Breast Pathology II Flashcards
What are some miscellaneous malignant tumours?
Malignant Phyllodes tumour (sarcomatous stromal component), angiosarcoma, lymphoma, metastatic tumours
What are some examples of metastatic tumours?
Carcinoma = bronchial, ovarian serous carcinoma, clear cell carcinoma of kidney
Malignant melanoma, soft tissue tumours
What are some ductal precursor lesions?
Epithelial hyperplasia of usual type, columnar cell change (+/- atypia), atypical ductal hyperplasia, ductal carcinoma in-situ
What are some lobular precursor lesions?
Atypical lobular hyperplasia, lobular carcinoma in-situ
What is a breast carcinoma?
A malignant tumour of breast epithelial cells = technically an adenocarcinoma but just called a carcinoma
Where do breast carcinomas arise?
Glandular epithelium of the terminal duct lobular unit
What is an in-situ breast carcinoma?
Carcinoma confined within basement membrane of acini and ducts = cytologically malignant but non-invasive
How are in-situ breast carcinomas classed?
Lobular or ductal = non-obligate precursors of invasive carcinoma
What are the two types of lobular in-situ carcinoma?
Atypical lobular hyperplasia = <50% lobule involved
Lobular carcinoma in-situ = >50% lobule involved
What occurs in lobular in-situ carcinoma?
Intra-lobular proliferation of characteristic cells = solid proliferation
What are some features of lobular in-situ carcinomas?
Small intermediate-sized nuclei
ER positive
Intracytoplasmic lumens/vesicles
Frequently multifocal and bilateral
What gene mutation is associated with lobular in-situ carcinomas?
Deletion and mutation of CDH1 gene = E-cadherin negative
How are lobular in-situ carcinomas usually detected?
Usually incidental finding = calcification on mammogram
Can you detect lobular in-situ carcinomas grossly?
No = not palpable or visible grossly
What happens to the incidence of lobular in-situ carcinomas after menopause?
It decreases
What is the risk of progression of lobular in-situ carcinomas?
Atypical lobular hyperplasia = 10% risk
Lobular carcinoma in-situ = 20%
What is the management of lobular in-situ carcinoma?
If found on core biopsy = excision or vacuum biopsy
If found on vacuum/excision biopsy = follow up
What are the different types of intraductal proliferation?
Epithelial hyperplasia of usual type, columnar cell change, columnar cell change with atypia, atypical ductal hyperplasia, ductal carcinoma in-situ
What is the risk of progression to invasive carcinomas associated with intraductal proliferation?
Epithelial hyperplasia = 2x risk
Atypical ductal hyperplasia = 4x risk
Low grade ductal carcinoma in-situ = 10x risk
How common is ductal carcinoma in-situ?
Accounts for 15-20% of breast malignancies
Where do ductal carcinomas in-situ occur?
Terminal duct lobular unit = characteristically unicentric
What is the cytological appearance of ductal carcinoma in-situ?
Malignant epithelial cells = confined within basement membrane of duct, may involve lobules
What is it called when ductal carcinoma in-situ involves the nipple skin?
Paget’s disease of nipple = high grade ductal carcinoma in-situ extending along ducts to reach epidermis of nipple
How common is progression of ductal carcinoma in-situ?
75% progress to invasion following incisional biopsy
What is the management of ductal carcinoma in-situ?
Surgery, adjuvant radiotherapy, chemotherapy
What is a microinvasive carcinoma?
Rare = high grade ductal carcinoma in-situ with invasion <1mm, treat as high grade ductal carcinoma in-situ
What is an invasive breast carcinoma?
Malignant epithelial cells which have breeched the basement membrane = infiltration of normal tissues with risk of metastasis and death
What are the risk factors for developing invasive breast carcinoma?
Age, previous breast disease, Western European, obesity and low levels of physical exercise, alcohol, high fat intake, smoking, hormones (HRT, OCP, endogenous)
What features of the reproductive history are risk factors for developing invasive breast carcinoma?
Age at menarche, age at first birth, parity, breastfeeding, age at menopause
What are some genetic influences for developing invasive breast carcinoma?
BRAC1/2 = 2% of all breast cancers, 45-65% risk
TP53 mutation = early onset, Li Fraumeni syndrome
PTEN mutation = Peutz-Jeghers syndrome
What is the 5 year survival rate of invasive breast carcinoma?
87%
How common is invasive breast carcinoma?
Commonest female cancer and 2nd commonest cause of cancer death in women
What are the stages of invasive breast carcinoma?
Local invasion = stroma of breast, skin, muscles of chest
Lymphatics = regional draining lymph nodes
Blood-borne metastases = bone, liver, lungs, abdominal viscera, brain, female genital tract
What is the classification of invasive breast carcinoma?
Ductal (70%), lobular (10%), mixed (10%), mucinous, medullary, tubular, cribriform, papillary
How are invasive breast carcinomas graded?
3 categories each given a score of 1-3 = tubular differentiation, nuclear pleomorphism, mitotic activity
What is the grading of invasive breast carcinomas?
Grade 1 = score of 3-5
Grade 2 = score of 6 or 7
Grade 3 = score of 8 or 9
What are the intrinsic breast cancer subtypes?
Basal-like = ER-, HER2-, basal CK+ Normal breast-like = ER-, non-epithelial Luminal A = ER+, low proliferation Luminal B = ER+, high proliferation Luminal C = ER+, high proliferation HER2 = ER-, HER2+
How common is hormone receptor involvement in invasive breast carcinomas?
80% are ER positive, 67% are PgR positive, 14% are HER2 positive
What does oestrogen receptor (ER) expression predict?
Response of invasive breast carcinoma to anti-oestrogen therapy
How common is HER2 involvement in invasive breast carcinoma?
Overexpression and amplification seen in 15% and predicts response to trastuzamab
What are the predictive factors of invasive breast carcinomas?
ER and HER2 involvement
How are invasive breast carcinomas staged?
Direct invasion of adjacent tissues = T0-4
Lymphatic spread = N0-3
Blood-borne spread = M0-1
What prognostic indices can be used for invasive breast carcinomas?
Nottingham prognostic index, Adjuvant!Online, NHS predict
What does the Nottingham prognostic index consist of?
Histopathology only = grade and stage
0.2 x tumour diameter (cm), tumour grade (1-3), lymph node status (1-3)
What does the Adjuvant!Online prognostic index consist of?
Histopathology + ER + clinical factors
What does the NHS predict prognostic index consist of?
Histopathology + ER + HER2 + clinical factors + mode of detection
