Breast Pathology Flashcards
what is the assessment model for a patient with breast disease
Triple assessment
- Clinical
- History and Examination - Imaging
- Mammography
- Ultrasound
- MRI - Pathology
- Cytopathology
- Histopathology
how is breast cytopathology obtained
fine needle aspiration
fluid
nipple discharge
nipple scrape
what are the 5 stages of breast FNA cytology
C1 - Unsatisfactory C2 - Benign C3 - Atypia, probably benign C4 - Suspicious of malignancy C5 - Malignant
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
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
what are non-neoplastic benign breast disease
Gynaecomastia Fibrocystic change Hamartoma Fibroadenoma Sclerosing lesions
what are inflammatory benign breast disease
Fat necrosis
Duct ectasia
Acute mastitis/abscess
what are benign breast tumours
Phyllodes tumour
Intraduct Papilloma
what is gynaecomastia
breast development in the male
what is the pathology of gynaecomastia
Ductal growth without lobular development
what can cause gynaecomastia
Exogenous/endogenous hormones
Cannabis
Prescription drugs
Liver disease
who are fibrocystic changes seen in
Women aged 20-50
Majority 40-50
very common
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
what is seen with fibrocystic changes of the breast
Menstrual abnormalities
Early menarche
Late menopause
what happens with fibrocystic changes after menopause
often resolve or diminish
how do fibrocystic changes often present
Smooth discrete lumps
Sudden pain
Cyclical pain
Lumpiness
what is the gross pathology of fibrocystic changes
Cysts
- 1mm – several cm
- blue domed with pale fluid
- usually multiple
- associated w/ other benign changes
what are the cysts in fibrocystic changes lined with
apocrine epithelium
Mx of fibrocystic changes
exclude malignancy
reassure
excise if necessary
what is a hamartoma
Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution
what are features of a fibroadenoma
common
usually solitary
commoner in african women
peak incidence in 3rd decade
presentation of fibroadenoma
Painless, firm, discrete, mobile mass
sometimes called “breast mouse” as they move so freely
how do fibroadenomas present on USS
solid
what is the pathology of a fibroadenoma
Circumscribed
Rubbery
Grey-white colour
Biphasic tumour/lesion
- Epithelium
- Stroma
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
- Ductal Carcinoma in situ
- Atypical ductal hyperplasia
- 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)
