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Repro and Sexual Health > Breast Pathology > Flashcards

Breast Pathology Flashcards

1
Q

What is the gold standard assessment of a patient with breast disease?

A

Triple assessment;
Clinical - hx and exam
Imaging - MMG, USS, MRI
Path - cytopathology, histopathology

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2
Q

What can give a sample of breast cytopathology?

A

FNA
Fluid
Nipple discharge
Nipple scrape

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3
Q

What is the grading of breast FNA cytology?

A 
C1 - unsatisfactory
C2 - benign
C3 - atypia but probs benign 
C4 - suspicious of malignancy
C5 - malignant
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4
Q

What are diagnostic breast histopathology mechanisms?

A

Needle core biopsy
Vacuum assisted biopsy
Skin biopsy
Incisional biopsy of mass

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5
Q

What are the therapeutic breast histopathology mechanisms?

A

Vacuum assisted excision
Excisional biopsy of mass
Resection of cancer; wide local, mastectomy

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6
Q

What is the grading for a needle core biopsy?

A 
B1; unsatisfactory
 B2; benign
B3; atypical probs benign 
B4; suspicious of malignancy
B5; malignant (B5a; CIS, B5b; invasive carcinoma)
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7
Q

What are developmental anomalies of benign breast disease?

A

Hypoplasia
Juvenile hypertrophy
Accessory breast tissue or nipple

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8
Q

What are the common non-neoplastic pathologies of benign breast disease?

A 
Gynaecomastia
Fibrocystic change
Hamartoma
Fibroadenoma
Sclerosing lesions; sclerosing adenosis or radial scar
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9
Q

What are the benign inflammatory pathologies of the breast?

A

Fat necrosis
Duct ectasia
Acute mastitis/ abscess

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10
Q

What are the benign tumours of the breast?

A

Phyllodes tumour

Intraductal 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 can cause gynaecomastia?

A

Exogenous/ endogenous hormones
Cannabis
Prescription drugs
Liver disease - increase in oestrogenic hormones

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13
Q

What is the etiology of fibrocystic change of the breast?

A

Women aged 20-50; mostly 40-50

Very common

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14
Q

What are risk factors for fibrocystic change of the breast?

A

Menstrual abnormalities
Early menarche
Late menopause

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15
Q

What is the presentation of fibrocystic change of the breast?

A 
Smooth discrete lumps
Sudden pain
Cyclical pain
Lympiness
Incidental finding
Screening
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16
Q

What is seen in the gross pathology of fibrocystic change of the breast?

A 
Cysts; 1mm to several cm 
Blue domed with pale fluid
Usually multiple
Assoc with other benign changes
Intervening fibrosis
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17
Q

What is the microscopic pathology of fibrocystic change of the breast?

A

Cysts; thin walled
Apocrine epithelium
Intervening fibrosis

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18
Q

What is metaplasia?

A

Change from one fully differentiated cell type to another fully differentiated cell type

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19
Q

What is the management of fibrocystic change of the breast?

A

Exclude malignancy
Reassure
Excise if necessary

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20
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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21
Q

What is a fibroadenoma?

A

Common
Usually solitary
Commoner in African Women

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22
Q

What is the clinical presentation of a fibroadenoma?

A 
Painless, firm, discrete, mobile mass
Solid on USS
Circumscribed
Rubbery
Grey-white colour
Biphasic tumour
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23
Q

What is a biphasic tumour?

A

Has epithelium and stroma

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24
Q

Tx for fibroadenoma?

A

Diagnose
Reassure
Excise if necessary

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25
Q

What is a sclerosing lesion?

A

Benign, disorderly proliferation of acini and stroma
Can cause mass or calcification
May mimic carcinoma

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26
Q

How will sclerosing adenosis present?

A

Pain
Tenderness
Lumpiness/ thickening
Can be asymptomatic

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27
Q

What is the pathology of a radial scar?

A 
If 1-9mm = radial scar
If >10mm = complex sclerosing lesion 
Stellate architecture
Central puckering
Radiating fibrosis
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28
Q

What is the histology of a radial scar?

A

Fibroelastic core
Radiating fibrosis containing distorted ductules
Fibrocystic change
Epithelial proliferation

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29
Q

What is the treatment for a radial scar?

A

Excise or sample extensively via vacuum biopsy

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30
Q

Is a radial scar premalignant?

A

No; but in situ or invasive carcinoma may occur within the lesion
Can mimic carcinoma radiologically
Shows epithelial proliferation

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31
Q

What can cause fat necrosis of the breast?

A

Local trauma; seat belt injury

Recently stared warfarin therapy

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32
Q

What is the pathology of fat necrosis?

A

Damage and disruption of adipocytes
Infiltration by acute inflammatory cells
Foamy macrophages
Subsequent fibrosis and scarring

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33
Q

Tx for fat necrosis of breast?

A

Confirm diagnosis

Exclude malignancy

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34
Q

What are the clinical features of duct ectasia?

A 
Affects subareolar ducts
Pain
Acute episodic inflammatory changes
Bloody +/- purulent discharge
Fistulation 
Nipple retraction and distortion 
Periductal inflammation and fibrosis
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35
Q

What environmental factor is assoc with duct ectasia?

A

Smoking

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36
Q

Tx for duct ectasia?

A

Treat acute infections
Exclude malignancy
Stop smoking
Excise ducts

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37
Q

What are the 2 main aetiologies for acute mastitis?

A

Duct ectasia; mixed organisms, anaerobes

Lactation; staph aureus, strep pyogenes

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38
Q

Mx for acute mastitis/ abscess?

A

Antibiotics
Percutaneous drainage
Incision and drainage
Treat underlying duct ectasia if present

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39
Q

What are the clinical features of a phyllodes tumour?

A

Slow growing unilateral breast mass
Biphasic tumour
Stromal overgrowth

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40
Q

What does the behaviour of a phyllodes tumour depend on?

A

Stromal features; benign, borderline, malignant (sarcomatous)

41
Q

Does a phyllodes tumour tend to metastasize?

A

No

But, prone to local recurrence if not adequately excised

42
Q

What are the different forms of papillary lesion seen in the breast?

A

Intraductal papilloma
Nipple adenoma
Encapsulated papillary carcinoma

43
Q

What is the presentation of an intraductal papilloma?

A

Nipple discharge +/- blood

Asymptomatic at screening; nodules or calcification

44
Q

What are the histological features of an intraductal papilloma?

A

Papillary fronds containing a fibrovascular core

Covered by myoepithelium and epithelium which may show proliferative activity

45
Q

What are the miscellaneous malignant tumours of the breast (not carcinomatous)?

A 
Malignant phyllodes; sarcomatous stromal 
Angiosarcoma; post XRT
Lymphoma; breast +/- lymph nodes
Metastatic tumours 
Malignant melanoma 
LEiomyosarcoma
46
Q

What primary cancers can metastasize to the breast?

A

Bronchial
Ovarian serous
Clear cell carcinoma of kidney

47
Q

What is the definition of a breast carcinoma?

A

A malignant tumour of breast epithelial cells

48
Q

Where will a breast carcinoma arise from?

A

Glandular epithelium of the terminal duct lobular unit (TDLU)

49
Q

What is the precursor lesion to ductal carcinoma of the breast?

A

Epithelial hyperplasia of usual type
Columnar cell change (+/- atypia)
Atypical ductal hyperplasia
Ductal carcinoma in situ

50
Q

What is the precursor lesion to lobular carcinoma of the breast?

A

Atypical lobular hyperplasia
Lobular carcinoma in situ
Lobular in situ neoplasia

51
Q

What is an in situ carcinoma of the breast?

A

Confined within the basement membrane of acini and ducts

Cytologically malignant but non-invasive

52
Q

Will all in situ carcinomas transform into an invasive carcinoma?

A

No; they are non-obligate

53
Q

What is the difference between atypical lobular hyperplasia and lobular carcinoma in situ?

A

ALH; <50% of lobule

LCIS; >50% of lobule

54
Q

Describe the histopathology of lobular in situ neoplasia

A 
Intralobular proliferation of characteristic cells 
Small intermediate sized nuclei 
Solid proliferation 
Intra-cytoplasmic lumens/ vacuoles 
ER positive 
E-cadherin neg
55
Q

What is E-cadherin in terms of breast carcinoma?

A

Deletion and mutation of the CDH1 gene on chromosome 16

56
Q

What are the clinical features of lobular in situ neoplasia?

A 
Multifocal and bilateral 
Incidence decreases after menopause
Not palpable, not visible grossly 
May calcify; seen on MMG 
Incidental finding
57
Q

What is the significance of lobular in situ neoplasia?

A

Marker of subsequent risk

True precursor lesion

58
Q

Mx for lobular in situ neoplasia?

A

Discovered on core biopsy; excision or vacuum biopsy to exclude higher grade lesion
Discovered on vacuum or excision biopsy; follow up

59
Q

What is the follow up for lobular in situ neoplasia found on vacuum or excision biopsy?

A

Annual MMG for 5 years

60
Q

Describe the natural history of intraductal proliferation

A 
Epithelial hyperplasia of usual type 
Columnar cell change 
CCC with atypia
Atypical ductal hyperplasia
Ductal carcinoma in situ
61
Q

What is the risk of progression to invasive carcinoma from DCIS (low grade)?

A

10x RR

25% over 10 years

62
Q

How many breast malignancies are DCIS?

A

15-20%
Arises in TDLU
Characteristically unicentric

63
Q

Describe the histopathology of DCIS?

A

Cytologically malignant epithelial cells
Confined within BM of duct
Can involve lobules (cancerisation)
Can involve nipple skin (Paget’s)

64
Q

What is paget’s disease of the nipple?

A

High grade DCIS extended along ducts to reach the epidermis of nipple
Still in situ

65
Q

How is DSCIS classified?

A

Cytological grade
Histological type
Presence of necrosis

66
Q

Mx for DCIS?

A

Diagnosis
Surgery
Adjuvant radiotherapy
Chemoprevention; endocrine therapy

67
Q

What is a microinvasive carcinoma of the breast?

A

DCIS (high grade) with invasion of <1mm beyond BM

Treat as high grade DCIS

68
Q

What is the commonest cancer for women?

A

Breast

69
Q

What is the peak incidence for breast cancer in women?

A

50-70

70
Q

What are risk factors for carcinoma of the breast?

A

Age
Repro hx; age at menarche, age at first birth, parity, breastfeeding, age at menopause
Hormones; endogenous, exogenous (OCP, HRT)
Previous breast dx (esp malignant)
Geography
Lifestyle; BMI, physical activity, alcohol, diet, NSAIDs (lowers risk), smoking
Genetics; BRCA

71
Q

Which genetic anomalies increase the risk for breast cancer?

A 
BRCA 1 and 2 
Tp53 
PTEN 
STK11/ LKB1
ATM
72
Q

What cancer syndrome and associated tumours will the BRCA mutations cause?

A

BRCA1 = breast, ovarian, bowel, prostate

BRCA 2 = breast (inc male), ovarian, prostate, pancreatic

73
Q

What cancer syndrome and assoc tumours will the Tp53 mutation cause?

A

Li Fraumeni Syndrome

Childhood sarcoma, brain, leukaemia, adrenocortical carcinoma, early-onset breast

74
Q

What cancer syndrome and assoc tumours will the pTEN mutation cause?

A

Cowden’s syndrome

Breast, GI, thyroid

75
Q

What cancer syndrome and assoc tumours will the STK11/LKB1 mutation cause?

A

Peutz-Jeghers Syndrome

Breast, GI, pancreatic, ovarian

76
Q

What cancer syndrome and assoc tumours will the ATM mutation cause?

A

Ataxia Telangiectasia
Non-hodgkin’s lymphoma
Ovarian
Breast (in heterozygous carriers)

77
Q

What percentage of breast cancers are caused by BRCA mutations?

A

2%

Present in 0.1% of population; 1 in 450 is a carrier

78
Q

What is the lifetime risk for breast ca with BRCA mutations?

A

45-64% life-time risk

79
Q

What is the net survival for women with breast cancer; age standardised?

A

1 yr; 96%
5 yr; 87%
10 yr; 78%

80
Q

How many women will develop breast ca?

A

1 in 8

81
Q

Describe the natural history of invasive breast ca

A 
Local invasion (T); stroma of breast, skin, muscles of chest wall 
Lymphatics (N); regional draining lymph nodes
Bloodborne (M); bone, liver, brain, lungs, abdominal viscera, female genital tract
82
Q

Where does the majority of lymph from the breast drain to?

A

Axillary nodes

83
Q

What are the routes for drainage of the breast?

A

Internal mammary
Intramammary
Axillary

84
Q

What are the sentinel lymph nodes of the breast?

A

Apical nodes
Infraclavicular nodes
Supraclavicular nodes

85
Q

How is invasive breast cancer classified?

A

Morphological; type, grade
Gene expression profiling
Hormone receptor; ER, PR, HER2

86
Q

What is the most common histopathological type of breast ca?

A

Ductal (NST); 70%

Lobular; 10%

87
Q

What is the grade of a tumour?

A

Measure of tumour differentation

88
Q

How is breast carcinoma graded?

A 
Tubular differentiation (1-3) 
Nuclear pleomorphism (1-3) 
Mitotic activity (1-3) 
Score of 3-5 = grade 1
Score 6-7 = grade 2 
Score 8-9 = grade 3
89
Q

What is a basal like intrinsic breast cancer sub-type?

A

ER -ve
HER2 -ve
Basal CK +

90
Q

What is a HER2 intrinsic breast cancer sub-type?`

A

ER -ve

HER2 +ve

91
Q

What is a luminal A intrinsic breast cancer sub-type?

A

ER +ve

Low proliferation

92
Q

What are luminal B and C intrinsic breast cancer sub-type?

A

ER +ve

High proliferation

93
Q

In terms of ER, PgR and HER2 hormone receptors, what percentage of breast ca are positive for them?

A

80% ER +ve
67% PgR +ve
14% HER2 +ve

94
Q

What will ER positive breast ca respond to in terms of hormonal therapy?

A 
Oophorectomy (don't really do anymore) 
Tamoxifen 
Aromatase inhibitors ( letrozole) 
GnRh antagonists (goserelin) - only in pre-menopausal women
95
Q

What will HER2 +ve breast ca respond to in terms of hormonal tx?

A

Trastuzumab (herceptin)

96
Q

In terms of hormone receptors, which subtype of breast cancers have the best outcome?

A

ER +ve
PR +ve
HER2 -ve

97
Q

In terms of hormone receptors, which subtype of breast ca have worst outcome?

A

HER 2 +ve
THEN
Triple neg is worst

98
Q

What prognostic indices are used for breast ca?

A

Nottingham Prognostic Index

NHS PREDICT

99
Q

How is Nottingham Prognostic Index calculated?

A

0.2 x tumour diameter (cm)
Tumour grade (1-3)
Lymph node status (1-3)

Repro and Sexual Health (77 decks)

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