Breast Pathology Flashcards
What is the definition of screening?
The process of identifying people who appear healthy but may be at an increased risk of a disease or condition
What is the aim of the breast screening programme?
Which women are invited?
The aim is to reduce mortality from breast cancer
women aged 50-70 are invited every 3 years
the main tool used is mammography
What is meant by the breast triple assessment?
- Clinical examination
- radiological examination
- pathological examination
What is involved in the 3 areas of the breast triple assessment?
Clinical:
- history
- physical examination
Imaging:
- ultrasound
- mammography
pathology:
- core cut biopsy
- FNAC (cytology) - used in cystic lesions or when a biopsy is not possible
How is the breast triple assessment graded?
A code is given based on the degree of suspicion of the lesion
B1 / B2 - benign
B3 - unsure
B4 / B5 - suspicious of malignancy
the scores from each of the 3 areas need to correlate
What is looked for during a breast screen?
A 2 view mammogram is used to look for calcification
What happens if the mammogram comes back as positive?
how is it treated at each stage?
Core biopsy is performed
B1 - normal so return to screening (rebiopsy if biopsy from wrong area)
B2 - benign so reassure and return to screening
B3 - uncertain malignant potential - excision
B4 - suspicion of malignancy - rebiopsy or excision
B5 - malignant - surgical excision
What are the subcategories of a B5 malignancy?
B5a - DCIS
this is in situ disease
B5b - invasive
this has broken through the basement membrane and become invasive
If someone has a core biopsy which comes back negative, what is done?
They are returned to the screening programme
they will be screened again in 3 years
What are the 2 different types of biopsy?
how are they examined?
Core needle biopsy is examined at 3 levels
mammotome biopsy is divided into 3 different blocks
each block is examined at 4 levels to try and determine how much calcification is present
Who are the members of the breast MDT?
What is their role?
- Surgeons
- oncologists
- radiologists
- pathologists
- specialist nursing team
- research nurses
- genetic counsellors
a group of experts with a specialist role in diagnosis, treatment and management of patients with breast cancer
What is the glandular parenchyma of the breast like?
- 15 - 20 lobes
- they are drained by a lactiferous duct
- all lobes converge towards the areola
- near the areola, lactiferous duct dilates to form the lactiferous sinus
the areola is surrounded by fatty tissue
What is the structure of the breast ducts like?
What are the cells that make up the acini?
There is an inner layer of ciliated epithelial cells
there is an outer layer of myoepithelial flattened cells
a lesion becomes an invasive lesion if it passes through the myoepithelial cell boundary
What would a fibrocystic change look like under the microscope and on radiology?
Benign breast tissue with apocrine metaplasia and some microcysts, all associated with microcalcifications
on X-ray there are small calcifications but nothing to feel
What is shown in this biopsy?
Fibrocystic change
the normal acini are slightly dilated to form microcysts
What is discussed in a multidiscplinary meeting about a fibrocystic change?
Ensure the triple diagnosis
there is no further action and they are returned to breast screening
What are the synonyms for fibrocystic changes?
- Fibrous mastopathy
- mammary dysplasia
- schimmelnbusch’s disease
- chronic cystic mastitis
Who tends to be affected by fibrocystic change?
Generally affects pre-menopausal women
it is usually bilateral and multifocal
fibrocystic changes in approximately 60% of normal breasts
What increases risk of fibrocystic change?
Risk of FCC development is increased in women with hyperoestrogenism
there is no increased risk for subsequent carcinoma development
What is fibrocystic disease?
A constellation of benign, hormonally mediated breast changes including cyst formation, stromal fibrosis and mild epithelial hyperplasia without atypia
atypia is always classified in the B3 category
What are the clinical features of fibrocystic disease?
Lumpy, premenstrually painful breasts
When may the symptoms stop with fibrocystic disease?
FCC symptomatically generally ceases 1-2 years following menopause
What would the core biopsy of a fibroadenoma look like?
Benign breast tissue with a well defined benign lesion showing proliferation of both epithelial and stromal components
What people tend to be affected by fibroadenoma?
What does it present like?
It is common and usually in women aged 20-30 years
it is more common in Afro-Caribbean women
it is a mobile, painless, well-defined breast lump
Why may a fibroadenoma become painful?
It is usually found as an asymptomatic lump
rarely, it may undergo infarction due to a lack of blood supply to a part of the lesion
this produces a sudden onset of pain
What does fibroadenoma look like radiologically?
What is the treatment?
Well defined homogenous, hypoechoic mass on ultrasound
it is asymptomatic so is usually not treated
in the case of infarction, surgical excision can be performed
some may recur
What is the difference between an incident screen and a prevalent screen?
A prevalent screen is someone’s first screen
an incident screen is not a first visit and something is picked up later in life
What would be seen in a core biopsy of a high grade DCIS (B5a)?
A high-grade ductal carcinoma in situ is associated with comedonecrosis and calcifications
the inside epithelial cells have undergone a lot of proliferation
atypical epithelial cells from rounded structures and the ductules have a rounded appearance (cribiform appearance)
What is the general treatment for a high-grade ductal carcinoma in situ (DCIS)?
Wide local excision with localisation wire
the surgeon cannot feel the calcification, so a wire is inserted radiologically into the middle of the calcification
the surgeon removes the region around the wire
When performing a wide local excision, what 3 things is it important to check?
- Check for orientation sutures
- measure in 3 dimensions
- paint the external surface
How is the local excision coloured to identify different borders?
Red - medial margin
green - lateral margin
black - superior margin
orange - posterior margin
yellow - anterior margin
In the case of high grade DCIS, what should be discussed in the 2nd multidisciplinary meeting?
The final pathology should be reviewed to confirm high grade DCIS
check for the completeness of excision
no need for markers
What is DCIS?
Ductal carcinoma in situ
it is a malignant clinal proliferation of cells within breast parenchymal structures
there is no evidence of invasion
How is DCIS identified during screening?
What happens if it is not treated?
It is most commonly identified as microcalcifications on screening
pure DCIS cannot produce a metastasis
but it is a precursor of invasive carcinoma and has the potential to progress to invasion if left
What would a core biopsy for an invasive ductal carcinoma (B5b) look like?
For any invasive malignancy in the breast, you look for 3 different markers
These are ER & PR and HER2
the mammogram appears very dense and a palpable lump is present
What is shown here?
Invasive breast carcinoma
cannot see the ductules
can only see malignant appearing cells trying to invade the desmoplastic looking stroma
these are high grade tumour cells
What 3 categories are used to grade invasive cancers?
- Tubule formation
- Pleomorphism score
- Mitotic score (how many mitoses are seen)
Each category is scored out of 3
Grade 1 is a score of 4-5
Grade 2 is a score of 6-7
Grade 3 is a score of 8-9
What are the risk factors for invasive breast carcinoma?
(breast cancer)
Breast cancer is linked to oestrogens and increased with:
- early menarche
- late menopause
- obesity in postmenopausal women
- oral contraceptive pills
- hormonal therapy for menopause
- alcohol
What type of staining is showed here?
How is it scored?
Orange score
ER and PR are nucleus based receptors (nucleus picks up the stain)
the score is based on the intensity of the staining and the proportion of nuclei that take up the stain
What is shown here?
HER-2 staining which is a membranous stain
the membranes of the cells look darker
for a sample to be herceptin positive, a minimum of 10% of the sample needs to look like this
What is discussed in the second multidisciplinary meeting for invasive breast carcinoma?
If the tumour is less than 10mm, it is localised with a wire and taken out for excision
as it is an invasive cancer, a sentinel node biopsy is also performed
the sentinel node is the first node that drains the tumour
What would be discussed in third multidisciplinary meeting for invasive breast carcinoma?
The margins are clear but lymph nodes may be involved
an axillary clearance is performed followed by chemotherapy and radiotherapy
What should a path report tell you about malignancy?
- In situ or invasive
- type - ductal / lobular
- grade
- size
- vascular invasion
- nodal status
- relationship to margins
- molecular marker status - ER, PR, HER2
How can vascular invasion be identified?
There are collections of cells sitting in spaces lined by endothelial cells
endothelial markers (CD31 and CD34) may be present
How do you know if you have removed enough tumour?
Measure the distance from the margin
if the distance is less than 1mm then a second surgery is performed
What are the 3 key prognostic factors in invasive breast carcinoma?
- Tumour grade
- Tumour size
- Nodal status
all 3 are used to calculate the Nottingham prognostic index
What is the calculation for Nottingham prognostic index?
What do the scores represent?
Grade + nodal status + (0.2 x tumour size)
no nodes score 1, 1-3 nodes score 2, 4 or more nodes score 3
- 4 or less - good 80% + 16 year survival
- 41 - 5.4 - moderate 46%
- 41 + - poor 10%
What are the hormonally targeted therapies used in breast cancer?
ER and PR positive:
- tamoxifen
- aromatase inhibitors
- bisphosponates
HER-2 targeted approach:
- trastuzumab
