Breast pathology - benign Flashcards
What assessment is done in a women with suspected breast disease ?
Triple assessment
- Clinical - History & Examination
- Imaging - Mammography, Ultrasound, MRI
- Pathology - Cytopathology or Histopathology done (histopathology more commonly now as it allows you to see the cells in context of the whole tissue)
What is the main technique used for obtaining breast cytopathology samples ?
Fine need aspiration (FNA)
What do the 5 different gradings mean for cystopathology breast results ?
- C1 - Unsatisfactory
- C2 - Benign
- C3 - Atypia, probably benign
- C4 - Suspicious of malignancy
- C5 - Malignant
What are the different diagnostic and theraputic options for obtaining breast histopathology samples ?
Diagnostic:
- (Needle) core biopsy
- Vacuum assisted biopsy (large volume)
- Skin biopsy
- Incisional biopsy of mass
Therapeutic:
- Vacuum assisted excision
- Excisional biopsy of mass
- Resection of cancer
- Wide local excision (WLE)
- Mastectomy
What do the 5 gradings of breast histopathology mean ?
- B1 - Unsatisfactory / normal
- B2 - Benign
- B3 - Atypia, probably benign
- B4 - Suspicious of malignancy
- B5 - Malignant - B5a - carcinoma in situ or B5b - invasive carcinoma
List the 4 main developmental (congenital) breast anomalies
- Hypoplasia
- Juvenile hypertrophy
- Acessory breast tissue (polymastia)
- Acessory nipple
List the 4 main non-neoplastic breast conditions
- Gynaecomastia
- Fibrocystic change
- Hamartoma
- Sclerosing lesions - sclerosing adenosis, radial scar/complex sclerosing lesions
List the 3 main inflammatory breast conditions
- Fat necrosis
- Duct ectasia
- Acute mastitis/abscess
List the 2 main benign breast tumours
- Phyllodes tumour
- Intraduct papilloma
Define what breast hypoplasia (micromastia) is
This is postpubertal underdevelopment of a womans breast tissue
Define what juvenile hypertrophy is
- At the onset of puberty the breast grow rapidly & out of proportion, they become a severe physical & psychological burden
- Microscopically there is no abnormality seen, the enlargement is simply due to overgrowth of adipose & connective tissue
Think kenna
What is the treatment of juvenile hypertrophy?
Surgical reduction
Define what acessory breast tissue (polymastia) is
- This is where abnormal breast tissue is seen in addition to the presence of normal breast tissue.
- This can present as a mass anywhere along the course of the embryological mammary streak (axilla to inguinal region)
Describe what gynaecomastia is
- This is breast development in males, occuring in response to high oestrogen levels
- Ductal growth occurs without lobular development
What are the causes of gynaecomastia ?
- Exogenous/endogenous hormones e.g. hormonal therapy for prostate cancer
- Cannabis
- Chronic liver disease
- Drugs e.g. digoxin, sprinolocatone
What condition causes breast enlargement like gynaecomastia but histologically the breasts are similar to female breasts with lobules seen ?
Kleinfelters syndrome (47 XXY)
What is the most common breast lesion in women ?
Fibrocystic change
What age range of women does fibrocystic change affect ?
Any between 20-50 but esp premenopausal women 40-50
What causes fibrocystic change to occur ?
Occurs due to changes in hormone levels/sensitivity hence often associated with menstrual abnormalities, early menarche & late menopause
What results in a sharp delcine in symptomatic cases of fibrocystic change ?
Having been through menopause
What are the presenting features of fibrocystic change ?
- Smooth discrete lumps
- Sudden pain
- Cyclical pain
- Lumpiness/thickening
- Breast changes similar in both breasts
- Incidental finding or on screening
What is the gross pathological appearance of fibrocystic change ?
- Cysts which are blue domed with pale fluid and usually multiple
- Fibrosis - increased fibrous stroma
Note - stroma of the breast is the supporting framework of the gland, it is partly fibrous & partly fatty. Fatty stroma = the main bulk of the breast, fibrous stroma forms the suspensory ligaments
What is the microscopic appearance of fibrocystic change ?
- Cysts - thin walled fibrotic, lined with apocrine epithelium (apocrine metaplasia)
- Fibrosis - increased fibrous stoma
What is the management of fibrocystic change ?
- Exclude malignancy
- Reassure
- Excise if necessary
Define what a hamartoma is
This is a ‘circumscribed (has boundries) lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution’ - disordered collection of lobules, stroma & fat
Who is fibroadenomas more common in ?
African women
Describe the presenting features of a fibroadenoma
- Well-defined mobile solitary lump (1-3cm)
- Painless & rubber-firm & smooth
What age range is fibroadenomas most common in ?
Most common in 20-30’s
What is the gross pathological appearance of a fibroadenoma ?
A well-circumscribed, rubbery, grey-white lump
What is the microscopic appearance of a fibroadenoma ?
- There is proliferation of the intralobular stroma with interspread epithelial tubules or clefts.
- It is a biphasic tumour/lesion (consists of epithelial tissue & mesenchymal tissue)
What is the management of fibroadenomas ?
- Diagnose & reasure (no increased risk of malignancy)
- Excise usually if > 3cm
What does sclerosing lesions ecompass ?
Sclerosing adenosis & radial scar/ complex sclerosing lesions
Describe what sclerosing adenosis is
- This is a benign disorderly proliferation of the TDLU (acini & stroma)
- There is negligable risk of developing into a carcinoma
Describe what a radial scar/complex sclerosing lesion is
It is a benign lesion with central fibrous scarring & radiating fibrosis containing distorted ductules (spiculated). Alos epithelial proliferation & entrapped tubular structures
How do radial scars/complex sclerosing lesions present on mammography?
As spiculate (mass with spikes or points going from the centre) masses, which is why they are often mistaken for carcinoma
How does sclerosing adenosis commonly present ?
- As microcalcifications on mammogram
- Rarley it may present as a mass
What is the problem with sclerosing lesions ?
There appearance radiologically can mimic carcinoma so may be mistaken for one
What are the presenting features of sclerosing lesions ?
- Pain/tenderness
- Lumpiness/thickening
- Asymptomatic
- Presents in 20-70 year olds
What is the treatment of radial scars/complex sclerosing lesions ?
Excise or sample extensively by vaccum biopsy - this is because although the are not thought to be pre malignant, insitu or invasive. Carcinomas may occur within these lesions
How do you differentiate between a radial scar and a complex slcerosing lesion ?
- Radial scar = 1-10mm
- Complex sclerosing lesion = > 10mm
Describe what fat necrosis is
- This is a resulting lesion whihc becomes heavily infiltrated by ‘foamy’ macrophages resulting in fibrosis & scarring.
- It is due to damage & distruption of adpiocytes caused by local trauma e.g. seat belt injury or warfarin therapy
Describe the presenting features of fat necrosis
- Firm or hard lump
- May cause retraction or fixation of the nipple
What is the management of fat necrosis ?
Confirm diagnosis & exclude maligancy using imaging & core biopsy
Describe what duct ectasia is
This is progressive dilatation of the large or intermediate sub-areolar ductus (within 3cm of the nipple) with surrounding inflammatory change
What is duct ectasia associated with ?
Smoking
What are the presenting features of duct ectasia ?
Often asymptomatic, but if symptomatic:
- Usually presents with nipple discharge (creamy) +/- blood +/- purulent
- Pain
- Nipple retraction & distortion (may raise concern of carcinoma)
- Very rarley palpable - if so described as a ‘bag of worms’
What complications may arise in someone with duct ectasia ?
- Periareolar fistula or abcess formation
- Infection (it is one of the aetiologies of mastitis)
What is the microscopic appearance of duct ectasia ?
- Dilatation of the ducts + surrounding fibrosis & inflammation (fibrosis infiltrated with plasma cells & lymphocytes)
- Foamy macrophages present in the lumen of the ducts & in nipple discharge
What is the management of duct ectasia
- Treat acute infections
- Exclude malignancy
- Stop smoking
- Microdochectomy (if young) or total duct excision (if older).
What is Acute mastitis?
This is inflammation of the breast tissue, which can quickly become infected
What can delayed or inadequate treatment of mastitis lead to and how does it present ?
- Breast abscess formation
- Presents as a flocculent sometimes-bulging mass usually in the central area of mastitis
What are the 2 main aetiologies for masitis development and the organisms involved ?
- If they have duct ectasia - caused by Mixed organisms or anaerobes
- By lactation - caused by Staph aureus or Strep pyogenes
What are the presenting features of mastitis ?
- Painful breast - usually unilateral
- Fever or general malaise
- Tender, red or swollen hard area of breast
How is mastitis differentiated from simply duct ectasia ?
Mastitis presents in younger women, the vast majority of whom are smokers. Periductal mastitis typically presents with periareolar or subareolar infections and may be recurrent.
What is mastitis very strongly linked to ?
Smoking (more so than duct ectasia)
What is the treatment of mastitis and abscess?
- 1st line if breastfeeding is to continue to breastfeed (unaffected breast can also be pumped)
- Ensure complete drainage of breast at each feed by baby +/- expressing. Symptom relief w ith NSAIDs and warm compresses can help. Consider antibiotics if symptoms do not improve or are worsening after 12-24 hours
- Antibiotics = 1st line - Flucloxacillin 2nd line - clindamycin (if abscess will require also incision & drainage, if repeated aspirations ineffective then needs open surgical drainage)
What is chronic mastitis associated with?
- This is uncommon but may be associated with subareloar abscess.
- Periareolar fistula may occur & should be surgically treated
Mastitis unresponsive to antibiotics & particularly if it seem to spread over entire breast should make you consider what?
Inflammatory carcinoma
Describe the presentation of a phyllodes tumour
- Slow growing unilateral breast mass - ressemble fibroadenomas but tend to occur in older women, are usually larger than a fibroadenoma (3-6cm) and tend to increase in size
- May cause breast enlargement or ulceration
Is a phyllodes tumour benign?
Can be benign or malignant - rarely metastasise
What age group are most commonly affected by phyllodes tumours ?
Middle aged women 40-50
Why is it important to ensure a phyllodes tumour is completely excised?
Because they are prone to local recurrence
What is the gross pathological appearance of a phyllodes tumour ?
Twisted surface that resembles a compressed leaf with visible clefts & cystic spaces
What is the microscopic pathological appearance of a phyllodes tumour ?
Densley packed stromal cells, surrounding elongated cleft like spaces lined by epithelial cells
What is a papilloma ?
It is a benign papillary proliferation - occuring within a breast cyst
What is the presenting feature of a papilloma ?
- Breast cyst features, but it is often associated with bloody cyst fluid on aspiration
- If cyst fluid is grossly bloody or residual mass is felt after FNA (should always check no residual mass after breast cyst aspiration) of cyst then intracystic carcinoma suspected
- If this is the cause then U/S guided core biopsy would be needed
What is the normal nipple discharge from a female nipple ?
It is clear, yellow & watery (can be elicited from most of repro age)
What is a intraduct papilloma
Growth of papilloma in a single duct (sub-areolar ducts)
Are intraduct papillomas benign or malignant ?
Benign - no increased risk of breast cancer
What are the typical presenting features of a intraduct papilloma ?
- Clear or blood stained nipple discharge - it is the most common cause of bloody nipple discharge
- Sometimes a small lump near the nipple
- May be asymptomatic
What is the microscopic appearance of a intraduct papilloma ?
Papillary fronds (leaf-life) formed from a fibrovascular core covered by myoepithelium & epithelium
What should be done for all intraduct lesions (mass/lump) ?
Excision & histo evaluation so to not miss rare intraduct carcinoma
What is benign mastalgia ?
It is a common cause of breast pain in younger females.
What are the characterisitc features of benign mastalgia ?
- It is usually cyclic (varies according to menstrual cycle) but can be non-cyclic
- Cyclical mastalgia is not usually associated with point tenderness of the chest wall (more likely to be Tietze’s syndrome).
- It is usually bilateral, but pain can be unilateral
- Pain is most intense during the immediate premenstrual phase of the cycle (and increases upto this point) then it decreases after menses
Is mastalgia associated with malignancy ?
Rarley associated with malignancy unless there is a palpable breat mass
How is mastalgia diagnosed ?
- Breast pain diary
- Investigations to exclude breast cancer, infection & pregnancy
What is the management of mastalgia ?
- Better fitting supportive bra & regular exercise
- Paracetamol/ibuprofen PRN
- Keep pain diary to help evaluating response to treatment
If the pain has not responded to conservative measures after 3 months, and is affecting the quality of life or sleep, then referral should be considered - Hormonal agents such as bromocriptine and danazol
What are breast cysts ?
These are palpable cysts commonly occuring during late reproductive years
What are the charactersitic features of breast cysts ?
- Typically palpable, clearly defined, soft mobile & smooth
- Often tender esp before menstruation
- Often multiple &/or bilateral
What is the treatment & diagnosis of breast cysts?
- 1st line = FNA to remove fluid
- 2nd line = those which are blood stained or persistently refill should be biopsied or excised
Are breast cysts premalignant ?
No
What is a lipoma ?
- It is an uncommon benign breast lesion which presents as a palpable lump with a smooth border
- Only adipose cells are seen on biopsy
