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REPRODUCTION & GYNAECOLOGY > Breast Pathology > Flashcards

Breast Pathology Flashcards

1
Q

What is meant by a triple assessment of a patient with breast disease and where is this approach usually carried out?

A

Clinical
=> History
=> Examination

Imaging
=> Mammography (XRay - not done under age of 40)
=> Ultrasound
=> MRI

Pathology
=> Cytopathology
=> Histopathology

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2
Q

What is the difference between cyto- and histo-pathology?

A

Cytopathology
- study of fluid samples (FNA, discharge etc)

Histopathology
- study of tissue samples

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3
Q

What 4 samples can be analysed for breast cytopathology?

A

Fine Needle Aspiration (FNA)
Fluid
Nipple discharge
Nipple scrape

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4
Q

Why was a fine needle aspiration previously the first choice for Pathology analysis?

A

Fast to sample and analyse

=> diagnosis can be given quickly

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5
Q

How is an FNA analysed?

A

Nuclear:cytoplasm ratio
- if large dark nuclei, this indicates suspicion

enlarged/irregular cells?
- if yes, increased suspicion

are epithelial cells stuck together or pulling apart?
- normal cells stick together, malignant pull away from each other

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6
Q

Why is tissue sampling for histopathology still required after analysing an FNA?

A

Cannot predict if cancer is invasive or in situ

=> often needle core biopsy is used as first line rather than putting pt through both procedures

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7
Q

How can samples of tissue be taken for histopathology?

A

(Needle) core biopsy (like a punch biopsy)

Vacuum assisted biopsy (large volume - and can remove small benign lumps)

Skin biopsy

Incisional biopsy of mass

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8
Q

What are the various ways in which a breast lump could be removed?

A 
Vacuum assisted excision
Excisional biopsy of mass
Resection of cancer
Wide local excision (preserves breast)
Mastectomy (can be skin sparing to allow better reconstruction)
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9
Q

What are the advantages of a needle core biopsy?

A
  • less painful than FNA
  • same needle can be used multiple times in same patient
  • spring loaded (like punch biopsy)
  • can determine if invasive or not
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10
Q

What are the advantages of a vacuum assisted biopsy?

A
  • no GA required
  • doesn’t need to be completed in hospital
  • needle can be left in patient to take more samples and remove a full benign lesion
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11
Q

What developmental anomalies in the breast are included in benign pathology?

A

Hypoplasia
Juvenile hypertrophy
Accessory breast tissue (most common in axillae)
Accessory nipple

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12
Q

Describe how disease of the breast can spread within the organ itself?

A

Retrograde - into the lobules

Anterograde - into lactiferous ducts

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13
Q

What distinguishes that a breast cancer has become invasive?

A

Breach of the basement membrane under the myoepithelial cells

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14
Q

What types of benign breast disease are non-neoplastic?

A
  • Gynaecomastia
  • Fibrocystic change
  • Hamartoma
  • Fibroadenoma
  • Sclerosing lesions
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15
Q

What causes of benign breast disease are inflammatory?

A

Fat necrosis (often due to trauma - e.g. seatbelt in RTA)
Duct ectasia
Acute mastitis/abscess

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16
Q

What types of breast tumour are benign?

A

Phyllodes tumour

Intraduct Papilloma

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17
Q

What is gynaecomastia?

A
  • Breast development in the male

- Ductal growth without lobular development

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18
Q

What can cause gynaecomastia?

A

Exogenous/endogenous hormones
- neonates can get this if mother had transferred excess hormones to them during pregnancy

Cannabis

Prescription drugs

Liver disease
(especially alcoholic LD)

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19
Q

Describe the patient groups who usually present with Fibrocystic change

A
  • Women aged 20-50 (But majority 40-50)
  • Menstrual abnormalities
  • Early menarche/Late menopause (excess stimulation)
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20
Q

How do patients with fibrocystic change usually present?

A
  • Smooth discrete lumps
  • Sudden pain/Cyclical pain
  • Lumpiness
  • Incidental finding
  • May be picked up on screening
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21
Q

How does fibrocystic change appear macroscopically?

A
  • Cysts (1mm – several cm)
  • Blue domed with pale fluid
  • Usually multiple and bilateral
  • Associated with other benign changes e.g. fibrosis
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22
Q

Describe how fibrocystic change appears microscopically

A
  • Thin walled (may have fibrotic wall)

- Lined by apocrine epithelium

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23
Q

How should fibrocystic change be managed?

A
  • Exclude malignancy
  • Reassure patient
  • Excise if necessary
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24
Q

What is a hamartoma?

A
  • Benign circumscribed lesion
  • composed of cell types normal to breast tissue
  • BUT these are present in an abnormal proportion or distribution
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25
Q

Fibroadenomas are commonly bilateral and multiple. TRUE/FALSE?

A

TRUE

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26
Q

What ethnicity is at higher risk of fibroadenomas?

A

African women

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27
Q

How do fibroadenomas normally present?

A
  • Peak incidence in 3rd decade
  • May be picked up at screening
  • Painless, firm, discrete, mobile mass
  • “Breast mouse” => moves away from hand when you try to examine it
  • Solid on US
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28
Q

How does a fibroadenoma appear macroscopically?

A
  • Circumscribed
  • Rubbery
  • Grey-white colour
  • Biphasic tumour => Epithelium and Stroma involved
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29
Q

How does a fibroadenoma appear microscopically?

A

Biphasic tumour => Epithelium and Stroma involved
Localised hyperplasia
Proliferation of intralobular stroma

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30
Q

How are fibroadenomas treated?

A

Diagnose
Reassure
Excise

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31
Q

What is meant by sclerosing lesions of the breast?

A
  • Benign
  • disorderly proliferation of acini and stroma
  • Cause a mass or calcification
  • May mimic carcinoma
    (Adenosis or radial scar)
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32
Q

How do patients normally present with sclerosing lesions of the breast?

A
  • Pain/ Tenderness
  • Lumpiness/thickening
  • May be asymptomatic
  • Large age range => 20-70
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33
Q

Describe the macroscopic appearance of a radial scar?

A
  • Stellate architecture
  • central puckering
  • Radiating fibrosis
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34
Q

If a radial scar is >10mm, what is it then called?

A

Radial Scar = 1-9mm

Complex Sclerosing Lesion = >10mm

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35
Q

What investigation can pick up a radial scar during breast screening?

A

Mammography

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36
Q

How do radial scars appear microscopically?

A
  • Fibroelastotic core
  • Radiating fibrosis containing distorted ductules
  • Fibrocystic change
  • Epithelial proliferation
37
Q

Radial scars often mimic carcinoma on radiological investigations. TRUE/FALSE?

A

TRUE - mimic carcinoma on radiology

38
Q

How are radial scars often treated?

A

Excise OR sample extensively by vacuum biopsy

39
Q

There is a small chance that In situ or invasive carcinoma can occur within radial scar lesions. TRUE/FALSE?

A

TRUE

40
Q

What can cause inflammatory fat necrosis in the breast?

A
  • Local trauma
  • Seat belt injury
  • Commencing Warfarin therapy
41
Q

Describe the process of fat necrosis in the breast?

A
  • Damage and disruption of adipocytes often due to trauma
  • Infiltration by acute inflammatory cells
    (macrophages)
  • Subsequent fibrosis and scarring (this causes distortion of the breast - e.g. nipple inversion)
42
Q

HOw should fat necrosis be managed?

A

Confirm diagnosis

Exclude malignancy

43
Q

HOw does a patient usually present with duct ectasia?

A
  • Affects sub-areolar ducts
  • Pain
  • Acute episodic inflammatory changes
  • Bloody and/or purulent discharge from nipple
  • Fistulation
  • Nipple retraction/distortion
44
Q

What factor in a patient’s social history is a large indication for the development of duct ectasia?

A

Associated with smoking

45
Q

Describe the appearance of duct ectasia

A

Sub-areolar duct dilatation
Periductal inflammation
Periductal fibrosis
Scarring and distortion

46
Q

What are the main causes of mastitis or breast abscess?

A

Duct ectasia (infection of Mixed organisms/Anaerobes)

Lactation (Staph aureus/Strep pyogenes on skin)

47
Q

How is acute mastitis treated?

A

Antibiotics
Percutaneous drainage
Incision + drainage
Treat underlying cause

48
Q

Describe the typical presentation of a Phyllodes Tumour

A

Age 40-50

Slow growing unilateral breast mass

49
Q

What tissue is overgrown in Phyllodes Tumour?

A

Stromal overgrowth (But still a Biphasic tumour)

50
Q

Phyllodes Tumour can become malignant. TRUE/FALSE?

A

TRUE

can be benign, borderline or malignant depending on the activity seen in the stroma

51
Q

Phyllodes tumour is prone to recurrence. TRUE/FALSE?

A

TRUE

Prone to local recurrence if not adequately excised

52
Q

What type of papillary lesions occur in the breast tissue?

A

Intraduct papilloma
Nipple adenoma
Encapsulated papillary carcinoma

53
Q

How does an intraduct papilloma usually present?

A
  • Age 35-60
  • Nipple discharge +/- blood
  • Asymptomatic at screening
  • Nodules and calcification
54
Q

Describe the appearance of intraduct papillomas

A
  • In sub-areolar ducts
  • Between 2-20 mm diameter
  • Papillary fronds (leaf) containing a fibrovascular core
  • Covered by myoepithelium and epithelium
  • Epithelium may show proliferative activity (can vary)
55
Q

How can the epithelial proliferation of an intraduct papilloma vary?

A
  • None
  • Hyperplasia
  • Atypical ductal hyperplasia
  • Ductal carcinoma in situ (DCIS)
56
Q

Malignant Phyllodes tumour’s occur due to overgrowth of what component?

A

Stroma
=> This is why it is called sarcomatous
=> they appear slightly like a fibroadenoma

57
Q

When do Angiosarcomas usually occur in the breast?

A

After radiation treatment

58
Q

What other malignant tumours can occur in the breast?

A

Maignant Phyllodes
Angiosarcoma
Lymphoma (breast/lymph nodes)
Metastases from other cancers

59
Q

What other cancers can potentially metastasise to the breast?

A

Carcinomas:

  • Bronchial
  • ovarian serous
  • clear cell kidney

Melanoma

Uterine Leiomyosarcoma

60
Q

What makes a breast cancer a “carcinoma”?

A
  • tumour of glandular epithelium in the TDLU

- ductal/acinar epithelial cells are affected

61
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)
62
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)
63
Q

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

A
  • Confined within basement membrane

- Cytologically malignant but non-invasive

64
Q

Describe how Lobular in situ Neoplasia would be identified?

A
  • often ER positive => stimulated by oestrogen
    => often incidence decreases after menopause
  • multiple and bilateral
  • not palpable or grossly visible
  • May calcify - seen on mammography
  • Usually incidental finding
65
Q

Many cases of lobular in situ neoplasia are identified on core biopsy, yet higher grade lesions are found on open biopsy. TRUE/FALSE?

A

TRUE

66
Q

Lobular in situ neoplasia can put patients at risk of invasive carcinoma and other lesions. TRUE/FALSE?

A

TRUE

67
Q

If Lobular in situ neoplasia is found on a 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 the larger biopsy

  • Follow up
  • Clinical trials
68
Q

What s meant by atypical duct hyperplasia?

A

duct formation within other ducts

69
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
70
Q

How many duct systems are usually involved in DCIS?

A

ONE

singular duct system

71
Q

How can DCIS spread locally?

A

May involve lobules (cancerisation)

May involve nipple skin (Paget’s - still in situ)

72
Q

How is ductal carcinoma in situ (DCIS) treated?

A
  • Surgery
  • Mammographic follow-up if low risk
  • Adjuvant radiotherapy
  • Chemoprevention
  • Endocrine therapy
73
Q

What is microinvasive DCIS defined as?

A

DCIS (high grade) with invasion of <1mm

74
Q

Is the incidence of breast cancers increasing or decreasing?

A

increasing

75
Q

What age does Breast Screening normally take place and why?

A

50-70
- most people diagnosed at this age
=> screening most cost effective in this age group

76
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
77
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 Breastfeeding
=> Hormones (OCP, HRT)
78
Q

What life-style factors can increase a patients risk of breast cancer?

A 
Bodyweight
Alcohol consumption
Diet
NSAID (lowers the risk)
Smoking
79
Q

The mortality due to breast cancer is increasing. TRUE/FALSE?

A

FALSE

decreasing

80
Q

Compare the 1 year and 10 year survival of breast cancer?

A

1 year - 96%

10 year - 78%

81
Q

What is the normal background risk that a woman will develop breast cancer in her life?

A

1 in 8

82
Q

Where do breast cancers locally spread to?

A

Stroma of breast
Skin
Muscles of chest wall

83
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 (mainly)
  • some medial cancers will drain to internal mammary node
84
Q

Where do breast cancers normally metastasise to?

A 
Bone
liver
brain
lungs
abdominal viscera
female genital tract
85
Q

Why is it important to classify invasive tumours by their receptor subtypes?

A

predicts what treatments can be used and targeted

86
Q

What is the difference between Grade and Stage of the tumour?

A

Grade - how differentiated the lesion is

Stage - how far it has spread in the body

87
Q

WHat treatments can be aimed at tumours with oestrogen receptor expression

A

Oophorectomy
Tamoxifen
Aromatase inhibitors (Letrozole)
GnRH antagonists - (Zoladex inj.)

88
Q

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

A

Trastuzamab (Herceptin)

REPRODUCTION & GYNAECOLOGY (58 decks)

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