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Reproduction & Sexual Health > Breast pathology > Flashcards

Breast pathology Flashcards

1
Q

Features of a typical benign aspirate?

A

apocrine cells (ductile epithelial cells in honeycomb sheet)

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2
Q

Features of a malignant breast aspirate?

A

enlarged cells, some are very dark and falling apart, degenerate

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3
Q

What is the significance of C5 cytological sample by FNA?

A

C5 normally means malignant but in breast tissue it doesn’t indicate if the cells are invasive or just within the duct

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4
Q

What is the gold standard diagnostic test for breast cancer? Why is it used more now?

A

needle core biopsy

can give categories B5a (carcinoma in situ) and B5b (invasive carcinoma)

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5
Q

What is the difference in prognosis with B5a and B5b breast cancer?

A

carcinoma in situ (5a) is localised to one segment since lobules supply one lobe of breast each; whereas invasive carcinoma (5b) is not confined to one segment

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6
Q

Where is the milk line? What can appear anywhere on this line?

A

from nipple down anterior abdominal wall - accessory breast tissue can develop anywhere down this line

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7
Q

Patient in a minor RTA but was wearing seatbelt so no t much damage. She presents soon after the accident to GP complaining of a sore, red, hot left breast.
Diagnosis?

A

fat necrosis - common after trauma, seatbelt is clue

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8
Q

What type of growth is seen in gynaecomastia?

A

ductal growth WITHOUT lobular development

hyper plastic epithelium, almost always benign

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9
Q

List some causes of gynaecomastia.

A

exogenous/endogenous hormones
cannabis
prescription drugs (spironolactone, digoxin)
liver disease

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10
Q

Why would anovulatory menstrual cycles be linked with fibrocystic (non-neoplastic) change?

A

prolonged oestrogen stimulation (no ovum released - no corpus luteum to switch off oestrogen production)

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11
Q

45 y/o woman presents with cyclical pain, lumps which are smooth and discrete. She noticed them after checking her breasts in the shower, she says both breasts feel lumpy.

A

fibrocystic change - smooth discrete lumps are cysts, benign

exclude malignancy, reassure, excise if necessary (most resolve or diminish after menopause)

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12
Q

cytology of breast tissue shows thin-walled structures which are blue domed and have pale fluid in centre. There appears to be intervening fibroids and they are lined by apocrine sweat glands.
Pathology?

A

Fibrocystic change - cysts

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13
Q

What is metaplasia?

A

the change from one fully differentiated cell type to another fully differentiated cell type

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14
Q

Hamartoma definition.

A

Circumscribed lesion composed of cell types normal to the breast but present in an abnormal (architectural) proportion or distribution.

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15
Q

Most common lump in young women?

A

Fibroadenoma

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16
Q

African lady presents aged 40 asking for her breasts to be checked. She thought she felt a firm, painless lump in her right breast but isn’t sure. You examine her and feel a firm, discrete mass which seems to move with your palpation.
Diagnosis?

A

Fibroadenoma
“breast mouse” - moves away from finger as examined

diagnose, reassure, excise

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17
Q

Why is a fibroadenoma described as a biphasic tumour/lesion?

A

epithelium - localised hyperplasia

stroma - proliferation of interlobular stroma

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18
Q

benign, disorderly proliferation of acini and stroma

A

sclerosing adenosis / complex sclerosis lesion (radial scar)

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19
Q

50 y/o woman presents for breast screening - she has no symptoms.
Mammography is done and a central area of low density with long spiculated bands running concentrically are seen. The mass is calculated as being 8mm in size.
Diagnosis and treatment?

A

radial scar since 1-9mm
complex sclerosis lesion = >10mm

probably not malignant but in situ or invasive carcinoma may occur within these lesions

treatment - excise or sample extensively by vacuum biopsy

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20
Q

sclerosing adenosis

A

benign proliferative condition of the terminal duct lobular units characterised by an increased number of acini and their glands

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21
Q

50 y/o woman presents with cyclical breast pain and complaints of tender and “thickened” breast tissue. Multiple small firm nodules felt.
Diagnosis and treatment?

A

sclerosis adenosis - small lumps are calcifications

negligible risk of subsequent carcinoma - no further treatment necessary.

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22
Q

Screening mammogram showed central puckering, stellate architecture and radiating fibrosis. What would you expect histology to show?

A

fibroelastic core
radiating fibrosis containing distorted ductules
fibrocystic change
epithelial proliferation

radial scar/complex sclerosing lesion

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23
Q

causes of fat necrosis

A

local trauma - seat belt injury, dogs jumping up on women

initiation of warfarin therapy

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24
Q

Which ducts are affected in duct ectasia?

A

sub-areolar ducts

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25
Q

55 y/o female smoker presents with a Hx of mild breast pain over past months but has now noticed a green coloured discharge from her nipple area. The pain has increased since noticing this discharge and her nipple is also retracted.
Diagnosis and management?

A

duct ectasia which has become infected

treat acute infection, exclude malignancy, stop smoking, excise ducts to stop recurrence.

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26
Q

Likely organisms for non-lactating mastitis? treatment?

A

mixed organisms, anaerobes
flucloxacillin 1g qds + 400mg metronidazole tds
OR
co-trimoxazole 960mg bd + metronidazole 400mg tds
7 days

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27
Q

Likely organisms for lactating mastitis? treatment?

A

staph aureus & strep pyogenes
NSAIDs + warm compresses at first and if no improvement by 12-24hrs move to antibiotics.
flucloxacillin 1g qds or clindamycin 450mg tds for 7-10days

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28
Q

50 y/o patient presented with a slow growing unilateral breast mass. You palpate the mass and think it is around 5cm in size. Histology shows variation in stromal overgrowth from benign to borderline.
Diagnosis and management?

A

Phyllodes tumour
Prone to local recurrence if not excised adequately; rarely metastasise.
Wide local excision (1cm).

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29
Q

List some possible papillary lesions. Age range of patients and some common features?

A

Intra-duct papilloma
Nipple adenoma
Encapsulated papillary carcinoma

Age 35-60
Nipple discharge ± blood
Asymptomatic at screening - calcification / nodules.

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30
Q

Pathology of intraduct papilloma?

A

originate from walls of milk (sub-areolar) ducts, typically grow within the duct and cause local obstruction.
Covered by myoepithelium and epithelium; fibrovascular core with papillary frond, forming a small, smooth well-circumscribed nodules.

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31
Q

What size are papillomas?

A

2-10mm

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32
Q

Epithelium covering papillomas may show proliferative activity. Which type of proliferation might be seen in benign introduction papilloma (IDP)?

A

none or usual type hyperplasia (UTH) –> benign IDP

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33
Q

Apart from benign IDP, what other type of epithelial proliferation might be seen?

A

IDP with atypical ductal hyperplasia (ADH)

IDP with ductal carcinoma in situ (DCIS) / Papillary DCIS

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34
Q

What type of nipple discharge would not worry you?

A

clear, yellow and watery discharge - can be elicited from the nipples of women of reproductive age.

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35
Q

What type of nipple discharge would worry you?

A

bloody discharge especially from a single duct

36
Q

Commonest cause of spontaneous nipple discharge?

A

intraductal papilloma - benign lesions

37
Q

When might nipple discharge be a sign of malignancy?

A

when there is an associated palpable mass

38
Q

What investigations are done for pathological nipple discharge?

A

mammography, ultrasound, surgical excision of the discharging ducts (to establish cause and relieve the discharge)

39
Q

50 y/o woman present with nipple discharge. The left nipple is indurated with some superficial erosion. She reports it being previously dry and eczematous lesion around the areola. But it is now red and weeping.
Investigation and diagnosis?

A

incisional or punch biopsy for histology

high grade DCIS extending along ducts to reach epidermis of nipple = Paget’s disease of nipple

40
Q

Which tumours are likely to metastasise to the breast?

A

bronchial carcinoma, ovarian serous carcinoma, clear cell carcinoma of kidney

malignant melanoma
leiomyosarcoma (uterine)

41
Q

Describe breast carcinoma.

A

malignant tumour of breast epithelial cells - ductal or acinar epithelial cells.
Arise in the glandular epithelium of the terminal duct lobular unit (TDLU).
technically an adenocarcinoma since arise from glandular epithelium

42
Q

describe atypical ductal hyperplasia (ADH)

A

(incomplete) ducts forming within established ducts

43
Q

Where is carcinoma in-situ found and what does cytology show?

A

confined within basement membrane of acini and ducts

cytologically malignant but non-invasive

44
Q

There are 2 types of lobular in situ neoplasia, what are they?

A

Atypical lobular hyperplasia (ALH): <50% of lobule involved.

Lobular carcinoma in situ (LCIS): >50% of lobule involved

45
Q

Describe the characteristic cells fo intra-lobular proliferation.

A 
small-intermediate sized nuclei 
solid proliferation  
intra-cytoplasmic lumens/vacuoles
ER positive 
E-cadherin negative
46
Q

What is the significance of E-cadherin molecule in breast carcinoma diagnosis?

A

e-cadherin is a cell adhesion molecule; deletion & mutation of CDH1 gene on chromosome 16 is useful for diagnosis of ALH/LCIS (E-cadherin negative)

47
Q

Incidence of lobular in situ neoplasia (LCIS/ALH) increases after menopause.
T/F?

A

FALSE
incidence decreases after menopause since the cells are oestrogen receptor (ER) positive which means they require oestrogen to grow (levels drop after menopause)

48
Q

List some features of LCIS/ALH.

A

frequently multifocal & bilateral
not palpable, not visible grossly
may calcify - mammography
usually an incidental finding

49
Q

Lobular neoplasia is discovered on core biopsy. What do you do?

A

Excision or vacuum biopsy to exclude higher-grade lesion

50
Q

Lobular neoplasia discovered on vacuum or excision biopsy. What do you do?

A

Follow up (annual mammography for 5 years); clinical trials

51
Q

Describe a typical ductal carcinoma in situ (DCIS).

A

10-20% of breast malignancies are DCIS
Arise in TDLU
Characteristically unicentric (single duct system)
Duct dilated and filled with cells
Necrosis within centre of ducts (if high grade) which can calcify due to regular cell death

52
Q

What is the significance of DCIS being confined to the basement membrane of a duct?

A

It can move either forward to nipple or backwards to lobules within the duct

53
Q

If DCIS involves the nipple skin what is this condition? Describe it.

A

Paget’s disease of the nipple - high grade DCIS extending along the reach the epidermis of the nipple; still in situ carcinoma (i.e. non-invasive)

54
Q

What is the criteria for micro-invasive carcinoma?

A

DCIS (high grade) with invasion of <1mm

treat as high grade DCIS

55
Q

Peak incidence for invasive breast carcinoma?

A

50-70

56
Q

List some risk factors for invasive breast carcinoma.

A 
Age (50-70)
Age at menarche
Age at first birth (>35)
Parity 
Breastfeeding
Age at menopause 
Endogenous / exogenous hormones (OCP, HRT)
Previous breast disease
Geography (western world disease)
Body weight (BMI>30)
Physical inactivity (exercise is protective)
Alcohol consumption (higher level of oestrogen in alcohol consumers)
Diet (high fat - small increase risk)
Smoking
57
Q

Effect of reproductive history on risk of breast carcinoma?

A

Related to oestrogen exposure - things that decrease oestrogen exposure will reduced risk of breast cancer.
E.g. early menarche increases risk but multiparty and breastfeeding all your kids decreases risk since less exposure to oestrogen during pregnancy and breastfeeding

58
Q

Impact of having a 1st degree relative affected by breast cancer?

A

doubles risk

59
Q

Difference between prophylactic management for BRCA1 & BRCA2 mutations?

A

prophylactic bilateral mammectomy in BRCA1; prophylactic surgery in BRCA2

60
Q

Breast carcinoma grading.

A

Assessing tubular differentiation (1-3), nuclear pleomorphism (1-3) and mitotic activity (1-3)
score 3-5 = grade 1
score 6 or 7 = grade 2
score 8 or 9 = grade 3

61
Q

ER+ breast cancer sub-types will respond to anti-oestrogen therapy. What are some options for anti-oestrogen therapies?

A

oophrectomy
tamoxifen
aromatase inhibitors (letrozole)
GnRH antagonists (Goserilin)

62
Q

Better survival outcomes seen in ER+ sub-types vs. ER- subtypes.
T/F?

A

TRUE

63
Q

Better survival probability if progesterone receptor positive (PR+) vs. PR-
T/F?

A

TRUE

64
Q

What is HER2?

A

human epidermal growth factor receptor 2

65
Q

Significance of over expression and amplification of HER2?

A

predicts response to Trastuzamab (herceptin)

- monoclonal antibody that is very active in HER2+ disease

66
Q

HER2- sub-types have worse survival outcomes vs. HER2+

T/F?

A

FALSE

HER2- has better survival outcomes vs. HER2+

67
Q

What test can be done to detect HER2 amplification?

A

FISH - membrane staining - lots of red signals since lots of gene amplification

68
Q

HER2 breast cancer sub-type receptors?

A

ER-, HER2+

69
Q

Basal-like breast cancer sub-type receptors?

A

ER-, HER2-, basal cytokeratins (CK)+

70
Q

Luminal A, B and C breast cancer sub-type receptors?

A

Luminal A: ER+, low proliferation

Luminal B & C: ER+, high proliferation

71
Q

Combination of of ER, PR and HER2 receptors for best outcomes?

A

ER+, PR+, HER2-

72
Q

Combination of ER, PR and HER2 receptors for worst outcomes?

A

ER-, PR-, HER2- (triple negative)
OR
HER2+

73
Q

How would you assess the response to neoadjuvant breast cancer chemotherapy?

A

mammography, ultrasound, MRI

74
Q

What are the neoadjuvant treatment options for breast conservation?

A

Chemotherapy (standard FEC100 + taxane) ± Herceptin

Endocrine: aromatase inhibitors > tamoxifen so reserved for post-menopausal women

Both methods reduce mastectomy rates

75
Q

What is considered equivalent disease free in breast conservation treatment?

A

clear margins >= 1mm PLUS breast radiotherapy

76
Q

What is “oncoplastic” surgery?

A

safe oncological (cancer) surgery while avoiding tissue deformity

77
Q

Large breast / large tumour + reshaping –> ?

A

therapeutic mammoplasty

78
Q

Small breasts –> ?

A

volume replacement techniques

79
Q

What are the main problems with implant reconstruction?

A 
loss of implants (infection)
capsular contracture
implant rippling
implant migration  
40% require revision surgery

older implants have <1:25,000 risk of Anaplastic Large Cell lymphoma

80
Q

Describe the current 2 stage implant reconstruction.

A

1st stage: mastectomy and creation of sub muscular pocket w/ expander insertion
Clinical visits for expansion 2 weekly.
2nd stage: exchange of expander for permanent implant

81
Q

What are the advantages of Acellular Dermal Matrix (ADM) /implants?

A

“one stage” implant reconstruction by providing lower pole coverage.
Better lower pole expansion
Reduced post-op pain
improved aesthetic outcome
permanent implant can be used at 1st operation
also useful for revision surgery

82
Q

TRAM/DIEP flaps?

A

Transverse rectus abdominus flap
Deep inferior epigastric artery perforator flap (have to take both sides as an ellipse but only use half of it - large portion of tummy)

83
Q

IGAP flap?

A

Inferior gluteal artery perforator flap - top of buttock (slight asymmetry of bums)

84
Q

What comprises pre-operative axillary staging?

A

USS axilla ± core biopsy

85
Q

What can be used for contralateral symmetrising?

A

liposuction: syringe from stomach, spin it out and separate it into blood, fat & excess oil, inject fat only into breast

86
Q

what is first line therapy for metastatic breast cancer?

A

Bevacizumab - a recombinant humanised monoclonal antibody against vascular endothelial growth factor (VEG-F)

Reproduction & Sexual Health (15 decks)

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