- Circumscribed lesion - made up of breast cell types - but abnormal amount/distribution of them

Breast Pathology Flashcards by Zoe Doak

What sample can be taken from the breast for cytopathology analysis?

fine needle aspiration

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Describe how the cytology of an FNA is graded?

C1 - Unsatisfactory
C2 - Benign
C3 - Atypia, probably benign
C4 - Suspicious of malignancy
C5 - Malignant

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What samples of breast tissue can be taken for histopathology to make a diagnosis?

(Needle) core biopsy
Vacuum assisted biopsy (large volume)
Skin biopsy
Incisional biopsy of mass

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How can breast tissue be removed therapeutically (i.e. for diagnosis and treatment)?

Vacuum assisted excision
Excisional biopsy of mass
Resection of cancer (Wide local OR Mastectomy)

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Describe how a needle core biopsy can be graded

B1 - Unsatisfactory / normal
B2 - Benign
B3 - Atypia, probably benign
B4 - Suspicious of malignancy
B5 - Malignant
B5a - carcinoma in situ
B5b - invasive carcinoma

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Give examples of developmental anomalies in the breast

Hypoplasia
Juvenile hypertrophy
Accessory breast tissue
Accessory nipple

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What non-neoplastic causes are there for benign breast lumps to occur?

Gynaecomastia
Fibrocystic change
Hamartoma
Fibroadenoma
Sclerosing lesions (e.g. radial scar/complex lesion)

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What inflammatory conditions can cause benign breast disease?

Fat necrosis
Duct ectasia
Acute mastitis/abscess

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What types of breast tumour can be benign?

Phyllodes tumour

Intraduct Papilloma

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What is gynaecomastia?

Male breast development

- ducts grow but lobules dont form

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What causes gynaecomastia?

Hormones
Cannabis
Prescription drugs
Liver disease

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When does fibrocystic change normally present?

Women aged 20-50 (Majority 40-50)
pain cysts and masses in breast that may worsen at points in menstrual cycle
Early menarche/Late menopause

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What symptoms are common in a presentation of fibrocystic change?

Smooth discrete lumps
Sudden pain
Cyclical pain
Lumpiness (“doughy”)

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How does fibrocystic change appear macroscopically?

Usually multiple cysts
blue domed with pale fluid
intervening fibrosis

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How do the cysts in fibrocystic change look microscopically?

Thin walled (may have fibrotic wall)

- Lined by apocrine epithelium

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What is a hamartoma?

Circumscribed lesion
made up of breast cell types
but abnormal amount/distribution of them

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When do fibroadenomas usually present?

3rd decade most common

- usually picked up on self examination or screening

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How do fibroadenomas feel on palpation and how do they appear on US?

Painless
firm
discrete
mobile mass

Solid on ultrasound

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How do fibroadenomas look macroscopically?

Circumscribed
Rubbery
Grey-white colour

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What tissue in the breast undergoes hyperplasia to form a fibroadenoma?

INTRA-lobular stroma

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What is meant by sclerosing lesions of the breast?

Benign

- proliferation of acini and stroma

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Why do people worry about sclerosing lesions?

Can cause a mass or calcification

May mimic carcinoma

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What symptoms are caused by sclerosing adenosis?

Pain, tenderness or lumpiness/thickening
Some pts are Asymptomatic
affects any age (20-70)

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Sclerosing adenosis has a very low risk of progressing to carcinoma of breast. TRUE/FALSE?

TRUE

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What are the common pathological features of a radial scar/ complex scerlosing lesion?

Stellate architecture central puckering Radiating fibrosis

A radial scar of over what size is then defined as a complex sclerosing lesion?

RS – 1-9mm | CSL - >10mm

How are radial scars normally detected?

incidental finding | picked up on imaging/screening

What can develop within a radial scar?

In situ or invasive carcinoma may occur within these lesions

How are radial scars/ CSLs treated?

Excise | OR sample extensively by vacuum biopsy

What can cause fat necrosis?

``` Local trauma (e.g. Seat belt injury) Warfarin therapy ```

Describe the pathogenesis of fat necrosis?

disruption of adipocytes => inflammatory cells recruited “foamy” macrophages Subsequent fibrosis and scarring

How does duct ectasia normally present?

``` Pain Acute episodic inflammatory changes Bloody/ purulent discharge Fistulae Nipple retraction and distortion ```

What is duct ectasia commonly caused by/ associated with ?

Smoking

Describe the pathogenesis of duct ectasia

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

How is duct ectasia treated?

- Treat acute infections - Stop smoking - Excise ducts

Duct ectasia can go on to cause mastitis and abscesses. What organisms are normally involved?

- Mixed organisms | - Anaerobes

If lactation causes mastitis or an abscess, what organisms are normally involved?

- Staph aureus | - Strep pyogenes

How is mastitis or an abscess treated?

Antibiotics Percutaneous drainage Incision & drainage Treat underlying cause (if possible)

How does a Phyllodes tumour usually present?

Age 40-50 Slow growing unilateral breast mass contains both epithelium and stroma (biphasic)

Describe the normla behaviour of a phyllodes tumour

- can be benign OR borderline OR malignant (depends on degree of stromal overgrowth) - Prone to local recurrence if not adequately excised - Rarely metastasize

How does an intraduct papilloma usually present?

- Age 35-60 - May present with nipple discharge +/- blood - Many = asymptomatic at screening

What ducts are affected in an intraduct papilloma?

Sub-areolar ducts

The epithelium of the ducts in intraduct papilloma may show proliferative activity. What does this mean?

May convert to: - Usual type hyperplasia - Atypical ductal hyperplasia - Ductal carcinoma in situ (DCIS)

What tumours commonly metastasise to the breast?

Bronchial carcinoma Ovarian serous carcinoma Clear cell carcinoma of kidney Malignant melanoma Leiomysarcoma

Where does carcinoma of the breast arise and what type of carcinoma is it?

Arises in glandular epithelium of the terminal duct lobular unit (TDLU) glandular tissue => "adenocarcinoma"

What precursor lesions may exist prior to developing breast carcinoma?

``` Ductal: Epithelial hyperplasia Columnar cell change (+/- atypia) Atypical Ductal Hyperplasia Ductal Carcinoma in situ (DCIS) ``` Lobular: Lobular in situ neoplasia Atypical lobular hyperplasia Lobular carcinoma in situ (LCIS)

What is the difference in Atypical Lobular Hyperplasia and LCIS?

``` ALH = <50% of lobule involved LCIS = >50% of lobule involved (=> more chance of developing into cancer) ```

Lobular in situ neoplasia is usually oestrogen receptor positive TRUE/FALSE?

TRUE

What is the significance of Lobular in situ neoplasia on a biopsy?

15-20% of cases with LN on core biopsy have a HIGHER grade lesion on open diagnostic biopsy => may not be invasive cancer, but a higher grade lesion has more risk of developing into cancer

If lobular in situ neoplasia is found on a core biopsy, how is this treated?

excision or vacuum biopsy to exclude higher grade lesion

DCIS is characteristically UNIcentric (i.e. only involves one duct system.) TRUE/FALSE?

TRUE

DCIS is confined within what structure?

basement membrane of duct | - if it invades this it becomes cancer

If DCIS involves the lobules or the skin of the nipple, what is it referred to as in each of these situations?

- if involves lobules => cancer (spread from ducts) | - May involve nipple skin => Paget’s disease (still IN SITU i.e. non-invasive)

How is DCIS treated?

- Surgery - Adjuvant radiotherapy - Chemoprevention - Endocrine therapy **Low risk DCIS trial of no surgery just mammography follow up**

What is meant by microinvasive carcinoma of the breast?

- DCIS (high grade) with invasion of <1mm | - Treated as high grade DCIS

What are the risk factors for developing invasive breast cancer?

Age Reproductive Hx - menarche/first birth/Parity/Breastfeeding/menopause Hormones - HRT/ OCP Lifestyle - obesity/smoking Genetics - BRCA - TP53 (Li Fraumeni)

Breast screening takes place at what age?

50-70

Where can breast cancer locally spread to?

Stroma Skin Muscles of chest wall

Where can breast cancer metastasise to?

``` Bone Liver brain lungs abdominal viscera female genital tract ```

What lymph nodes drain the breast tissue first?

sentinel lymph nodes

What is considered before grading breast cancer?

Tubular differentiation Nuclear pleomorphism Mitotic activity

Breast cancers can express what hormone receptors?

80% ER positive 67% Progesterone Recep. positive 14% HER2 positive

Oestrogen receptor positive breast cancer responds to anti-oestrogen therapy. Give examples of these.

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

HER2 positive breast cancer responds to what medication?

Trastuzamab (Herceptin)