Breast Pathology (benign) Flashcards by Zoe Blackburn

What is FNA?

Fine needle aspiration is a method of analysing the cells in a tissue (cytology)

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What are the gradings of cytology in FNA?

C1 = unsatisfactory

C2 = Benign

C3 = atypical but probably benign (requires further investigation)

C4 = probably malignant

C5 = malignant

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What are the features looked for on cytology?

The types of cells present, and any abnormalities in the cells e.g. high N:C ratio, open chromatin structure, rouleaux (stacked on top of each other), variation in nuclei

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How is histopathology carried out?

Diagnostically = core needle biopsy, vacuum biopsy, incisional biopsy, skin biopsy

Therapeutically = excisional biopsy or resection (wide local excision or mastectomy)

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When would vacuum biopsy be preferred?

If need to get a lot of samples - core needle biopsy requires need to be removed every time a sample has been taken

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Is histopathology or cytology better?

Histopathology as gives more information regarding the lesion you are investigating

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What are some developmental abnormalities that can occur in the breast?

hypoplasia, juvenile hyperplasia, accessory breast tissue/nipple

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What is gynaecomastia?

The growth of breast tissue in the male (ducts become enlarged but not the lobules)

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What are some causes of gynaecomastia?

exogenous/endogenous steroid use

cannabis

prescription drugs (spironolactone)

liver disease

(anything that causes an increase in the oestrogen:androgen ratio in the male)

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What is fibrocytic change?

This is when the breast tissue develops cysts (blue domed and pale fluid filled) that are surrounded by fibrosis. It is very common

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Who is affected by fibrocytic change?

Women ages 20-50 (commonly 40)

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What is the presentation of fibrocytic change?

may be associated with menstrual change, early menarche or late menopause but is usually asymptomatic and picked up at screening. The breast may feel lumpy or tender (cyclical pain).

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How is fibrocystic pain managed?

managed with reassurance as benign, only excise if necessary

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Describe the gross pathological findings of fibrocystic change

Cysts (1mm to several cm in diameter) that are blue domed and filled with pale fluid. There will be fibrosis between the cysts

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What cells line the fibrocytic cysts?

Apocrine cells

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What is a hamartoma?

This is a well circumscribed lesion that is made up of cells local to the breast tissue in abnormal proportion or distribution - benign

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Describe the presentation of a fibroadenoma

This will present in the 3rd decade of life with small smooth rubbery lumps in the breast tissue. They will be mobile and can be described as the ‘breast mouse’. Not painful

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How are fibroadenomas diagnosed?

solid mass of USS, rubbery, grey in colour

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How do you manage a fibroadenoma?

reassure, dont tent to excise but can use vacuum biopsy if <2cm in diameter.

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What is sclerosing adenosis?

This is the transformation of stroma to sclerosis that presents in 20-70s. it is benign

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What is the architecture like in sclerosis adenosis?

Architecture is normal but distorted due to the sclerosis of stroma causing compression of the lobules

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How will sclerosing adenosis present?

Pain, tenderness, lumpiness, thickening of breast tissue, may cause skin retraction

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What is a radial scar?

this is a sclerosing lesion that is often found incidentally on mamogram as a radiating lesion of fibrosis.

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When is it a radial scar and when is it a ‘complex sclerosing lesion’?

RS = 1-9mm

CSL = 10mm >

What can radial scar mimic?

Breast carcinoma - therefore diagnosis cannot be made on radiology alone - there can also be change within the scar to in-situ carcinoma and invasive carcinoma

What is fat necrosis?

This is disruption and damage of the adipocytes due to trauma. There will then be infiltration of inflammatory cells and foamy macrophages which will cause scarring and sclerosis

What are some causes of fat necrosis?

trauma (seatbelt injury) and warfarin therapy

How may fat necrosis present?

painful breast, puckering, lumpiness, skin retraction

What is duct ectasia?

This is inflammation of the sub-areolar ducts

How will duct ectasia present?

pain, discharge (blood +/- purulence), puckering of the nipple and retraction

What is the management of duct ectasia?

treat the acute infection STOP SMOKING investigate for malignancy can excise ducts if still problematic

What is acute mastitis and causes?

acute inflammation of the breast due to either duct ectasia or breastfeeding if duct ectasia = anaerobes, mixed if breast feeding = staph aureus or strep pyogenes

How is acute mastitis treated?

antibiotics +/- draining (if abscess) via percutaneous or incisional drainage.

How will acute mastitis present?

red, hot, swollen, painful breast

What is a Phyllodes tumour?

This is a slow-growing tumour associated with the overgrowth of stroma - staging dependent on this factor Similar presentation to a fibroadenoma but will present in older women and are larger

Is phyllodes tumour prone to recurrence?

yes - if not fully excised

Who is affected by phyllodes tumour?

40-50s

What is an intraduct papilloma?

this is a benign tumour characterised by the growth of a cauliflower-like lesion into the lumen of a duct

Who is affected by intraduct papillomas?

35-60s

What will pathology show on an intraduct papilloma?

sub-areolar ducts infiltration, 2-20mm in diameter, fibrovascular core, covered in myoepithelium

How will a intraduct papilloma present?

discharge (with or without blood) may be asymptomatic

What can intraduct papilloma develop into?

DCIS or atypical ductal hyperplasia

How should a phyllode tumours be treated?

Wide (1cm) local excision with clear margins and follow-up

What is mastalgia?

this is breast pain. Can be cyclic or non-cyclic. Cyclic = usually bilateral Non-cyclic = more constant, unilateral, need to exclude anterior chest wall pain

Is mastalgia a sign of malignancy?

rarely unless there is a breast lump present

If FNA aspirate from a cyst is grossly bloody what should be done?

sent for cytology as risk of intracystic carcinoma

What is another risk factor for intracystic carcinoma if the FNA in clear?

If there is a residual mass after aspiration - send for core needle biopsy and histology

How is a mastitis with abscess diagnosed?

Will present with a flocculent swelling in the centre of the mastitis. Will be detected as a flui-filled cavity on USS Using an 18-guage needle to aspirate can be diagnostic and therapeutic - send for microbiology

If pueperal mastitis then what is the treatment?

Causative organism will most likely be staph aureus so give flucloxacillin 500mg orally every 6 hours

Should you still breast feed if mastitis?

Yes - feed from non-infected breast, the mastitis breast can be pumped until infection cleared

If abscess associated with mastitis is not clearing with needle aspiration what should be done?

sugrical clearing under GA and continuation/re-evaluation of antibiotic regime

What is the initial therapy for non-pueperal mastitis ?

augmentin 625mg every 8 hours for 7 days

What is a complication of chronic mastitis?

can cause peri-areolar fistulae as chronic mastitis is often associated with subareolar abscess

Inflammatory carcinoma is suspected if...

unresponsive to multiple antibiotic therapy and the entire breast is affected

What is a galatocele?

a milk-filled cyst

What is mondor's disease?

this is phlebitis affecting the superficial veins of the breast - usually in response to trauma. It will present with a vertical clot (cord-like) structure in the superficial breast tissue

How is mondor's disease treated?

Usually will resolve itself in 8-12 weeks