Breast Pathology

Question 1

First off list 5 benign breast conditions

Answer 1

1. Fibrocystic change
2. Fibroadenoma
3. Intraductal papilloma
4. Fat necrosis
5. Duct Ectasia

Question 2

What is a fibroadenoma and who gets it?

Answer 2

Proliferation of the epithelial and stromal elements leads to a circumscribed mobile, non-painful nodule.

Occurs in women of reproductive age, peaking at 3rd decade May regress with age if left untreated

Question 3

When would we suspect fat necrosis?

Answer 3

If it looks clinically and on mammogram like a carcinoma PLUS they have a h/o trauma or surgery

Question 4

What benign conditions commonly cause nipple discharge?

Answer 4

Intraduct Papillomas and Duct Ectasia

Question 5

Name a breast condition that can be benign and malignant?

Answer 5

Phyllodes tumour

Question 6

What is a Phyllodes tumour?

Answer 6

A fibroepithelial fleshy tumour (leaf like pattern) cysts on its cut surface

Question 7

How many women get and die from breast carcinoma?

Answer 7

1 in 8 women (22% of all female cancers)

1 in 3 affected women die of it

Question 8

How does a carcinoma of the breast look clinically?

Answer 8

A hard fixed mass that tethers to the skin

With “orange peel” skin dimpling (peau d’orange)

Question 9

Where does breast carcinoma spread to?

Answer 9

1. Locally to skin and pecs
2. Lymphatically to axillary and internal mammary nodes
3. By blood to bones, lungs, liver and brain

Question 10

What tests can we do to identify a breast carcinoma?

Answer 10

• Clinical examination
• Radiology (Mammogram, ultrasound, MRI)
• Fine needle aspiration cytology FNA
• Needle core biopsy
• Wide local excision with adequate margins

Question 11

We histologically classify breast carcinoma into Non-invasive (in situ) and Invasive. What are the subtypes of carcinoma in-situ?

Answer 11

Ductal Carcinoma in-situ (DCIS)

Lobular Carcinoma in-situ (LCIS)

Question 12

Carcinoma in-situ is pre-invasive so non-palpable and can’t be detected clinically, how do we find it then?

Answer 12

On breast cancer screening

Question 13

How do we determine the risk a non-invasive carcinoma will become invasive?

Answer 13

By its grade, which requires biopsy.

Low grade DCIS - 30% in 15yrs

High Grade DCIS - 50% in 8yrs

LCIS - 19% in 25yrs

Question 14

What are the subtypes of invasive carcinoma of breast and which is the most common?

Answer 14

• Invasive Ductal Carcinoma 85%
• Invasive Lobular Carcinoma 10%
• Special 5% (tubular, mucinous and medullary)

Question 15

What do we use to estimate prognosis for breast carcinoma, and what factors is it based on?

Answer 15

The Nottingham Prognostic Index (NRI)

Uses size, grade and nodal status

Question 16

Whats the 5yr survival for breast cancer?

Answer 16

64% mean 5yr survival

Question 17

How do we determine if a breast carcinoma will respond to hormonal therapies?

Answer 17

Check if its Oestrogen receptor or Progesterone receptor +VE (ER/PR)

Question 18

What are the risk factors for breast carcinoma?

Answer 18

• Gender
• Age
• Early Menarche
• Older age of first pregnancy
• FH and H/O
• Radiation
• Hormonal treatment
• Obesity
• Alcohol
• Genetic Factors

Question 19

What are the major genetic risk factors for breast carcinoma?

Answer 19

BRCA1 or BRCA2

Question 20

What options do we have for managing breast cancer?

Answer 20

• Surgery (mastectomy, breast conserving surgery – WLE) +lymph nodes
• Radiotherapy
• Antihormonal therapy (Tamoxifen)
• Chemotherapy

Question 21

What is Paget’s disease of the nipple?

Answer 21

An intraepithelial spread of intraductal carcinoma

It leads to large pale-staining cells in the epidermis of the nipple

Question 22

How does Paget’s disease of nipple present?

Answer 22

• Pain and itching
• Scaling
• Redness
• It’s easily mistaken for eczema
• You may see ulcers, crusting and serous or bloody discharge

Question 23

What are the major male pathologies of the breast?

Answer 23

Carcinoma (very rare)

Gynaecosmastia (actually quite common)

Question 24

What can cause gynaecomastia?

Answer 24

• Hyperthyroidism
• Cirrhosis
• Chronic renal or pulmonary disease
• Hypogonadism
• Certain medications e.g. hormone therapies, spironolactone, Tricyclic Antidepressants

Question 25

What are other types of adenomas?

Answer 25

Tubular adenoma

• Far less common than fibroadenomas
• Young women, discrete, freely movable masses
• Uniform sized ducts

Lactating Adenoma

• Enlarging masses during lactation or pregnancy
• Prominent secretory change

Question 26

What are the features of a carcinoma in situ?

Answer 26

• Pre-invasive: non palpable so not detected clinically
• Multicentral
• Bilateral
• No metastatic spread as in basement membrane
• Risk of invasion depending on grading

Question 27

What does a mammogram detect?

Answer 27

Masses and microcalcifications

Question 28

What are microcalcifications?

Answer 28

Tiny deposits of calcium can appear anywhere in the breast and often show up on a mammogram

• Most women have one or more areas of microcalcifications of various sizes
• Majority of calcium deposits are harmless
• A small percentage may be in precancerous or cancerous tissue

Question 29

What does prognosis depend on?

Answer 29

• Patient related and tumour related
• Node status (best prognostic indicator)
• Tumour size ( < 2cm)
• Type - Grade (1,2,3 )
• Age
• Lymphovascular space invasion
• Oestrogen receptors ( ER )
• Progesterone receptors ( PR )
• HER-2
• Proliferative rate of tumour
• Gene expression profiling
• Nottingham Prognostic Index ( NPI ) based on tumour size, grade and nodal status