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Breast > Breast Pathology > Flashcards

Breast Pathology Flashcards

1
Q

what does “triple assessment” entail when assessing patient with breast disease?

A

clinical - history and exam

imaging - mammography, US, MRI

pathology - cytopathology, histopathology

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2
Q

how can breast cytopathology be carried out?

A

fine needle aspiration (FNA)
fluid
nipple discharge
nipple scrape

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3
Q

how is breast FNA cytology classified?

A 
C1 - unsatisfactory 
C2 - benign 
C3 - atypica, probably benign 
C4 - suspicious of malignancy 
C5 - malignant
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4
Q

what are diagnostic methods of breast histopathology?

A

needle core biopsy
vacuum assisted biopsy (large mass)
skin biopsy
incisional biopsy or mass

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5
Q

what are therapeutic methods of breast histopathology?

A

vacuum assisted excision
excisional biopsy of mass
resection of cancer - wide local excision, mastectomy

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6
Q

how can breast needle core biopsy be classified?

A 
B1 - unsatisfactory / normal 
B2 - benign 
B3 - atypia, probably benign 
B4 - suspicious of malignancy 
B5 - malignant (B5a = carcinoma in situ, B5b = invasive carcinoma)
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7
Q

what are developmental anomalies which are benign breast disease?

A

hypoplasia
juvenile hypertrophy
accessory breast tissue
accessory nipple

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8
Q

what are the non-neoplastic benign breast diseases?

A 
gynaecomastia 
fibrocystic change 
hamartoma
fibroadenoma 
sclerosing lesions (sclerosing adenosis, radial scar / complex sclerosing lesions)
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9
Q

what are inflammatory causes of benign breast disease?

A

fat necrosis
duct ectasia
acute mastitis / abscess

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10
Q

what are the benign tumours within the breast?

A

phyllodes tumour

intraduct papilloma

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11
Q

what is gynaecomastia?

A

breast development in the male

ductal growth without lobular development

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12
Q

what are the causes of gynaecomastia?

A

exogenous / endogenous hormones
cannabis
prescription drugs
liver disease

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13
Q

who does fibrocystic change normally occur in?

A

women aged 20-50

*majority 40-50

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14
Q

fibrocystic change is very common - true or false?

A

true - 19-34% in autopsy studies

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15
Q

what are the different causes of fibrocystic

A

menstrual abnormalities (particularly anovulatory cycles)
early menarche
late menopause
often resolve or diminish after menopause

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16
Q

how does fibrocystic change present?

A 
smooth discrete lumps 
sudden pain 
cyclical pain 
lumpiness 
incidental finding 
screening
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17
Q

what does fibrocystic change look like on gross pathology?

A

cysts

  • 1mm - several cm
  • blue domed with pale fluid
  • usually multiple
  • assoc with other benign changes

intervening fibrosis

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18
Q

what does fibrocystic change look like on microscopic pathology?

A

cysts

  • thin walled but may have fibrotic wall
  • lined by apocrine epithelium

intervening fibrosis

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19
Q

what is the definition of metaplasia?

A

the change from one fully differentiated cell type to another fully differentiated cell type

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20
Q

what is the management of fibrocystic change?

A

exclude malignancy
reassure
excise if necessary

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21
Q

what is a hamartoma?

A

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

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22
Q

who is fibroadenomas more common in?

A

african women

*these are common and usually solitary

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23
Q

what are the clinical features of a fibroadenoma?

A 
peak incidence in 3rd decade 
picked up on screening 
painless, firm, discrete, mobile mass
"breast mouse" - move about
solid on US
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24
Q

what does a fibroadenoma look like?

A

circumscribed
rubbery
grey-white colour
biphasic tumour / lesion (epithelium, stroma)

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25
Q

how are fibroadenomas treated?

A

diagnose
reassure
excise

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26
Q

what are sclerosing lesions?

A

benign, disorderly proliferation of acini and stroma
can cause a mass or calcification
may mimic carcinoma

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27
Q

how does sclerosing adenosis usually present?

A

pain, tenderness or lumpiness / thickening
asymptomatic
age 20-70

*these are benign, no further treatment necessary

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28
Q

what does radial scar look like pathologically?

A

stellate architecture
central puckering
radiating fibrosis

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29
Q

what does radial scar look like histologically?

A

fibroelastotic core
radiating fibrosis containing distorted ductules
fibrocystic change
epithelial proliferation

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30
Q

in situ or invasive carcinoma may occur with radial scar lesions - true or false?

A

true

they often show epithelial proliferation and mimic carcinoma radiologically

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31
Q

what is the treatment of radial scar?

A

excise or sample extensively by vacuum biopsy

32
Q

what can cause fat necrosis of breast?

A

local trauma - seat belt injury, frequently no history

warfarin therapy

33
Q

what does fat necrosis look like?

A

damage and disruption of adipocytes
infiltration by acute inflammatory cells
“foamy” macrophages
subsequent fibrosis and scarring

34
Q

what is the treatment of fat necrosis?

A

confirm diagnosis

exclude malignancy

35
Q

what are the clinical features of duct ectasia?

A 
affects sub-areolar ducts 
pain 
acute episodic inflammatory changes 
blood and/or purulent D/C
fistulation 
nipple retraction and distortion
36
Q

what lifestyle habit is duct ectasia associated with?

A

smoking

37
Q

what is the management of duct ectasia?

A

treat acute infections
exclude malignancy
stop smoking
excise ducts

38
Q

what are the 2 main causes of acute mastitis / abscess?

A

duct extasia - mixed organisms, anaerobes

lactation - staph aureus, strep pyogenes

39
Q

what is the management of acute mastitis / abscess?

A

antibiotics
percutaneous drainage
incision and drainage
treat underlying cause

40
Q

what are the clinical features of a phyllodes tumour?

A

40-50

slow growing unilateral breast mass

41
Q

what are the characteristics of a phyllodes tumour?

A

biphasic tumour
stromal overgrowth

*behaviour depends on benign, borderline or malignant (sarcomatous)

42
Q

phyllodes tumours are not prone to local recurrence - true or false?

A

false - prone to local recurrence if not adequately excised

43
Q

do phyllodes tumours often metastasise?

A

no

44
Q

what are the clinical features of intraduct papilloma?

A

age 35-60
nipple discharge +/- blood
asymptomatic at screening (nodules, calcification)

45
Q

what does intraduct papilloma look like?

A

sub-areolar ducts
2-20mm diameter
papillary fronds containing a fibrovascular core
covered by myoepithelium and epithelium
epithelium may show proliferative activity

46
Q

what determines the severity / what we call intraduct papilloma?

A

the epithelial proliferation

  • none
  • usual type hyperplasia
  • atypical ductal hyperplasia
  • ductal carcinoma in situ
47
Q

malignant phyllodes tumours occur due to overgrowth of what component?

A

stroma

  • this is why it is called sarcomatous
  • they appear slightly like a fibroadenoma
48
Q

when do angiosarcomas usually occur in the breast?

A

after radiation

49
Q

what other malignant tumours can occur in the breast?

A

malignant phyllodes
angiosarcinoma
lymphoma (breast / lymph nodes)
mets from other cancers

50
Q

what other cancers can potentially metastasise to the breast?

A

carcinomas - bronchial, ovarian serous, clear cell kidney

melanoma

uterine leiomyosarcoma

51
Q

what makes a breast cancer a “carcinoma”

A

tumour of glandular epithelium in the TDLU

ductal / acinar epithelial cells are affected

52
Q

what various precursor lesions may be identified prior to development of a ductal cancer?

A

usual type epithelial hyperplasia

columnar cell change

atypical ductal hyperplasia

ductal carcinoma in situ (DCIS)

53
Q

what various precursor lesions may be identified prior to development of a lobular cancer?

A

lobular in situ neoplasia (LISN)

atypical lobular hyperplasia

lobular carcinoma in situ (LCIS)

54
Q

what makes a cancer of the breast “in situ”?

A

confined within basement membrane

cytologically malignant but non-invasive

55
Q

describe how lobular in situ neoplasia would be identified?

A

often ER positive - stimulated by oestrogen so often incidence decreases after menopause

multiple and bilateral

not palpable or grossly visible

may calcify - seen on mammography

usually incidental finding

56
Q

many causes of lobular in situ neoplasia are identified on core biopsy yet higher grade lesions are found on open biopsy - true or false?

A

true

57
Q

lobular in situ neoplasia can put patients at risk of invasive carcinoma and other lesions - true or false?

A

true

58
Q

if lobular in situ neoplasia is found on core biopsy, what is the next step to exclude other lesions?

A

excision or vacuum biopsy to exclude higher grade lesion

if LISN is discovered on larger biopsy then follow up and clinical trials

59
Q

what is meant by atypical duct hyperplasia?

A

duct formation within other ducts

60
Q

describe the appearance of high grade DCIS?

A

necrosis in centre of duct as not receiving nutrients from out in stroma

large atypical cells

large nuclei

mitotic figures

61
Q

how many duct systems are usually involved in DCIS?

A

one - singular duct system

62
Q

how can DCIS spread locally?

A

may involve lobules (cancerisation)

may involve nipple skin (Pagets - still in situ)

63
Q

how is ductal carcinoma in situ (DCIS) treated?

A

surgery

mammographic follow up if low risk

adjuvant radiotherapy

chemoprevention

endocrine therapy

64
Q

what is microinvasive DCIS defined as?

A

DCIS (high grade) with invasion of <1mm

65
Q

is the incidence of breast cancers increasing or decreasing?

A

increasing

66
Q

what age does breast screening normally take place and why?

A

50-70

most people diagnosed at this age so screening most cost effective

67
Q

what are the main risk factors for carcinoma of breast?

A 
age 
more oestrogen exposure
previous breast disease
geography (western world) 
life-style 
genetics
68
Q

what can increase a patients oestrogen exposure and put them at higher risk of breast cancer?

A

age at menarche / menopause

later age at first birth

decreased parity

lack of breast feeding

hormones (OCP, HRT)

69
Q

what lifestyle factors can increase a patients risk of breast cancer?

A 
bodyweight 
alcohol consumption 
diet 
NSAIDs (lowers the risk) 
smoking
70
Q

where do breast cancers locally spread to?

A

stroma of breast
skin
muscles of chest wall

71
Q

what lymph nodes do breast cancers normally infiltrate?

A

sentinel nodes drain tumour first
- if not affected no need for axillary clearance

most cancers will drain from sentinel to axillary

some medial cancers will drain to internal mammary node

72
Q

where do breast cancers normally metastasise to?

A 
bone 
liver 
brain 
lungs 
abdominal viscera
female genital tract
73
Q

what is the difference between grade and stage of tumour?

A

grade = how differentiated lesion is

stage = how far it has spread in body

74
Q

what treatments can be aimed at tumours with oestrogen receptor expression?

A

oophrectomy
tamoxifen
aromatase inhibitors (letrozole)
GnRH antagonists (zoladex inj)

75
Q

what treatments can be aimed at tumours expressing the HER2 receptor?

A

trastuzaman (herceptin)

Breast (6 decks)

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