Breast Pathology Flashcards by Chloe .

What imaging modalities are used for the breasts?

Mammogram
Ultrasound
MRI

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What are the 5 classifications from fine needle aspiration?

C1 - unsatisfactory 
C2 - benign 
C3 - atypia 
C4 - suspicious 
C5 - malignant

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Describe how fine needle aspiration is carried out

Orange or blue needle syringe put into the area of interest and aspirated

(Epithelial cells come out easier than stromal cells)

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What samples from the breast can be sent for cytopathology?

Fluid from cysts
Nipple discharge
Nipple scrape

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What histopathological techniques can be used for investigation of breast lumps?

Needle core biopsy
Vacuum assisted biopsy
Skin biopsy
Incisional biopsy

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What are the classifications given from needle core biopsy?

B1 - Unsatisfactory 
B2 - Benign 
B3 - atypia 
B4 - suspicious 
B5 - malignant 
B5a - carcinoma in situ 
B5b - invasive carcinoma

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Which muscle does the blood supply to the breast pass through?

Pec major

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Give examples of developmental abnormalities of the breast

Hypoplasia
Juvenile hypertrophy
Accessory tissue/nipples

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Give examples of non-neoplastic benign breast disease

Gynaecomastia
Fibrocystic change
Hamartoma 
Fibroadenoma
Sclerosing lesions - sclerosing adenosis, radial scar, complex sclerosing lesions

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What is gynaecomastia?

Breast development in the male

Duct growth without lobular development

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What can cause gynaecomastia?

Hormones
Cannabis
Prescription drugs
Liver disease

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Who gets fibrocystic changes in the breast?

Women 20-50

But mostly 40-50

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What menstrual features are associated with fibrocystic change?

Early menarche
Late menopause
Menstrual abnormality

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How does fibrocystic change in the breast present?

Smooth discrete lumps
Sudden pain due to bleeding or rupture
Cyclical pain
Lumpiness

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Describe the cysts found in fibrocystic change in the breasts

1mm - several cm 
Blue domed with pale fluid 
Multiple 
Thin walled
Lined with apocrine epithelium

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How is fibrocystic change in the breast managed?

Exclude malignancy
Reassure
Can excise if necessary

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What is a hamartoma?

Well circumscribed lesion composed of cell types normal to breast but present in abnormal proportion or distribution

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Who commonly gets fibroadenomas?

African women

20s

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How does a fibroadenoma present?

Solitary 
Painless
Firm
Mobile
Grey-white colour 
Local hyperplasia 
"Breast mouse"

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How does a fibroadenoma appear on ultrasound?

Solid

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How is a fibroadenoma managed?

Reassure

Excise

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What is the difference between a radial scar and a complex sclerosing lesion?

Size
Radial scar 1-9mm
CSL 10+mm

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What is sclerosing adenosis?

Proliferative lesion which has become hardened, damaged or distorted

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How does a radial scar appear?

With central puckering

Translucent, oval lesions in the middle

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How does a radial scar/CSL appear histologically?

Fibro-elastic core Radiating fibrosis Fibrocystic change Epithelial proliferation

Give examples of inflammatory breast disease

Fat necrosis Duct ectasia Acute mastitis Abscess

What causes fat necrosis?

Local trauma eg surgery, seatbelt injury | Warfarin therapy

Describe the pathophysiology of fat necrosis

Trauma causing damage and disruption of adipocytes Infiltration by acute inflammatory cells Foamy macrophages enter Subsequent fibrosis and scarring

How is fat necrosis managed?

Exclude malignancy

What is duct ectasia?

Blockage or clogging or one lactiferous duct

How does duct ectasia present?

``` Inflammation, pain, hot Fibrosis and scarring Distortion Discharge Nipple retraction/distortion ```

How is duct ectasia managed?

Treat acute infection Exclude malignancy Stop smoking Excise ducts

What is a Phyllode's tumour?

Biphasic, slow-growing, unilateral tumour with stromal overgrowth

What age group most commonly get Phyllode's tumour?

40-50

How may intraduct papilloma present?

Nipple discharge and blood | Can be asymptomatic

What age group commonly get intraduct papilloma?

35-60

Which cell type covers intraduct papilloma?

Myoepithelium

Describe the core of an intraduct papilloma

Fibrous

What is the malignant component of a Phyllode's tumour?

Sacromatous stromal component

When do women tend to get angiosarcoma of the breast?

Post radiotherapy

Which malignant tumours can spread to breast?

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

Where does a breast carcinoma arise?

Glandular epithelium of the terminal duct unit

Give examples of precursor lesions to malignant breast tumour

``` Ductal - Epithelial hyperplasia of usual type Columnar cell change Atypical ductal hyperplasia Ductal carcinoma in situ ``` Lobular - Atypical hyperplasia Lobular carcinoma in situ

Where is an in situ breast carcinoma confined to?

Basement membrane of acini and ducts

Describe a lobular in situ neoplasia

Small - int sized nuclei Intracytoplasmic lumen and vacuoles Bilateral and multifocal

Which hormonal receptors does a lobular neoplasia in situ have?

Oestrogen

Which gene is affected in lobular neoplasia in situ and how?

Deletion and mutation of CDHI gene on chromosome 16q22.1

What is the risk of invasive carcinoma increased by with ductal carcinoma in situ?

10x

What is the most common breast malignancy?

DCIS

How is DCIS managed?

Excised Adjuvant radiotherapy Anti-oestogen

What is Paget's disease of the nipple?

High grade DCIS which extends along the ducts to the epidermis of the nipple

What is a micro-invasive carcinoma?

DCIS of a high grade with invasion of less than 1mm

What are protective factors for invasive carcinoma?

First child early Breastfeeding Exercise

Which genes are associated with breast and ovarian cancer?

BRCA1 and 2

Which gene is associated with Li Fraumeni syndrome?

TP53

Which tumours are associated with Li Fraumeni syndrome?

``` Childhood sarcoma Brain Leukaemia Adrenocortical carcinoma Early-onset breast ```

Which tumours are associated with BRCA 1?

Breast Ovarian Bowel Prostate

Which tumours are associated with BRCA2 gene?

Breast (incl male) Ovarian Prostate Pancreatic

Which gene is associated with Cowden's syndrome?

PTEN

Which tumours are associated with Cowden's syndrome?

Breast GI Thyroid

Which genes are associated with Peutz-Jeghers syndrome?

STK11 | LBK1

Which tumours are associated with Puetz-Jegher's syndrome?

Breast GI Pancreatic Ovarian

Which gene is associated with ataxia telangiectasia?

ATM

Which tumours are associated with ataxia telangiectasia?

Non-Hodgkin lymphoma Ovarian Breast

What hormone receptors may invasive carcinoma have?

Oestrogen Progesteron HER2

In assessment of an invasive carcinoma, which score makes it Grade 1?

3-5

In assessment of an invasive carcinoma, which score makes it Grade 2?

6-7

In assessment of an invasive carcinoma, which score makes it Grade 3?

8-9

What factors are used in the assessment of an invasive carcinoma?

Tubular differentiation Nuclear pleomorphism Mitotic activity

How can oestrogen receptor positive cancers be manged?

Tamoxifen Aromatase inhibitors (letrozole) GnRH inhibitors (Goserilin, zoladex) Oophorectomy

What is the role of aromatase in the female?

Convert androgen to oestrogen

What does HER2 stand for?

Human epidermal growth factor receptor 2

What prognostic tools are used for breast malignancy?

Nottingham Prognostic Index Adjuvant! Onine PREDCIT

What factors does the Nottingham Prognostic Index take into account?

0.2x tumour diameter Tumour grade Lymph node status

What factors does Adjuvant! Online take into account?

Histopathology ER pos/neg Clinical factors

What factors does PREDICT take into account?

``` Histopathology Clinical factors HER2 ER pos/neg Mode of detection ```

How does sclerosing adenosis present?

Can be painful or symptomatic

Which age group commonly gets sclerosing adenosis?

20-70

How is a radial scar treated?

Excise

How does duct ectasia change breast structure?

Dilates subareolar ducts

Describe the discharge found in duct ectasia

Purulent | Bloody

Phyllode's tumour commonly metastasises to axillary nodes | True/false

False | Recurrence common but mets rare

What is the difference between atypical lobular hyperplasia and lobular carcinoma in situ?

Atypical lobular hyperplasia <50% lobule involved Lobular CIS >50% lobule involved

What is the next step if lobular neoplasia found on core biopsy?

Excisional or vacuum biopsy to exclude higher grade malignancy

How is a micro-invasive carcinoma managed?

Same as DCIS

What is an invasive breast carcinoma?

Malignant epithelial cells which have breached the basement membrane

Why is high BMI associated with higher rates of breast cancer?

Increased oestrogen production

Which chemo drug are HER2 positive cancers sensitive to?

Trastuzumab (Herceptin)