Breast Pathology

Question 1

Breast Anatomy

Answer 1

15-20 lobes

Each composed of groups of lobules

Question 2

What is the functional unit of the breast?

Answer 2

TDLU - terminal duct lobular unit

Question 3

Triple Assessment

Answer 3

Clinical - history and examination
Radiological - mammography (>35y) USS
Pathological - FNA, core biopsy

Question 4

Pathology reporting categories

Answer 4

C1/B1 - inadequate or not diagnostic
C2/B2 - benign
C3/B3 - favours benign
C4/B4 - favours malignant 
C5/B5 - malignant

Question 5

Fibroadenoma

Answer 5

Commonest benign tumour
Typically under the age of 30
Firm, painless, mobile lump - may be multiple
Well circumscribed

Reassurance, dischange, excision

Question 6

Fibrocystic change

Answer 6

result of minor aberrations in the normal response to cyclical hormonal changes
Typically in women 25-45 years
Changes affect the TDLU - characterised by fibrosis and cyst formation

Breast pain, tenderness, lumps/cysts

Triple assessment

Reassurance, analgesics, cyst aspiration, excision (rare)

Question 7

Major risk factors for breast cancer

Answer 7

Increasing lifetime oestrogen exposure
Family history
Alcohol consumption

Question 8

Clinical features of breast cancer

Answer 8

50% in outer quadrant of breast
Hard painless lump
fixed to wall or overlying skin
nipple incursion and skin dimpling
ulceration/fungation
peau d'orange
nipple eczema (Paget's disease)
palpable axillary nodes
metastatic disease
B symptoms

Question 9

Breast cancer investigations

Answer 9

Triple assessment

Biopsy = grade
Staging needs to be done

Question 10

Breast cancer pathophysiology

Answer 10

Most are invasive adenocarcinomas

75% are ductal carcinoma
10-15% are lobular carcinoma

Question 11

Ductal Carcinoma In Situ (DCIS)

Answer 11

epithelial cells showing cytological changes of malignancy
present in the TDLE
basement membrane is in tact - cells have not invaded through

PRE CANCER

Question 12

Invasive Ductal Carcinoma (IDC)

Answer 12

tumour cells have invaded through the basement membrane into adjacent tissue

CANCER

Question 13

Paget’s disease of the nipple

Answer 13

due to the presence of DCIS cells in the epidermis which may extend along the major ducts and reach the nipple
the affected skin reacts to their presence and give the characteristic eczematous appearance

biopsy is required for a definite diagnosis

Question 14

Invasion Lobular Carcinoma (ILC)

Answer 14

second most common type of invasive breast cancer
10-15% of cases
tumour cells infiltrating the normal breast tissues linear cords of cells (single file)
due to loss of E-cadherin-catenin cell adhesion system

Question 15

What are the other less common types of breast cancer?

Answer 15

Tumular
Cribriform
Mucinous

Question 16

What are the genetic subdivisions of invasive breast cancers?

Answer 16

Luminal A
Luminal B
HER-2-enriched
Basal-like

Question 17

Prognostic factors of breast cancer

Answer 17

Tumour stage (TNM)
Tumour grade
Histological subtype
Vascular invasion
Excision markings
Oestrogen receptor and HER2 status

Question 18

Oestrogen receptors (ER)

Answer 18

correlates with aggressiveness and predicts response to therapy

ER +ve = lower grade, less aggressive, likely to respond to hormonal therapy

ER -ve = higher grad,e more aggressive, less likely to respond to hormonal therapy

Question 19

HER2

Answer 19

oncogene that encodes transmembrane tyrosine kinase receptor
over expressed in about 15% of invasive breast cancers
over expression is associated with poorer prognosis, but good response to Herceptin

Question 20

What is the sentinel lymph node

Answer 20

the first node draining a cancer

if it doesn’t contain cancer then there is a very high likelihood that the cancer has not spread to any other nodes or elsewhere

Question 21

Advantages of the sentinel node technique

Answer 21

important prognostic information

patients with a negative sentinel node are spared an axillary node clearance

Question 22

how is the sentinel node identified?

Answer 22

dye/isotope injected into the tissue around the tumour
visually inspect nodes for staining and uses a gamma prove to assess which nodes have taken up the radionuclide
can then be identified and removed

Question 23

NHS breast screening programme

Answer 23

Identify premalignant or very early stage cancer

All women aged 50-70 (pushing to 47-73) are screened every 3 years

Question 24

Further assessment following screening

Answer 24

Imaging e.g. ultrasound
clinical examination
needle test, usually core biopsy