Breast Pathology (malignant) Flashcards
What is an angiosarcoma and what is the most common cause?
malignant tumour of the blood vessels most commonly associated with x-ray treatment (previous radiotherapy)
What are the mets associated with breast?
carcinomas (ovarian, bronchial, clear cell), melanoma and leimyosarcoma
What is a breast carcinoma?
this is a malignant lesion of the breast glandular tissue - specifically the terminal duct lobular unit (TCLU). This makes it an adenocarcinoma
What are the ductal precursors to breast carcinoma?
epithelial hyperplasia of usual type, columnar cell change, atypical ductal hyperplasia and ductal carcinoma in situ (DCIS)
What are the lobular precursors to breast carcinoma?
atypical lobular hyperplasia and lobular carcinoma insitu
How do you differentiate between atypical lobular hyperplasia and lobular carcinoma in situ?
<50% of the lobule involves in ALH >50% of the lobule involves in LCIS
What are the changes observed in the precursors to lobular carcinoma?
small-medium sized nuclei
solid proliferation
intracytoplasmic vacuoles
ER positive
E-cadherin -ve
What is the presentation of lobular in-situ neoplasia?
frequently multifocal and bilateral
not palpable, not visible and usually an incidental finding on mammogram (may calcify)
When decreases the incidence of lobular in-situ neoplasia?
post-menopause
How do you manage lobular in-situ neoplasia if found on core biopsy?
investigate further with vacuum biopsy/excision
How do you manage a lobular in-situ neoplasia found on vacuum biopsy/excision?
follow-up and clinical trials
What is DCIS?
this is the pre-cursor to ductal breast carcinoma. It is the cancerous growth of cells within the terminal ductule lobular unit (TDLU) without the breaching of the BM. It tends to be unicentric (affecting only one unit)
What is Paget’s disease of the nipple?
when there is DCIS tracking up a lobule to the epidermis
Is Pagets disease invasive?
no - it will not have breached the BM
When does a cancer become invasive?
when it breaches the basement membrane of the tissue
How should you manage DCIS?
surgery (if low-grade adopt a watch and wait approach to avoid overtreatment)
radiotherapy to reduce recurrence
chemoprevention trial
Low grade DCIS will develop into…
G1 ductal carcinoma
Intermediate grade DCIS will devlop into
G2 ductal carcinoma
High grade DCIS will develop into
G3 ductal carcinoma
What is microinvasive carcinoma?
when high grade DCIS invades less than 1mm beyond the BM - treat as HG DCIS
Describe breast cancer indicence?
it is the most common cancer affecting women in the UK and will likely affect 45-70 year olds. 1 in 8 will get breast cancer
What is the trend in mortality with breast cancer?
Decreasing (although incidence is increasing) due to screening techniques
What is the breast screening program offered in the UK?
offered from 50-71st birthday every 3 years
What are some risk factors for breast carcinoma?
older age, early menarche, increased age of first child, nulliparous, no breastfeeding, late menopause
increased endogenous and exogenous hormones (OCP, HRT)
higher BMI, decreased physical activity, high fat diet, smoking
History of previous breast disease
BRCA1 and 2 mutations
Where will a breast carcinoma locally invade?
skin, nipple, muscle, intercostals, stroma of breast
Where will a breast cancer drain to lymphatically?
regional draining lymph nodes
Axillary nodes drain the lateral part of breast (75%)
Parasternal (internal thoracic nodes) drains the medial border of breast (20%)
posterior intercostal (5%)
What makes up the axillary nodes (5)?
Apical
central
lateral
posterior
pectoral
(all drain to the apical nodes)
Where will breast cancer spread haematologically?
brain, bone, liver, lung, abdomen, vscera, genital tracts
What is a sentinel node?
This is the node to which the cancer drains first. It can be biopsied to determine the risk of mets and prognosis
what proportion of cancers are ductal or lobular?
70% ductal
10% lobular
If a cancer is ‘well differentiated’ what does this mean?
low grade carcinoma with a good prognosis
How are breast carcinomas graded?
tubular differentiation
nucleus pleomorphism
mitotic activity
3-5 = grade 1
6, 7 = grade 2
8, 9 = grade 3
Describe a ‘basal-like’ carcinoma?
triple negative
Describe luminal A and B carcinomas
A = ER positive and low proliferation
B = ER positive and high proliferation
If a cancer is ER positive what does this mean?
Means that the cancer will be responsive to anti-oestrogen treatment e.g. oophorectomy, tamoxifen, anti-GnRH, aromatase inhibitors
What is HER2?
Human Epidermal growth factor Receptor 2
If a cancer is HER2 receptive what does this mean?
responsive to trastuzamab treatment
What is trastuzamab?
This is a humanised mouse monoclonal antibody treatment that specifically targets the HER2 receptor
What is the likelihood of having breast cancer if BRCA1/2 positive?
45-64% lifetime risk
What percentage of cancers are triple negative?
13.6%
How is cancer prognosis calculated?
using the PREDICT tool online as takes into account the histopathology, HER2, ER status, clinical picture, and mode of detection
What does the nottingham prognostic index take into account?
only histopathology
How is breast cancer treated?
- breast conserving surgery (with radiotherapy)
- modified mastectomy (leaves the muscle, takes breast, skin and lymph nodes)
What is breast conserving surgery?
wide local excision with clear margins (hopefully) +/- oncoplastic reconstruction
When is radiotherapy indicated in BCS?
is the tumour was > 5cm, margins are not clear or >3 nodes involved
How long does radiation need to be given for in BCS?
5 days a week for 3-6 weeks post surgery
What is a modified total mastectomy?
removal of the entire breast, lymph nodes and associated skin but muscles are left to improve healing outcomes
What is a side effect of axillary lymph node extraction?
lymphoedema of the arm
What are autologous and prosthetic implants?
A = from own patients tissue
B= artificial tissue
When can reconstruction be done?
immediately or delayed
Does non-skin spraing total mastectomy have a good aesthetic outcome when reconstructing?
no - will have a large scar and abnormalities in the colour/texture of the breast.
Skin-sparing surgeries have the better outcomes aesthetically
Give the two main targetted treatment regimes for breast carcinoma?
ER positive = tamoxifen
HER2 positive = trastuzamab
What is comedo carcinoma?
this is a type of ductal carcinoma in situ that is associated with central necrosis of the breast.
Can the mirena coil be given as contraceptive to patients with breast carcinoma?
no!!
