Breast Pathology Flashcards
What is meant by a triple assessment of a patient with breast disease and where is this approach usually carried out?
Clinical
=> History
=> Examination
Imaging
=> Mammography (XRay - not done under age of 40)
=> Ultrasound
=> MRI
Pathology
=> Cytopathology
=> Histopathology
What is the difference between cyto- and histo-pathology?
Cytopathology
- study of fluid samples (FNA, discharge etc)
Histopathology
- study of tissue samples
What 4 samples can be analysed for breast cytopathology?
Fine Needle Aspiration (FNA)
Fluid
Nipple discharge
Nipple scrape
Why was a fine needle aspiration previously the first choice for Pathology analysis?
Fast to sample and analyse
=> diagnosis can be given quickly
How is an FNA analysed?
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
Why is tissue sampling for histopathology still required after analysing an FNA?
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
How can samples of tissue be taken for histopathology?
(Needle) core biopsy (like a punch biopsy)
Vacuum assisted biopsy (large volume - and can remove small benign lumps)
Skin biopsy
Incisional biopsy of mass
What are the various ways in which a breast lump could be removed?
Vacuum assisted excision Excisional biopsy of mass Resection of cancer Wide local excision (preserves breast) Mastectomy (can be skin sparing to allow better reconstruction)
What are the advantages of a needle core biopsy?
- 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
What are the advantages of a vacuum assisted biopsy?
- 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
What developmental anomalies in the breast are included in benign pathology?
Hypoplasia
Juvenile hypertrophy
Accessory breast tissue (most common in axillae)
Accessory nipple
Describe how disease of the breast can spread within the organ itself?
Retrograde - into the lobules
Anterograde - into lactiferous ducts
What distinguishes that a breast cancer has become invasive?
Breach of the basement membrane under the myoepithelial cells
What types of benign breast disease are non-neoplastic?
- Gynaecomastia
- Fibrocystic change
- Hamartoma
- Fibroadenoma
- Sclerosing lesions
What causes of benign breast disease are inflammatory?
Fat necrosis (often due to trauma - e.g. seatbelt in RTA)
Duct ectasia
Acute mastitis/abscess
What types of breast tumour are benign?
Phyllodes tumour
Intraduct Papilloma
What is gynaecomastia?
- Breast development in the male
- Ductal growth without lobular development
What can cause gynaecomastia?
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)
Describe the patient groups who usually present with Fibrocystic change
- Women aged 20-50 (But majority 40-50)
- Menstrual abnormalities
- Early menarche/Late menopause (excess stimulation)
How do patients with fibrocystic change usually present?
- Smooth discrete lumps
- Sudden pain/Cyclical pain
- Lumpiness
- Incidental finding
- May be picked up on screening
How does fibrocystic change appear macroscopically?
- Cysts (1mm – several cm)
- Blue domed with pale fluid
- Usually multiple and bilateral
- Associated with other benign changes e.g. fibrosis
Describe how fibrocystic change appears microscopically
- Thin walled (may have fibrotic wall)
- Lined by apocrine epithelium
How should fibrocystic change be managed?
- Exclude malignancy
- Reassure patient
- Excise if necessary
What is a hamartoma?
- Benign circumscribed lesion
- composed of cell types normal to breast tissue
- BUT these are present in an abnormal proportion or distribution
Fibroadenomas are commonly bilateral and multiple. TRUE/FALSE?
TRUE
What ethnicity is at higher risk of fibroadenomas?
African women
How do fibroadenomas normally present?
- 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
How does a fibroadenoma appear macroscopically?
- Circumscribed
- Rubbery
- Grey-white colour
- Biphasic tumour => Epithelium and Stroma involved
How does a fibroadenoma appear microscopically?
Biphasic tumour => Epithelium and Stroma involved
Localised hyperplasia
Proliferation of intralobular stroma
How are fibroadenomas treated?
Diagnose
Reassure
Excise
What is meant by sclerosing lesions of the breast?
- Benign
- disorderly proliferation of acini and stroma
- Cause a mass or calcification
- May mimic carcinoma
(Adenosis or radial scar)
How do patients normally present with sclerosing lesions of the breast?
- Pain/ Tenderness
- Lumpiness/thickening
- May be asymptomatic
- Large age range => 20-70
Describe the macroscopic appearance of a radial scar?
- Stellate architecture
- central puckering
- Radiating fibrosis
If a radial scar is >10mm, what is it then called?
Radial Scar = 1-9mm
Complex Sclerosing Lesion = >10mm
What investigation can pick up a radial scar during breast screening?
Mammography
How do radial scars appear microscopically?
- Fibroelastotic core
- Radiating fibrosis containing distorted ductules
- Fibrocystic change
- Epithelial proliferation
Radial scars often mimic carcinoma on radiological investigations. TRUE/FALSE?
TRUE - mimic carcinoma on radiology
How are radial scars often treated?
Excise OR sample extensively by vacuum biopsy
There is a small chance that In situ or invasive carcinoma can occur within radial scar lesions. TRUE/FALSE?
TRUE
What can cause inflammatory fat necrosis in the breast?
- Local trauma
- Seat belt injury
- Commencing Warfarin therapy
Describe the process of fat necrosis in the breast?
- 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)
HOw should fat necrosis be managed?
Confirm diagnosis
Exclude malignancy
HOw does a patient usually present with duct ectasia?
- Affects sub-areolar ducts
- Pain
- Acute episodic inflammatory changes
- Bloody and/or purulent discharge from nipple
- Fistulation
- Nipple retraction/distortion
What factor in a patient’s social history is a large indication for the development of duct ectasia?
Associated with smoking
Describe the appearance of duct ectasia
Sub-areolar duct dilatation
Periductal inflammation
Periductal fibrosis
Scarring and distortion
What are the main causes of mastitis or breast abscess?
Duct ectasia (infection of Mixed organisms/Anaerobes)
Lactation (Staph aureus/Strep pyogenes on skin)
How is acute mastitis treated?
Antibiotics
Percutaneous drainage
Incision + drainage
Treat underlying cause
Describe the typical presentation of a Phyllodes Tumour
Age 40-50
Slow growing unilateral breast mass
What tissue is overgrown in Phyllodes Tumour?
Stromal overgrowth (But still a Biphasic tumour)
Phyllodes Tumour can become malignant. TRUE/FALSE?
TRUE
can be benign, borderline or malignant depending on the activity seen in the stroma
Phyllodes tumour is prone to recurrence. TRUE/FALSE?
TRUE
Prone to local recurrence if not adequately excised
What type of papillary lesions occur in the breast tissue?
Intraduct papilloma
Nipple adenoma
Encapsulated papillary carcinoma
How does an intraduct papilloma usually present?
- Age 35-60
- Nipple discharge +/- blood
- Asymptomatic at screening
- Nodules and calcification
Describe the appearance of intraduct papillomas
- 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)
How can the epithelial proliferation of an intraduct papilloma vary?
- None
- Hyperplasia
- Atypical ductal hyperplasia
- Ductal carcinoma in situ (DCIS)
Malignant Phyllodes tumour’s occur due to overgrowth of what component?
Stroma
=> This is why it is called sarcomatous
=> they appear slightly like a fibroadenoma
When do Angiosarcomas usually occur in the breast?
After radiation treatment
What other malignant tumours can occur in the breast?
Maignant Phyllodes
Angiosarcoma
Lymphoma (breast/lymph nodes)
Metastases from other cancers
What other cancers can potentially metastasise to the breast?
Carcinomas:
- Bronchial
- ovarian serous
- clear cell kidney
Melanoma
Uterine Leiomyosarcoma
What makes a breast cancer a “carcinoma”?
- tumour of glandular epithelium in the TDLU
- ductal/acinar epithelial cells are affected
What various precursor lesions may be identified prior to development of a Ductal cancer?
- Usual type epithelial hyperplasia
- Columnar cell change
- Atypical Ductal Hyperplasia
- Ductal Carcinoma in situ (DCIS)
What various precursor lesions may be identified prior to development of a Lobular cancer?
- Lobular in situ neoplasia (LISN)
- Atypical lobular hyperplasia
- Lobular carcinoma in situ (LCIS)
What makes a cancer of the breast “in situ”?
- Confined within basement membrane
- Cytologically malignant but non-invasive
Describe how Lobular in situ Neoplasia would be identified?
- 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
Many cases of lobular in situ neoplasia are identified on core biopsy, yet higher grade lesions are found on open biopsy. TRUE/FALSE?
TRUE
Lobular in situ neoplasia can put patients at risk of invasive carcinoma and other lesions. TRUE/FALSE?
TRUE
If Lobular in situ neoplasia is found on a core biopsy, what is the next step to exclude other lesions?
Excision or vacuum biopsy to exclude higher grade lesion
If LISN is discovered on the larger biopsy
- Follow up
- Clinical trials
What s meant by atypical duct hyperplasia?
duct formation within other ducts
Describe the appearance of high grade DCIS?
- necrosis in centre of duct as not receiving nutrients from out in stroma
- large atypical cells
- large nuclei
- mitotic figures
How many duct systems are usually involved in DCIS?
ONE
singular duct system
How can DCIS spread locally?
May involve lobules (cancerisation)
May involve nipple skin (Paget’s - still in situ)
How is ductal carcinoma in situ (DCIS) treated?
- Surgery
- Mammographic follow-up if low risk
- Adjuvant radiotherapy
- Chemoprevention
- Endocrine therapy
What is microinvasive DCIS defined as?
DCIS (high grade) with invasion of <1mm
Is the incidence of breast cancers increasing or decreasing?
increasing
What age does Breast Screening normally take place and why?
50-70
- most people diagnosed at this age
=> screening most cost effective in this age group
What are the main risk factors for Carcinoma of Breast?
- Age
- More oestrogen exposure
- Previous breast disease
- Geography (western world)
- Life-style
- Genetics
What can increase a patients oestrogen exposure and put them at higher risk of breast cancer?
=> Age at menarche/menopause => Later age at first birth => Decreased Parity => Lack of Breastfeeding => Hormones (OCP, HRT)
What life-style factors can increase a patients risk of breast cancer?
Bodyweight Alcohol consumption Diet NSAID (lowers the risk) Smoking
The mortality due to breast cancer is increasing. TRUE/FALSE?
FALSE
decreasing
Compare the 1 year and 10 year survival of breast cancer?
1 year - 96%
10 year - 78%
What is the normal background risk that a woman will develop breast cancer in her life?
1 in 8
Where do breast cancers locally spread to?
Stroma of breast
Skin
Muscles of chest wall
What lymph nodes do breast cancers normally infiltrate?
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
Where do breast cancers normally metastasise to?
Bone liver brain lungs abdominal viscera female genital tract
Why is it important to classify invasive tumours by their receptor subtypes?
predicts what treatments can be used and targeted
What is the difference between Grade and Stage of the tumour?
Grade - how differentiated the lesion is
Stage - how far it has spread in the body
WHat treatments can be aimed at tumours with oestrogen receptor expression
Oophorectomy
Tamoxifen
Aromatase inhibitors (Letrozole)
GnRH antagonists - (Zoladex inj.)
What treatments can be aimed at tumours expressing the HER2 receptor?
Trastuzamab (Herceptin)
