Breast pathology Flashcards
benign breast disease is very common/rare
common
what is the difference between cytopathology and histopathology
cytopathology - cells are obtained from fluid by FNA
histopathology - pieces of tissue are examined from biopsy
techniques for obtaining cells for cytopathology
FNA
fluid from cyst
nipple discharge
nipple scrape
How is breast FNA cytology categorised
C1 - unsatisfactory C2 - benign C3 - atypia, probably benign C4 - suspicious of malignancy C5 - malignant
can FNA cytology differentiate between CIS and invasive carcinoma
no, which is why it is not used as much anymore
methods of obtaining breast histopathology samples
needle core biopsy
vacuum assisted biopsy
skin biopsy
incisional biopsy of a mass
how is needle core biopsy categorised
B1 - unsatisfactory/normal B2 - benign B3 - atypia, probably benign B4 - suspicious of malignancy B5 - malignant B5a CIS B5b invasive carcinoma
what is a wide local excision also known as
breast conservation therapy
removes tumour with clear margin
what groups of benign breast disease are there
developmental anomalies
non-neoplastic
inflammatory
tumours
what is breast hypoplasia
condition where 1 or both breasts don’t fully mature or develop
what is breast juvenile hypertrophy
rapid growth of 1 or both breasts
list the benign breast developmental anomalies
hypoplasia
juvenile hypertrophy
accessory breast tissue
accessory nipple
what is accessory breast tissue
mass anywhere along the embryological mammary streak
what is an accessory nipple
minor malformation of mammary tissue resulting in an extra nipple
what non-neoplastic changes can occur in the breast
gynaecomastia fibrocystic change hamartoma fibroadenoma sclerosing lesions
what inflammatory conditions of the breast are there
fat necrosis
duct ectasia
acute mastitis
abscess
what are the benign tumours of the breast
Phyllodes tumour
intraduct papilloma
what is gynaecomastia
breast development in males
ductal growth without lobular development
what are the causes of gynaecomastia
hormones - exogenous/endogenous
drugs - spironolactone, furosemide
cannabis
liver disease
who does fibrocystic change affect
women ages 20-50 (usually 40-50)
what is fibrocystic change associated with
menstrual abnormalities
early menarche
late menopause
fibrocystic change resolves after menopause, true or false
true
from reduced oestrogen
how does fibrocystic change present
smooth discrete lumps sudden pain (rupture or bleeding of cysts) cyclical pain lumpiness incidental / screening
what is the pathology of fibrocystic change
cysts
intervening fibrosis
what is a red flag in gross pathology
blood staining
define metaplasia
change of one fully differentiated cell type to another fully differentiated cell type
is metaplasia neoplastic/precursor lesion
no
management of fibrocystic change
exclude malignancy
reassure
only excise if it is a problem
define hamartoma
circumscribed lesion composed of cell types normal to the breast but are present in an abnormal proportion/distribution
in which group of women is fibroadenoma common
African women
3rd decade of life
presentation of fibroadenoma
painless
firm
discrete
mobile mass “breast mouse” as it moves away from your finger as you try to examine it
pathological features of a fibroadenoma
localised hyperplasia
proliferation of intralobular stroma
is fibroadenoma a biphasic tumour, what does this mean
yes
there is overgrowth of 2 components: epithelium and stroma
features of a fibroadenoma
circumsribed
rubbery
grey white colour
management of fibroadenoma
diagnose
reassure
excise
what are the subtypes of sclerosing lesions of the breast
sclerosing adenosis
radial scar
complex sclerosing lesion
what are sclerosing lesions
benign, disorderly proliferation of acini and stroma
can cause a mass or calcification
sclerosing lesions may/may not mimic carcinoma radiologically
may mimic carcinoma
characteristics of sclerosing adenosis
pain/tenderness
lumpiness/thickening
asymptomatic
20-70 yo
characteristics of radial scar
wide age range
incidental findings
what is a radial scar called if:
1-9mm
>10mm
1-9mm = radial scar >10mm = complex sclerosing lesion
histology of a radial scar
fibroelastic core
distorted ductules
fibrocystic change
epithelial proliferation
can CIS or invasive carcinoma occur within radial scars
yes
treatment of radial scars
excise or sample extensively by vaccum biopsy
causes of fat necrosis
local trauma
warfarin therapy
what is fat necrosis
damage to adipocytes
infiltration by acute inflammatory cells
foamy macrophages
subsequent fibrosis and scarring eg nipple indrawing
management of fat necrosis
confirm diagnosis
rule out malignancy
clinical features of duct ectasia
pain acute episodic inflammatory changes bloody/purulent discharge fistulation periductal inflammation and fibrosis nipple retraction and distortion
what does duct ectasia affect
sub areolar ducts
what is duct ectasia associated with
smoking
management of duct ectasia
treat acute infections
exclude malignancy
stop smoking
excise ducts
what are the 2 main causes of mastitis and which organisms are responsible
duct ectasia - mixed organisms, anaerobes
lactation - staph A, strep pyogenes
management of mastitis
antibiotics
percutaneous drainage
incision and drainage
treat underlying cause
clinical features of Phyllodes tumour
40-50s
slow growing unilateral breast mass
biphasic tumour
stromal overgrowth > epithelium
what is Phyllodes tumour also known as
Cytosarcoma phyllodes
what are the categories of Phyllodes tumour
benign
borderline
malignant sarcomatous
Are phyllodes tumours prone to recurrence if not adequately excised
yes
list papillary lesions of the breast
intraduct papilloma
nipple adenoma
ecapsulated papillary carcinoma
which age group os affected by intraduct papilloma
35-60
clinical features of intraduct papilloma
nipple discharge +- blood nodules calcification sub areolar ducts covered by MEp
what kinds of epithelial proliferation can you get in an intraduct papilloma
none
usual type hyperplasia
atypical ductal hyperplasia
ductal carcinoma in situ
what kind of malignant breast tumours can you get
breast carcinoma non-epithelial breast malignancies metastases malignant Phyllodes tumour angiosarcoma lymphoma
risk factor for angiosarcoma of the breast
history of previous radiotherapy
what is a malignant Phyllodes tumour treated as
sarcoma
which tumours metastasise to the breast
bronchial carcinoma Ovarian serous carcinoma clear cell carcinoma of the kidney malignant melanoma leiomyosarcoma
define breast carcinoma and what is its technical name
malignant tumour of breast epithelial cells (ductal/acinar cells)
breast adenocarcinoma
where does breast carcinoma arise from
glandular epithelium of the Terminal duct Lobular Unit TDLU
where can precursor lesions arise in the breast
ductal
lobular
list ductal precursor lesions of breast carcinoma
epithelial hyperplasia of usual type
columnar cell change +- atypia
atypical ductal hyperplasia
ductal carcinoma in situ
list lobular precursor lesions of breast carcinoma
atypical lobular hyperplasia
lobular carcinoma in situ
define carcinoma in situ CIS
cytologically malignant cells confined within basement membrane of acini and ducts
what types of CIS are there
ductal
lobular
what kinds of lobular in situ neoplasia are there
atypical lobular hyperplasia
lobular CIS
what % of the lobule is involved in atypical lobular hyperplasia
<50%
what % of the lobule is involved in lobular CIS
> 50%
pathological characteristics of lobular in situ neoplasia
small nuclei
solid
ER positive
E-cadherin negative
clinical features of lobular in situ neoplasia
multifocal and bilateral reduced incidence after menopause (because ER+) not palpable may calcify usually incidental
what is the significance of lobular in situ neoplasia
marker of subsequent risk
true precursor lesion
management of lobular in situ neoplasia
excision/vacuum biopsy
follow up
clinical trials
where does ductal CIS arise
TDLU
Pathological features of DCIS (ductal carcinoma in situ)
cytologically malignant epithelial cells
confined in basement membrane of duct
may involve lobules (cancerisation)
may involve nipple skin (Paget’s disease of the breast)
how does Paget’s disease of the breast arise and is it invasive
high grade DCIS moves along the duct to nipple epidermis
Paget’s is still in situ as basement membrane is in tact
how can you classify DCIS
cytological grade
histological type
presence of necrosis
what is the significance of DCIS
RF for developing invasive carcinoma
true precursor lesion for invasive carcinoma
management of DCIS
diagnose
surgery
adjuvant radiotherapy
chemoprevention
what is microinvasive carcinoma
rare condition where high grade DCIS has gone through the basement membrane but invasion is <1mm
how is microinvasive carcinoma treated
same as high grade DCIS
what are the pathways of breast carcinogenesis
low, intermediate and high grade
what does high grade DCIS turn into
G3 ductal carcinoma
define invasive breast carcinoma
malignant epithelial cells which have breached the basement membrane
infiltration of normal tissue
which age group is screened for breast cancer
50-70 year olds
what are risk factors for breast carcinoma
age reproductive history OCP, HRT previous breast disease western countries lifestyle alcohol genetics
which age group is screened for breast cancer
50-70 year olds
what are risk factors for breast carcinoma
age reproductive history: early menarche, late menopause, parity, breastfeeding (more oestrogen stimulation, increases risk) OCP, HRT previous breast disease western countries lifestyle - high BMI alcohol genetics
what aspects of reproductive history increases the risk of breast cancer
early menarche
late menopause
nulliparity
what lifestyle factors increase risk of breast cancer
high BMI
alcohol
less exercise
what procedure could you consider in those with BRCA mutations
prophylactic mastectomies
how is invasive breast carcinoma staged
T0-4, N1-3, M0-1
local invasion of breast stroma, skin, muscle
lymphatic involvement of axillae, internal mammary chain
blood spread to bone, liver, brain, lungs, female genital tract
what procedure could you consider in those with BRCA mutations
prophylactic mastectomies
how is invasive breast carcinoma staged
TNM
local invasion of breast stroma, skin, muscle
lymphatic involvement of axillae, internal mammary chain
blood spread to bone, liver, brain, lungs, female genital tract
which group of lymph nodes do the majority of breast cancer spread to
axilla
what are sentinel nodes
first nodes that drain the tumour
how can invasive breast carcinoma be classified
morphologically
gene expression profiling
hormone receptor expression
what does ER + mean
oestrogen receptor positive tumour
what does PR + mean
progesterone receptor positive tumour
what is the most common type of breast carcinoma
give examples of others too
ductal
lobular
mucinous
NST - no special type
what does tumour grade mean
how well differentiated the tumour is
ie how similar it is to the parent tissue
a well differentiated tumour is similar/not similar to its parent tissue
similar
how can you assess the grade of breast carcinoma
tubular differentiation
nuclear pleomorphism
mitotic activity
if a tumour is grade 1, what did it score
3, 4 or 5
if a tumour is grade 2, what did it score
6 or 7
if a tumour is grade 3, what did it score
8 or 9
which hormone receptor is most commonly positive in tumours
ER +
How do you manage ER+ tumours
anti-oestrogen therapy oophorectomy tamoxifen aromatase inhibitors GnRH agonists
what does HER2 stand for
Human Epidermal growth factor Receptor 2
in abnormal cells there are many multiple copies
what kind of drug is goserilin
GnRH agonist
what treatment is available for HER2 + tumours
herceptin (trastuzamab)
which cancer type (hormone receptor) has the best survival outcome
ER+
PR+
HER2 -
list protective factors for breast cancer
NSAIDs
having children
breast feeding
maintaining healthy weight and exercise
