Breast Pathology Flashcards by Kerry Hendrie

List the three steps to assessment of a patient with breast pathology

Clinical - history, exam
Imaging - mammography, US, MRI
Pathology - cytopathology, histopathology

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List the different methods of obtaining breast cytopathology specimens

Fine needle aspiration
Fluid
Nipple discharge
Nipple scrape

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Outline the grading method used for FNA

C1: Unsatisfactory
C2: Benign
C3: Atypia
C4: Suspicious 
C5: Malignant

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List the different methods of obtaining breast histopathology specimens

Needle core biopsy
Vacuum-assisted biopsy
Skin biopsy
Incisional biopsy of mass

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Outline the grading method used for needle core biopsy

B1: Unsatisfactory
B2: Benign
B3: Atypia
B4: Suspicious 
B5: Malignant
a. CISU
b. Invasive

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What types of therapeutic excision can be done for breast pathology?

Excisional biopsy of mass
Wide local excision of cancer
Mastectomy

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List the main categories of benign breast disease

Developmental anomalies
Non-neoplastic
Inflammatory
Tumours

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List aetiology of developmental anomaly causing benign breast disease

Hypoplasia
Juvenile hypetrophy
Accessory breast tissue
Accessory nipple

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List non-neoplastic causes of benign breast disease

Gynaecomastia
Fibrocystic change
Hamartoma
Fibroadenoma
Sclerosing lesions

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List inflammatory causes of benign breast disease

Fat necrosis
Duct ectasia
Acute mastitis/ abscess

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List benign tumours causing breast disease

Phyllodes tumour

Intraduct papilloma

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What is gynaecomastia?

Breast development in the male with ductal growth without lobular development

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List some causes of gynaecomastia

Exogenous/endogenous hormones
Cannabis
Drugs (furosemide)
Liver disease

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Fibrocystic change is non-neoplastic and typically affects women of what ages?

Aged 20-50, majority are 40-50

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List the clinical features of fibrocystic change of the breasts

Menstrual disturbance
Smooth, discrete lump
Sudden/cyclical pain

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Fibrocystic change of the breasts is associated with late menarche and late menopause. True/False?

False

Early menarche, late menopause

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Describe the pathological appearance of fibrocystic change of the breasts

Blue-domed cysts with pale fluid

Thin-walled but may be fibrous

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How is fibrocystic change managed?

Reassurance

Excision if necessary/symptomatic

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What is a hamartoma?

Circumscribed lesion consisting of normal breast tissue but present in abnormal proportion or distribution

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A fibroadenoma is a common benign lesion of the breasts - list some clinical features

Painless
Discrete, mobile mass
Peak incidence in 30’s

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Describe the pathological appearance of fibroadenoma of the breasts

Circumscribed, solid
Rubbery
Grey-white colour
Biphasic - consists of epithelium and stroma

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How is fibroadenoma of the breasts managed?

Reassurance

Excision if necessary

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What is sclerosing adenosis?

Benign, disordered proliferation of acini and stroma that can cause a mass (lumpiness, thickening) or calcification

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Describe the pathological appearance of a radial scar

Stellate architecture
Central puckering
Radiating fibrosis
Distorted ductiles

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Sclerosing adenosis and radial scars may mimic carcinoma. True/False?

True

How is radial scar of the breast managed?

Excise | Sample excessively using vacuum biopsy

List some common causes of fat necrosis of the breasts

``` Local trauma (seatbelt injury) Warfarin tehrapy ```

What is the characteristic pathological sign of fat necrosis?

Foamy macrophages

What is duct ectasia of the breast?

Lactiferous duct becomes blocked/clogged

List clinical features of duct ectasia

Pain Bloody/purulent discharge Fistulation Nipple retraction/distortion

How is duct ectasia managed?

Treat acute infection Exclude malignancy Stop smoking Excise ducts

What are the 2 main aetiologies that cause acute mastitis?

``` Duct ectasia Lactatory infection (Staph aureus, Step pyogenes) ```

How is acute mastitis managed?

Antibiotics Percutaneous drainage Incision and drainage Treat cause

What is a Phyllodes tumour?

Slow-growing unilateral benign breast mass

What is the characteristic pathological sign of Phyllodes tumour?

Stromal invasion

List types of papillary lesions causing benign breast disease

Intraduct papilloma Nipple adenoma Encapsulated papillary carcinoma

List clinical features of intraduct papilloma

Nipple discharge Bleeding Asymptomatic/ detected at screening

Which malignant breast cancer typically occurs following radiation for a previous breast cancer?

Angiosarcoma

List the main metastatic tumours to the breast

``` Bronchial carcinoma Ovarian serous carcinoma Clear cell carcinoma of kidney Malignant melanoma Leiomyosarcoma ```

Where does breast carcinoma arise?

Glandular epithelium of terminal duct lobular unit (TDLU)

What type of carcinoma is breast carcinoma?

Adenocarcinoma

List the precursor lesions that can give rise to breast carcinoma

``` Epithelial hyperplasia Columnar cell hyperplasia Atypical ductal hyperplasia Ductal carcinoma in situ Lobular in situ neoplasia ```

How is in situ carcinoma of the breast defined?

Confined to basement membrane of acini and ducts, i.e. non/pre -invasive

What are the 2 subtypes of lobular in situ neoplasia and how are they defined?

Atypical lobular hyperplasia (less than 50% of lobule affected) Lobular carcinoma in situ (more than 50% of lobule affected)

List pathological features of lobular in situ neoplasia

Small-intermediate sized nuclei Solid proliferation Intracytoplasmic vacuoles

How is lobular in situ neoplasia managed?

Core biopsy of lymph nodes | Excision/vacuum biopsy to exclude high grade lesion

Lobular in situ neoplasia is palpable. True/False?

False | Not palpable or grossly visible

Which precursor lesion equates to 15-20% of all breast malignancies?

Ductal carcinoma in situ

State the characteristic feature of ductal carcinoma in situ

Unicentric (single duct system)

Which disease is essentially high-grade ductal carcinoma in situ involving the nipple skin?

Paget's disease

How is ductal carcinoma in situ managed?

Surgery Adjuvant radiotherapy Chemoprevention

How is invasive carcinoma of the breast defined?

Malignant epithelial cells which have breached the basement membrane

What is the peak age range of incidence of breast carcinoma?

50-70's

List risk factors for breast carcinoma

Age Abnormal reproductive history (age at menarche/first birth/menopause, parity, breast feeding) Hormone therapy (OCP, HRT) Previous breast disease Poor lifestyle (weight, alcohol, diet, smoking) Genetics

NSAIDs lower the risk of breast carcinoma. True/False?

True

What aspect of lifestyle is a protective factor against breast carcinoma?

Physical activity

An affected first-degree relative increases the risk of breast cancer by how much?

Doubles the risk

What two cancer syndrome equates to a 45-64% lifetime risk of developing breast cancer?

BRCA1 | BRCA 2

TNM is the staging method used for breast carcinoma. What are the common sites of local invasion (T)?

Stroma of breast Skin Muscles of chest wall

TNM is the staging method used for breast carcinoma. What are the common sites of lymphatic spread (N)?

Internal mammary nodes Intramammary nodes Sentinel nodes

TNM is the staging method used for breast carcinoma. What are the common sites of blood-borne spread (M)?

``` Bone Liver Brain Lungs Abdominal viscera Femal genital tract ```

State the two main classifications of breast carcinoma and give their prevalence

Ductal (70%) | Lobular (10%)

List the pathological features that are assessed when grading a breast carcinoma

Tubular differentiation Nuclear pleomorphism Mitotic activity

What 2 factors/receptors help predict and offer prognosis for breast carcinoma?

HER2 Oestrogen receptor (ER) (Progesterone receptor)

If a patient shows overexpression of the ER harmone receptor, how does this affect their management?

Indicates a response to anti-oestrogen therapy

List examples of anti-oestrogen therapies used in breast cancer management

``` INVASIVE Oophrectomy NON-INVASIVE SERMs (Tamoxifen Aromatase inhibitors (letrozole) GNRH antagonists ```

List tumour markers that can be used to monitor the response of breast cancer to treatment

CEA CA15-3 CA125