation with Intraduct papilloma  what is the Dx

Benign IDP

if there is usual type hyperplasia of the epithelium with Intraduct papilloma  what is the Dx

Benign IDP

if there is atypical ductal hyperplasia of the epithelium with Intraduct papilloma  what is the Dx

IDP with Atypical ductal hyperplasia

what carcinomas often metastases to the breast

bronchial ovarian serous carcinoma clear cell carcinoma of the kidney melanoma

what is the definition of breast carcinoma

A malignant tumour of breast epithelial cells

where does breast carcinoma arise from

glandular epithelium of the terminal duct lobular unit (TDLU)

what are the 2 types of breast carcinomas

ductal carcinoma | lobular carcinoma

what is the precursors of ductal carcinoma

Epithelial hyperplasia of usual type (lowest i.e. least worrying) Columnar cell change (some premalignant potential) Atypical Ductal Hyperplasia Ductal Carcinoma in situ

what is the precursors of lobular carcinoma

Atypical lobular hyperplasia | Lobular carcinoma in situ

what is meant by in situ carcinoma

Confined within basement membrane of acini & ducts Cytologically malignant but non (pre) - invasive

what is the definition of atypical lobular hyperplasia (ALH)

<50% of lobule involved

what is the definition of lobular carcinoma in situ (LCIS)

> 50% of lobule involved

what is characteristic of the cells in LCIS

ER positive

features of LCIS

Incidence decreases after menopause (because it is ER positive) May calcify = can be seen mammogram

Mx of a lobular carcinoma precursor

if discovered on core biopsy proceed to excision or vacuum biopsy to exclude higher grade lesion

which intraductal precursor has the highest risk of progressing to cancer

highest risk 1. Ductal Carcinoma in situ 2. Atypical ductal hyperplasia 3. Epithelial hyperplasia of usual type

what are features of ductal carcinoma in situ

``` Arises in TDLU Characteristically unicentric (single duct system) ```

what is DCIS called when it invades the nipple skin

Paget's disease

what is Paget's Disease of the nipple

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

Mx of DCIS

surgery + radiotherapy

what its the definition of invasive carcinoma

Malignant epithelial cells which have breached the BM Infiltration of normal tissues

what factors affect prognosis of breast cancer

ER - absence of receptors carries adverse prognosis HER2 - absence of over expression carries adverse prognosis

what Tx should be given if the tumour expresses HER 2

trastuzumab

what is HER 2 and how does it related to breast cancer

Human Epidermal growth factor Receptor 2 overexpression and amplification seen in ~15%

what other hormone receptors are almost all tumours that are ER positive are also seen

Progesterone Receptors (PgR)