HISTO: Breast Flashcards
1
Q
How do you investigate breast disease?
A
Triple assessment
- Clinical
- Imaging - sonography, mammography, MRI
- Pathology - cytology or histopathology
2
Q
How is cytology carried out?
A
Lesion aspirated by 16/18 gauge needle and added to a slide and spread with stains to see the cells
3
Q
What is the cytopathology breast coding?
A
- C1 - inadequate
- C2 - benign
- C3 - atypia, probably benign
- C4 - suspicious malignancy
- C5 - malignant
NB:
M coding - clinical (1-5)
U coding - radiological (1-5)
4
Q
What is seen on each photo?
A
- RBC and can’t see monolayer
- Epithelial - sesame like and myoepithelial
- Fat cell - fat dissolved out during processing
- Cellular aspirate which you can look at more carefully, monolayer is seen and lots of myoepithelial cells. Epithelial and myoepithelial cells are the hallmark of the breast grandular unit.
- Glandular tissue seen to be forming branches BUT this is more likely to be a tumour
5
Q
What guidance is used for biopsy?
A
Ultrasound
6
Q
What is the difference between histopathology and cytology?
A
Histopathology:
Intact tissue removed, fixed in formalin, embedded in paraffin wax, thinly sliced, stained with H&E.
Core biopsies, surgical excisions.
Takes 24 hours to process.
Architectural & cellular detail.
7
Q
What cells/units are seen here?
A
- Terminal duct lobular units - lactiferous duct continues to branch in tissue
- Final functional units are acini which have secretory cells and these are blind ended ductules
- Cells shown by arrows make milk/secretions and the myoepithelial cells are the ones which cause contraction to get it out of the lactiferous ducts and out through the nipple
8
Q
What are features of duct ectasia?
A
- Inflammation and dilation of large breast ducts.
- Aetiology unclear.
- Usually presents with nipple discharge.
- Sometimes causes breast pain, breast mass and nipple retraction.
- Cytology of nipple discharge shows proteinaceous material and inflammatory cells only (e.g. macrophages).
- Benign condition with no increased risk of malignancy.
Easily diagnosed on aspirates or secretions. Usually secretions are seen when they are not expected.
9
Q
What is this?
A
Duct ectasia
- BM and fibrous tissue around is seen
- Duct is greatly enlarged
- Sometimes self resolves and other times it may need to be excised
10
Q
What are the features of acute mastitis? What organism usually causes this?
A
- Acute inflammation in the breast.
- Often seen in lactating women due to cracked skin and stasis of milk.
- May also complicate duct ectasia.
- Staphylococci the usual organism.
- Presents with a painful red breast.
- Drainage & antibiotics usually curative.
11
Q
What is this?
A
Cytology of acute mastitis
- Vacuolated large cells - purple is nucleus
- BAckgroung shows trinucelated cells which are polymorphs
- There is a mix of cells
- Inflammatory condition
12
Q
What are the features of fat necrosis?
A
- An inflammatory reaction to damaged adipose tissue.
- Caused by trauma, surgery, radiotherapy.
- Presents with a breast mass.
- Benign condition.
13
Q
What is this?
A
Fat necrosis
- Oval cells - histiocytes (?) due to smearing on slide
- Macrophages seen
- Some cells joining together
- Dark cells are lymphocytes
14
Q
What are the features of fibrocystic disease?
A
- A group of alterations in the breast which reflect normal, albeit exaggerated, responses to hormonal influences.
- Very common.
- Presents with breast lumpiness.
- No increased risk for subsequent breast carcinoma.
15
Q
What is this?
A
Fibrocystic disease
- HNE stain used
- normal lobule to middle far left with acini and ducts
- Due to imbalance prom prog and eostrogen
- Some units are calcifying
- Calcification is seen on mammogram but on histopathology you find out that it is actually benign
16
Q
What are the features of fibroadenoma?
A
- AKA breast mouse - moves easily
- A benign fibroepithelial neoplasm of the breast.
- Common.
- Presents as a circumscribed mobile breast lump in young women aged 20-30.
- Simple “shelling out” curative.
17
Q
What is this?
A
Fibroadenoma
FNA (left)
- monolayer sheet
- arrows point to myoepithelial cells
- sesame darker cells confirm that benign
Light microscope
- well circumscribed edge
- glands compressed due to proliferation of fibrous tissue
18
Q
What are the tumours of phyllodes tumours?
A
- A group of potentially aggressive fibroepithelial neoplasms of the breast.
- Uncommon tumours.
- Present as enlarging masses in women aged over 50.
- Some may arise within pre-existing fibroadenomas.
- Vast majority behave in a benign fashion but a small proportion can behave more aggressively.
19
Q
What is this?
A
Phyllodes tumour
- Stroma is cellular, dense and shows mitosis.
- A lot of cells in the tissue that is present
- Phyllodes means “leaf like”
- Cleft structures and leaf like structure
- All glandular epithelial cells on the outside
- Middle contains orange(?) cells
20
Q
What are the features of intraductal papilloma?
A
- A benign papillary tumour arising within the duct system of the breast.
- Arise within small terminal ductules (peripheral papillomas) or larger lactiferous ducts (central papillomas)
- Common.
- Seen mostly in women aged 40-60.
- Central papillomas present with nipple discharge.
- Peripheral papillomas may remain clinically silent if small.
- Excision of involved duct is curative (small portion can form invasive tumours later)
21
Q
What is this?
A
FNA of Intraductal papilloma
Rounded clusters of cells on left are characteristic
22
Q
What are the features of a radial scar?
A
- A benign sclerosing lesion characterised by a central zone of scarring surrounded by a radiating zone of proliferating glandular tissue. Stellate architecture
- Range in size from tiny microscopic lesions to large clinically apparent masses.
- Lesions >1 cm are sometimes called “complex sclerosing lesions”.
- Needs to be excised as can harbour cancerous cells which can cause tubular carcinomas
- Reasonably common lesions.
- Thought to represent an exuberant reparative phenomenon in response to areas of tissue damage in the breast.
- Usually present as stellate masses on screening mammograms which may closely a carcinoma.
23
Q
What is this?
A
Radial scar
24
Q
What are the features of proliferatve breast diseases?
A
A diverse group of intraductal proliferative lesions of the breast associated with an increased risk, of greatly different magnitudes, for subsequent development of invasive breast carcinoma.
Microscopic lesions which usually produce no symptoms.
Diagnosed in breast tissue removed for other reasons or on screening mammograms if they calcify.
25
What are the features of usual epithelial hyperplasia?
Not considered a direct precursor lesion to invasive breast carcinoma but is a marker for a slightly increased risk (relative risk of 1.5-2.0) for subsequent invasive carcinoma.
26
What is this?
Usual epithelial hyperplasia
27
What are the features of flat epithelial atypia? What may it be a percursor of?
May be a precuror of atypical ductal carcinoma (low grade ductal carcinoma in situ)
x4 relative risk of developing cancer
28
What is this?
Flat epithelial atypia/atypical ductal carcinoma
29
What are the features of in situ lobular neoplasia? What can it be a risk factor for?
RF for subsequent invasive breast carcinoma in either breast
x7-12 relative risk increase compared to that of women without lobular neoplasia
30
What is this?
In situ lobular neoplasia
31
What are the features of DCIS?
**DCIS = ductal carcinoma in situ**
* A neoplastic intraductal epithelial proliferation in the breast with an inherent, **but not inevitable,** risk of progression to i**nvasive breast carcinoma.**
* Common.
* Incidence has markedly increased since the introduction of breast screening programmes.
* 85% are detected on mammography as **areas of microcalcification.**
* 10% produce clinical findings such as a lump, nipple discharge, or eczematous change of the nipple (Paget’s disease of the nipple).
* 5% are diagnosed incidentally in breast specimens removed for other reasons.
* Subclassified histologically into **low, intermediate and high grade.**
32
What is this?
Low grade DCIS
White intermediate-sized rings are the areas of calcification
33
What is this?
High grade DCIS
White small ring-shaped areas are places of calcification
34
What is the managament of DCIS?
* Treatment is surgical excision.
* **Complete excision with clear margins is curative.**
* Recurrence is more likely with extensive disease and high grade DCIS.
35
What is the lifetime risk of invasive breast carcinomas? What are some risk factors for their development? How do invasive breast carcinomas usually present?
* A group of **malignant epithelial tumours** which infiltrate within the breast and have the capacity to spread to distant sites.
* The **most common cancer in women** with a **lifetime risk of 1 in 8.**
* Incidence rates rise rapidly with increasing age, such that most cases occur in older women.
* **RF:**
* **Early menarche, late menopause, increased weight, high alcohol consumption, oral contraceptive use, and a positive family history** are all associated with increased risk.
* About 5% show clear evidence of **inheritance**. BRCA mutations cause a lifetime risk of invasive breast carcinoma of up to 85%.
* **Presentation**:
* Breast lump
* Asymptomatic cases detected on screening mammography
36
What is this?
Histology of invasive ductal carcinomas
37
What is this?
Invasive lobular carcinoma- histology
Cancerous cells transverse the stroma in single line fashion
38
What is this?
Invasive tubular carcinoma histology
39
What is this?
Invasive mucinous carcinoma histology
Nests of tumour cells are floating in extravasated mucin (which has been dissolved away here but usually has a glassy appearance)
40
What are the features of basal-like carcinoma?
Recently described type of carcinoma discovered following genetic analysis of breast carcinomas.
Histologically characterised by:
* sheets of markedly atypical cells with a prominent lymphocytic infiltrate. Central necrosis is common.
Immunohistochemically characterised by:
* positivity for “basal” cytokeratins CK5/6 and CK14.
Often associated with BRCA mutations.
Seem to have particular propensity to **vascular invasion and distant metastatic spread.**
41
What is shown?
Basal like carcionoma
Histologically characterised by sheets of markedly atypical cells with a prominent lymphocytic infiltrate. Central necrosis is common.
Brown slide shows staining for CK14 and CK5/6
42
What are the 3 parameters used for histological grading of invasive breast cancers?
1. Tubucle formation
2. Nuclear pleomorphism
3. Mitotic activity
Each parameter is scored 1-3 and added to give a score.
43
What are the histological grading cut-offs for well - poorly differentiated breast carcinomas?
3-5 points = grade 1 (well differentiated)
6-7 points = grade 2 (moderately differentiated)
8-9 points = grade 3 (poorly differentated)
44
How is receptor status assessed? How are tumour grade and receptor status linked?
All invasive breast carcinomas are assessed for:
* oestrogen receptor (ER)
* progesterone receptor (PR)
* Her2 status
1. LOW grade tend to be ER/PR positive and Her2 NEGATIVE
2. HIGH grade tend to be ER/PR NEGATIVE and Her2 POSITIVE
3. BASAL-like carcinomas are often ER/PR/Her2 NEGATIVE ("triple negative")
45
What is the single most important prognostic factor for breast carcinomas? What are other important prognostic factors?
Status of the axillary lymph nodes
Other important factors include: tumour size, histological type and histological grade.
46
What is the aim of the NHS breast screening programme? How often is screening for women? What % are abnormal on screening?
* To pick up DCIS or early invasive carcinomas
* Mammograms used and women 47-73 invited for screening every 3 years
* 5% abnormal recalled for further investigation including mammograms or US with biopsy
47
How are core biopsies coded?
B1-B5 and B5a and b
1. B1 = normal breast tissue.
2. B2 = **benign** abnormality.
3. B3 = lesion of **uncertain** malignant potential.
4. B4 = **suspicious** of malignancy.
5. B5 = **malignant** (B5a = DCIS, B5b = invasive carcinoma).
48
What is seen in gynaecomastia histologically? Is there risk of malignancy?
Refers to enlargement of the male breast and affects pubertal boys and older men aged over 50.
Idiopathic or associated with drugs (both therapeutic and recreational).
Histologically the breast ducts show **epithelial hyperplasia with typical finger-like projections extending into the duct lumen.** The periductal stromal is often **cellular and oedematous.**
Benign, **no risk of malignancy.**
49
What is this?
Gynaecomastia
50
How common is male carcinoma of the breast? What is the age at diagnosis and what are the features?
Carcinoma of the male breast is rare (0.2% of all cancers).
Median age at diagnosis **65 years old.**
Most present with a **palpable lump.**
Histologically the tumours show **similar features to female breast cancers.**
51
What does cytopathology code’ C5’ denotes?
Cytopathology malignant
52
A benign lesion that most commonly mimics breast cancer on radiology?
Fat necrosis
Radial scar
53
What is the most common malignant breast tumour?
Invasive ductal cell carcinoma
54
How many parameters are included in breast tumour grading?
3
1. Tubule formation
2. Nuclear pleomorphism
3. Mitotic activity
