Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

*Medicine: Cellular Pathology > Breast pathology > Flashcards

Breast pathology Flashcards

1
Q

Describe breast anatomy

A
  • large sweat gland modified to produce milk (not sweat)
  • made of approx 15-25 lobes
  • each lobe composed of group of lobules
  • functional unit of breast = terminal duct lobular unit (TDLU)
  • lobule is composed of multiple acini (glands)
  • within acini is where milk is produced
  • milk drains via terminal ducts into main duct system
  • duct system eventually opens out at nipple, where baby suckles
  • the entire duct + lobular system is lined by epithelium surrounded by a basement membrane
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How diseases of the breast commonly present as?

A
  • palpable lumps
  • most common pres of breast cancer is a palpable lump
  • so all breast lumps must be investigated
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How does the cause of a breast lump vary according to age?

A
  • in a young woman, fibroadenoma + fibrocystic change are most common causes - cancer is much less common
  • in an older woman, cancer becomes an important cause, although fibroadenoma + fibrocystic changes also occur
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

ALL breast lumps must undergo triple assessment to determine their underlying nature. What is meant by this?

A
  • clinical - hx + exam
  • radiological - mammography + USS
  • pathological - a needle test: FNA and/or core biopsy

the diagnosis + mangement of each patient is discussed in a Multidisciplinary Team Meeting, when all 3 modailities concur, the pre-op diagnostic accurace is approx 99%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How/why is the use of mammography different to ultrasound for breast lumps?

A
  • mammography (in older pts >35yr) - identifies microcalcifications + densities
  • ultrasound (usually <35yr bc their breast tissue is too dense for mammography) - good for distinguishing solid + cystic lesions, can guide a needle test
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How is the use for FNA and core biopsy different?

A
  • FNA has ‘C’ prefix- cytology sample
  • Core biopsy has ‘B’ prefix - biopsy for histology
  • both use a numbering system, reporting categories are comparable although not identicle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the reporting categories for pathological assessment (FNA + core biopsy)?

A
  • C1/B1 - inadequate or not diagnostic
  • C2/B2 - benign* eg. fibroadenoma, fibrocystic change
  • C3/B3 - equivocal, favour benign
  • C4/B4 - equivocal, favour malignant
  • C5/B5 - malignant (DCIS is included here)

*in this context, benign refers to any lesion that isn’t malignant or premalignant - thus includes benign tumours (eg. fibroadenoma) and also non-neoplastic lesions such as fibrocystic change, abscesses etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is a fibroadenoma? How is it diagnosed? What is the treatment?

A
  • commonest benign tumour of breast
  • typically occurring in women under age of 30
  • usually presents w/ firm, mobile, painless lump
  • may be multiple
  • require triple assessment to confirm diagnosis
  • tumour is well circumscribed + composed of well differentiated glands embedded in a well differentiated connective tissue stroma
  • once dx established, pts offered reassurance + discharge or excision
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is fibrocystic change? Who is it seen in? Symptoms? How is diagnosis made? What is the treatment?

A
  • variety of benign, non-neoplastic changes in breast
  • result of minor aberrations in normal response to cyclical hormonal changes
  • typically seen in women 25-45yrs
  • changes affect the TDLU (terminal ductal lobular unit)
  • characterised by fibrosis (scarring) + cyst formation
  • breast pain, tenderness, lumps/cysts (esp during second 1/2 of menstrual cycle)
  • diagnosis -> triple assessment
  • treatment: reassurance, analgesics, cyst aspiration, rarely excision
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How common is breast cancer? What is the mean age of diagnosis?

A
  • most common cancer in UK
  • lifetime risk of being diagnosed is 1 in 8 women
  • may occur at any age
  • rare before 25yr
  • common between 40-70yr
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the risk factors for breast cancer?

A
  • increasing lifetime oestrogen exposure
  • female sex (>99% of cases)
  • increasing age (80% 50+)
  • obesity
  • early menarche, late menopause, long term combined pill, HRT >10yrs
  • family history
  • alcohol consumption
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the link with family history/genetics and breast cancer?

A
  • 5-10% of breast cancers familial
  • BRCA1 + BRCA2 - tumour suppressor genes
  • germline mutations in them -> account for 85% of familial cancers
  • inherited in autosomal dominant fashion
  • women w/ mutations in these genes have a lifetime risk of breast cancer of between 85-100%
  • also at high risk of developing ovarian cancer + so prophylactic risk-reducing bilateral mastectomy/salpingo-oophorectomy considered
  • germline mutations in P53 (Li-fraumeni syndrome) less common
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Where do most cancers occur in the breast?

A
  • 50% in the upper outer quadrant of the breast
  • here there is greatest proportion of breast parenchymal tissue
  • remainder are distributed equally throughout rest of breast
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What clinical features on examination may make you suspect breast cancer?

A
  • hard, painless lump; maybe fixed to chest wall or overlying skin
  • nipple inversion + skin dimpling
  • ulceration/fungation
  • peau d’orange
  • nipple eczema in Paget’s disease
  • palpable axillary nodes, suggesting spread of tumour to these nodes
  • metastatic disease eg. weight loss, pleural effusion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How do you investigate suspected breast cancer?

A
  • palpable breast lump -> triple assessment
  • biopsy will give grade of cancer
  • cancer needs to be staged (how depends on the scenario)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

All cancer patients are discussed in a multidisciplinary team meeting. Who is involved and what is discussed?

A
  • surgeon, oncolgist, radiologist, pathologist, specialist nurses + others
  • treatment plan is agreed
  • appropriate treatment depends on various factors including tumour type, grade and stage, patient fitness + patient choice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What type of tumours are breast tumours?

A
  • almost all malignant tumours arising in breast = invasive adenocarcinomas
  • adenocarcinoma = malignant tumour of glandular epithelium
  • as breast = gland
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the two most common types of breast cancer?

A
  • ductal carcinoma (approx 75%)
  • lobular carcinoma (approx 10-15%)

NOTE: It used to be thought that ductal carcinoma arose in the ducts and lobular carcinoma arose in the lobules. We now know that this is not the case and it is accepted that virtually all breast cancers arise from epithelium lining the terminal duct lobular unit (TDLU). Therefore some people argue that the terms ‘ductal carcinoma’ and ‘lobular carcinoma’ are outdated and misleading.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is ductal carcinoma in situ (DCIS)?

A
  • epithelial cells show cytological changes of malignancy
  • pleomorphism, hyperchromasia, inc nuclear:cytoplasmic ratios, mitotic activity present in TDLU
  • however, basement membrane in tact
  • cells have not invaded into the surrounding tissue
  • this is a form of carcinoma in situ
  • does not form a mass usually
  • associated w/ microcalcifications
  • usually unifocal lesion conc in 1 area of breast
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is invasive ductal carcinoma (IDC)?

A
  • IDC invades through basement membrane into adjacent breast tissue + has potential to metastasise
  • fulfils 2 defining criteria for a malignant tumour - it’s cancer
  • usually presents as palpable breast mass
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Why is DCIS (ductal carcinoma in situ) not cancer?

A
  • not invasive
  • no metastatic potential
  • doesn’t fill two defining criteria for malignancy
  • however, if left untreated, a significant proportion will progress to invasive ductal carcinoma
  • DCIS is pre-cancer
  • as it’s unifocal and can progress to IDC, DCIS is surgically excised
22
Q

Paget’s disease is a disease affecting the skin of the nipple + areola. What is it due to?

A
  • presence of DCIS cells in epidermis
  • may extend along major ducts + reach nipple
  • may enter deeper layers of epidermis + spread within it through nipple + areola
  • affected skin “reacts” to presence of DCIS cells
  • results in characteristic eczematous clinical appearance
23
Q

What is the main clinical differential diagnosis of Paget’s disease of the nipple?

A
  • eczema
  • a biopsy required to provide a definitive diagnosis
24
Q

Is invasive carcinoma related to Paget’s disease at all, or is it just DCIS cells?

A

In some cases of Paget’s disease there is also an underlying invasive carcinoma associated w/ the DCIS

25
Q

Do most women with DCIS have Paget’s disease?

A

No - Paget’s disease is a manifestation of DCIS but most women with DCIS do not have Paget’s disease.

This is because in most cases the DCIS cells do not extend all the way along the duct system to reach the skin surface.

26
Q

Is Paget’s disease of the bone the same thing as of the nipple?

A

No they are both completely unrelated diseases

27
Q

DCIS is classified as ‘B5/C5’. The ‘5’ category is used for malignant lesions. However, DCIS is not technically malignant. So why is DCIS classified as B5/C5?

A
  • as confusingly, breast surgeons + radiologists regard DCIS as ‘malignant’ and often describe it as ‘early cancer’ or ‘non-invasive cancer’
  • similar management to that of invasive carcinoma

lecturer: ‘non-invasive cancer’ is a contradiction in terms bc invasive growth is a prerequisite for calling something cancer - it is better to call it precancer instead. Also unsatisfactory as DCIS patients may suffer unnecessary psychological implications of it being called cancer. Similar treatment but biological behaviour not same.

28
Q

What is the second most common type of invasive breast cancer (accounting for approx 10-15% of cases)?

A
  • invasive lobular carcinoma
  • there is also a lobular carcinoma in situ but not relevant to T year syllabus
29
Q

Describe the microscropic structure of invasive lobular carcinoma (ILC)

A
  • composed of tumour cells
  • infilitrate normal breast tissue as linear cords of cells (‘a single file pattern’)
  • or as single cells which appear to be separate from one another
  • this discohesive growth pattern is a reflection of loss of function of the E-cadherin-catenin cell adhesion system
30
Q

What are the other breast cancers making up the remaining 15% not mentioned?

A
  • tubular carcinomas
  • cribiform carcinomas
  • mucinous carcinomas

each of these types of tumours is uncommon on an individual basis - not important in T year

31
Q

The classification of breast cancers according to the histological subtypes described is arguably outdated (especially when one considers that the terms ‘invasive ductal’ and ‘invasive lobular’ are misnomers).

Recent studies have shown that invasive breast cancers can be subdivided into four main groups based on the genetic changes seen in the tumour cells. What are these 4 categories?

A
  • Luminal A
  • Luminal B
  • HER2-enriched
  • Basal-like

This genomic classification is not used in the routine clinical setting

32
Q

What are luminal-type tumours like?

A
  • ER+ (cancer cells that need oestrogen to grow)
  • lower grade (grade 1 or 2)
  • Luminal type A prognosis better than type B
33
Q

What are HER-2 enriched tumours like?

A
  • overexpress HER2
  • potentially amenable to HER-2 targeted treatments
34
Q

What are Basal-like tumours like?

A
  • aggressive (almost always grade 3)
  • usually ER and HER2 negative
  • hormonal therapies + HER-2 targeted Tx not useful
  • share many genetic features w/ high-grade serous carcinoma of ovary
  • suggesting that cancers have a common molecular origin + may share therapeutic opportunities
35
Q

Prognostic factors are factors which help predict the probable course and outcome of a disease. In breast cancer, what is the most important prognostic factor?

A
  • tumour stage
  • in particular the lymph node status
  • it is a formal assessment of how far a malignant tumour has spread throughout the body
36
Q

In breast cancer, the TNM staging system is used. What does each letter mean?

A
  • primary Tumour spread - size of the primary tumour is important
  • regional lymph Node metastases
  • the presence of distant Metastases
37
Q

Another prognostic factor is tumour grade - what is this?

A
  • an assessment of differentiation
  • indicates how aggressively a malignant tumour is likely to behave
  • 3 tier grading system - as grade increases, prognosis worsens
38
Q

What are some other prognostic factors important for breast cancer?

A
  • histological subtype - some subtypes (eg. tubular carcinoma) associated w better prognosis
  • vascular invasion - if tumour in blood vessels then adverse prognostic factor
  • excision margins - complete excision indicates better prognosis
  • oestrogen receptor and HER2 status
39
Q

What link to oestrogen receptors have with breast cancer?

A
  • breast carcinomas can express ER (oestrogen receptors)
  • this correlates with aggressiveness + predicts response to therapy
  • ER positive tumours tend to be lower grade and less aggressive and likely to respond to hormonal therapy
  • ER negative tumours tend to be higher grade and more aggressive and unlikely to respond to hormonal therapy
40
Q

What link does the HER-2 gene have with breast cancer?

A
  • an oncogene
  • encodes a transmembrane tyrosine kinase receptor
  • it is overexpressed in about 15% of invasive breast cancers
  • HER2 over-expression by an invasive breast carcinoma is associated with:
    • poorer prognosis
    • good response to Herceptin (monoclonal antibody against HER2 receptor)
41
Q

What is the sentinel lymph node?

A

first node draining a cancer

42
Q

What is meant when a sentinel node does not contain cancer?

A

Very high likelihood that cancer has not spread to any other nodes or elsewhere (since the cancer has to pass through the sentinel node first.

If the sentinel node does contain cancer, then the other axillary nodes may or may not be involved - we cannot be sure.

43
Q

The principle regarding the sentinel node is useful for determining the management of the axilla in breast cancer. What happens if the sentinel node is ‘positive’?

A
  • ie contain metastatic tumour
  • patient will have an axillary clearance - removal of axillary nodes
  • since we cannot be sure whether other nodes in axilla are involved or not
44
Q

What happens if the sentinel node is ‘negative’?

A
  • ie no metastatic tumour present in node
  • no further surgery in axilla is required
  • since there is a v high likelihood that cancer has not spread to any other axillary nodes - we regard them as uninvolved
45
Q

What are the advantages of the sentinel node technique?

A
  • gives important prognostic information (axillary node status is important for staging + overall is the most important prognostic factor)
  • patients w/ a negative sentinel node are spared an axillary node clearance (and its associated morbidity eg. lymphoedema, shoulder stiffness) ie. the sentinel node technique reduces the number of unnecessary lymph node dissections
46
Q

How is the sentinel lymph node identified?

A
  • dye and/or isotope (Technetium-99m) is injected into tissue around tumour
  • surgeon visually inspects the nodes for staining
  • uses a Gamma probe to assess which nodes have taken up the radionucelide
  • one or several nodes may have taken up dye + radioactive tracer
  • these nodes are designated sentinel lymph nodes
  • the surgeon removes these nodes and submits them to pathologist for examination
47
Q

What is the aim of the NHS breast screening programme?

A
  • to identify DCIS (ie. pre-cancer)
  • and small invasive carcinomas
  • at an early stage, before symptoms + signs (eg lump) develop
  • by doing so, morbidity + mortality reduced
48
Q

What histopathological finding is DCIS often associated with?

A
  • often but not always associated w/ microcalcifications
  • this forms the basis for the detection of DCIS by mamographic screening
49
Q

Who is invited for NHS breast cancer screening?

A
  • all women aged 50-70 invited for screening mammogram every 3 years
  • age range is currently being extended to those aged 47-73
  • if suspicious features are detected on screening mamograms (eg. microcalcifications and densities), woman is called back for further assessment of abnormality
50
Q

What involves further assessment of abnormality?

A
  • imaging eg. ultrasound
  • clinical examination
  • a needle test, usually a core biopsy

in this way, triple assessment is completed and a firm diagnosis can be obtained

*Medicine: Cellular Pathology (16 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions