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Y4 Obstetrics and Gynaecology > Breast pathology - benign > Flashcards

Breast pathology - benign Flashcards

1
Q

What assessment is done in a women with suspected breast disease ?

A

Triple assessment

  1. Clinical - History & Examination
  2. Imaging - Mammography, Ultrasound, MRI
  3. Pathology - Cytopathology or Histopathology done (histopathology more commonly now as it allows you to see the cells in context of the whole tissue)
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2
Q

What is the main technique used for obtaining breast cytopathology samples ?

A

Fine need aspiration (FNA)

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3
Q

What do the 5 different gradings mean for cystopathology breast results ?

A
  • C1 - Unsatisfactory
  • C2 - Benign
  • C3 - Atypia, probably benign
  • C4 - Suspicious of malignancy
  • C5 - Malignant
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4
Q

What are the different diagnostic and theraputic options for obtaining breast histopathology samples ?

A

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
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5
Q

What do the 5 gradings of breast histopathology mean ?

A
  • B1 - Unsatisfactory / normal
  • B2 - Benign
  • B3 - Atypia, probably benign
  • B4 - Suspicious of malignancy
  • B5 - Malignant - B5a - carcinoma in situ or B5b - invasive carcinoma
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6
Q

List the 4 main developmental (congenital) breast anomalies

A
  1. Hypoplasia
  2. Juvenile hypertrophy
  3. Acessory breast tissue (polymastia)
  4. Acessory nipple
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7
Q

List the 4 main non-neoplastic breast conditions

A
  1. Gynaecomastia
  2. Fibrocystic change
  3. Hamartoma
  4. Sclerosing lesions - sclerosing adenosis, radial scar/complex sclerosing lesions
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8
Q

List the 3 main inflammatory breast conditions

A
  1. Fat necrosis
  2. Duct ectasia
  3. Acute mastitis/abscess
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9
Q

List the 2 main benign breast tumours

A
  1. Phyllodes tumour
  2. Intraduct papilloma
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10
Q

Define what breast hypoplasia (micromastia) is

A

This is postpubertal underdevelopment of a womans breast tissue

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11
Q

Define what juvenile hypertrophy is

A
  • 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

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12
Q

What is the treatment of juvenile hypertrophy?

A

Surgical reduction

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13
Q

Define what acessory breast tissue (polymastia) is

A
  • 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)
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14
Q

Describe what gynaecomastia is

A
  • This is breast development in males, occuring in response to high oestrogen levels
  • Ductal growth occurs without lobular development
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15
Q

What are the causes of gynaecomastia ?

A
  • Exogenous/endogenous hormones e.g. hormonal therapy for prostate cancer
  • Cannabis
  • Chronic liver disease
  • Drugs e.g. digoxin, sprinolocatone
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16
Q

What condition causes breast enlargement like gynaecomastia but histologically the breasts are similar to female breasts with lobules seen ?

A

Kleinfelters syndrome (47 XXY)

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17
Q

What is the most common breast lesion in women ?

A

Fibrocystic change

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18
Q

What age range of women does fibrocystic change affect ?

A

Any between 20-50 but esp premenopausal women 40-50

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19
Q

What causes fibrocystic change to occur ?

A

Occurs due to changes in hormone levels/sensitivity hence often associated with menstrual abnormalities, early menarche & late menopause

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20
Q

What results in a sharp delcine in symptomatic cases of fibrocystic change ?

A

Having been through menopause

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21
Q

What are the presenting features of fibrocystic change ?

A
  • Smooth discrete lumps
  • Sudden pain
  • Cyclical pain
  • Lumpiness/thickening
  • Breast changes similar in both breasts
  • Incidental finding or on screening
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22
Q

What is the gross pathological appearance of fibrocystic change ?

A
  • 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

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23
Q

What is the microscopic appearance of fibrocystic change ?

A
  • Cysts - thin walled fibrotic, lined with apocrine epithelium (apocrine metaplasia)
  • Fibrosis - increased fibrous stoma
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24
Q

What is the management of fibrocystic change ?

A
  1. Exclude malignancy
  2. Reassure
  3. Excise if necessary
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25
Q

Define what a hamartoma is

A

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

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26
Q

Who is fibroadenomas more common in ?

A

African women

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27
Q

Describe the presenting features of a fibroadenoma

A
  • Well-defined mobile solitary lump (1-3cm)
  • Painless & rubber-firm & smooth
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28
Q

What age range is fibroadenomas most common in ?

A

Most common in 20-30’s

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29
Q

What is the gross pathological appearance of a fibroadenoma ?

A

A well-circumscribed, rubbery, grey-white lump

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30
Q

What is the microscopic appearance of a fibroadenoma ?

A
  • 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)
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31
Q

What is the management of fibroadenomas ?

A
  • Diagnose & reasure (no increased risk of malignancy)
  • Excise usually if > 3cm
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32
Q

What does sclerosing lesions ecompass ?

A

Sclerosing adenosis & radial scar/ complex sclerosing lesions

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33
Q

Describe what sclerosing adenosis is

A
  • This is a benign disorderly proliferation of the TDLU (acini & stroma)
  • There is negligable risk of developing into a carcinoma
34
Q

Describe what a radial scar/complex sclerosing lesion is

A

It is a benign lesion with central fibrous scarring & radiating fibrosis containing distorted ductules (spiculated). Alos epithelial proliferation & entrapped tubular structures

35
Q

How do radial scars/complex sclerosing lesions present on mammography?

A

As spiculate (mass with spikes or points going from the centre) masses, which is why they are often mistaken for carcinoma

36
Q

How does sclerosing adenosis commonly present ?

A
  • As microcalcifications on mammogram
  • Rarley it may present as a mass
37
Q

What is the problem with sclerosing lesions ?

A

There appearance radiologically can mimic carcinoma so may be mistaken for one

38
Q

What are the presenting features of sclerosing lesions ?

A
  • Pain/tenderness
  • Lumpiness/thickening
  • Asymptomatic
  • Presents in 20-70 year olds
39
Q

What is the treatment of radial scars/complex sclerosing lesions ?

A

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

40
Q

How do you differentiate between a radial scar and a complex slcerosing lesion ?

A
  • Radial scar = 1-10mm
  • Complex sclerosing lesion = > 10mm
41
Q

Describe what fat necrosis is

A
  • 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
42
Q

Describe the presenting features of fat necrosis

A
  • Firm or hard lump
  • May cause retraction or fixation of the nipple
43
Q

What is the management of fat necrosis ?

A

Confirm diagnosis & exclude maligancy using imaging & core biopsy

44
Q

Describe what duct ectasia is

A

This is progressive dilatation of the large or intermediate sub-areolar ductus (within 3cm of the nipple) with surrounding inflammatory change

45
Q

What is duct ectasia associated with ?

A

Smoking

46
Q

What are the presenting features of duct ectasia ?

A

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’
47
Q

What complications may arise in someone with duct ectasia ?

A
  • Periareolar fistula or abcess formation
  • Infection (it is one of the aetiologies of mastitis)
48
Q

What is the microscopic appearance of duct ectasia ?

A
  • 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
49
Q

What is the management of duct ectasia

A
  • Treat acute infections
  • Exclude malignancy
  • Stop smoking
  • Microdochectomy (if young) or total duct excision (if older).
50
Q

What is Acute mastitis?

A

This is inflammation of the breast tissue, which can quickly become infected

51
Q

What can delayed or inadequate treatment of mastitis lead to and how does it present ?

A
  • Breast abscess formation
  • Presents as a flocculent sometimes-bulging mass usually in the central area of mastitis
52
Q

What are the 2 main aetiologies for masitis development and the organisms involved ?

A
  1. If they have duct ectasia - caused by Mixed organisms or anaerobes
  2. By lactation - caused by Staph aureus or Strep pyogenes
53
Q

What are the presenting features of mastitis ?

A
  • Painful breast - usually unilateral
  • Fever or general malaise
  • Tender, red or swollen hard area of breast
54
Q

How is mastitis differentiated from simply duct ectasia ?

A

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.

55
Q

What is mastitis very strongly linked to ?

A

Smoking (more so than duct ectasia)

56
Q

What is the treatment of mastitis and abscess?

A
  • 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)
57
Q

What is chronic mastitis associated with?

A
  • This is uncommon but may be associated with subareloar abscess.
  • Periareolar fistula may occur & should be surgically treated
58
Q

Mastitis unresponsive to antibiotics & particularly if it seem to spread over entire breast should make you consider what?

A

Inflammatory carcinoma

59
Q

Describe the presentation of a phyllodes tumour

A
  • 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
60
Q

Is a phyllodes tumour benign?

A

Can be benign or malignant - rarely metastasise

61
Q

What age group are most commonly affected by phyllodes tumours ?

A

Middle aged women 40-50

62
Q

Why is it important to ensure a phyllodes tumour is completely excised?

A

Because they are prone to local recurrence

63
Q

What is the gross pathological appearance of a phyllodes tumour ?

A

Twisted surface that resembles a compressed leaf with visible clefts & cystic spaces

64
Q

What is the microscopic pathological appearance of a phyllodes tumour ?

A

Densley packed stromal cells, surrounding elongated cleft like spaces lined by epithelial cells

65
Q

What is a papilloma ?

A

It is a benign papillary proliferation - occuring within a breast cyst

66
Q

What is the presenting feature of a papilloma ?

A
  • 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
67
Q

What is the normal nipple discharge from a female nipple ?

A

It is clear, yellow & watery (can be elicited from most of repro age)

68
Q

What is a intraduct papilloma

A

Growth of papilloma in a single duct (sub-areolar ducts)

69
Q

Are intraduct papillomas benign or malignant ?

A

Benign - no increased risk of breast cancer

70
Q

What are the typical presenting features of a intraduct papilloma ?

A
  • 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
71
Q

What is the microscopic appearance of a intraduct papilloma ?

A

Papillary fronds (leaf-life) formed from a fibrovascular core covered by myoepithelium & epithelium

72
Q

What should be done for all intraduct lesions (mass/lump) ?

A

Excision & histo evaluation so to not miss rare intraduct carcinoma

73
Q

What is benign mastalgia ?

A

It is a common cause of breast pain in younger females.

74
Q

What are the characterisitc features of benign mastalgia ?

A
  • 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
75
Q

Is mastalgia associated with malignancy ?

A

Rarley associated with malignancy unless there is a palpable breat mass

76
Q

How is mastalgia diagnosed ?

A
  1. Breast pain diary
  2. Investigations to exclude breast cancer, infection & pregnancy
77
Q

What is the management of mastalgia ?

A
  • 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

78
Q

What are breast cysts ?

A

These are palpable cysts commonly occuring during late reproductive years

79
Q

What are the charactersitic features of breast cysts ?

A
  • Typically palpable, clearly defined, soft mobile & smooth
  • Often tender esp before menstruation
  • Often multiple &/or bilateral
80
Q

What is the treatment & diagnosis of breast cysts?

A
  • 1st line = FNA to remove fluid
  • 2nd line = those which are blood stained or persistently refill should be biopsied or excised
81
Q

Are breast cysts premalignant ?

A

No

82
Q

What is a lipoma ?

A
  • It is an uncommon benign breast lesion which presents as a palpable lump with a smooth border
  • Only adipose cells are seen on biopsy

Y4 Obstetrics and Gynaecology (63 decks)

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