Histo: Breast pathology Flashcards
1
Q
What are the three components of investigating breast disease?
A
- Clinical examination
- Imaging (ultrasound, mammography or MRI)
- Pathology (cytopathology and/or histopathology)
2
Q
Outline the coding used by cytopathologists when assessing breast aspirates.
A
- C1 = inadequate
- C2 = benign
- C3 = atypia, probably benign
- C4 = suspicious of malignancy
- C5 = malignant
3
Q
What is the gold standard for diagnosing breast cancer?
A
Histopathology
NOTE: 24-hour turnaround time
4
Q
Describe the appearance of normal breast histology.
A
- Glandular tissue will be stained purple with pink stroma around it
- Myoepithelial cells will be seen around the outside of the epithelial cells - they help pump milk
5
Q
What is the terminal ductal lobular unit
A
The lobule and extralobular terminal duct are together referred to as the terminal duct lobular unit (TDLU)
6
Q
What are acini?
A
The sack-like glandular structures within a lobule that produce milk
7
Q
Define duct ectasia. Describe its presentation.
A
- Blockage of lactiferous ducts leading to inflammation and dilatation
- Usually asyptomatic, although can present with a breast lump, nipple discharge (usually greenish), and pain
8
Q
Which group does duct ectasia typically present in?
A
50-60 yrs old muliparous women
9
Q
Describe the histology of duct ectasia.
A
- The duct will be distended and full of proteinaceous material
- Foamy macrophages will also be present
10
Q
Define acute mastitis.
A
Acute inflammation of the breast.
11
Q
Which group of women tend to be affected by acute mastitis?
A
Often seen in lactating women due to cracked skin and stasis of breast milk.
12
Q
Which organism is usually responsible for acute mastitis?
A
Staphylococci
13
Q
Describe the cytological appearance of acute mastitis.
A
Lots of neutrophils
14
Q
Define fat necrosis.
A
Death of adipose tissue due to trauma to the breast
15
Q
Describe the cytological appearance of fat necrosis.
A
Fat cells surrounded by macrophages.
16
Q
How do galactoceles form and how do they present?
A
- Cystic dilatation of ducts during lactation affecting mulitple ducts
- Present as tender papable breast nodules
- Can present as mastitis if they become infected
17
Q
What is fibrocystic disease of the breast and how does it present?
A
- A group of alterations in the breast which reflect normal, albeit exaggerated, responses to hormonal influences
- Presents with lumpy breast and CYCLICAL tenderness (cyclic mastalgia)
18
Q
Which age group does fibrocystic diease affect
A
- 20-50 yrs old
- Most common benign breast lesion
- Affects 50% of women
19
Q
Descibe the histology of fibrocystic disease
A
- On histology, the ducts are usually dilated and calcified
- No increased risk of breast cancer
20
Q
Define fibroadenoma.
A
Benign neoplasm consisting of fibrous and glandular tissue
21
Q
Which age group does fibroadenoma effect? How does it present?
A
- 20-30 year old women
- Presents as well-circumscribed, mobile breast lump
- Non-tender
22
Q
Describe the histology of fibroadenoma.
A
Consists of lots of glandular and stromal cells.
23
Q
How is fibroadenoma treated?
A
- Small (<2cm) - expectant
- Large (>2cm) or symptomatic - surgical excision
24
Q
Define Phyllodes tumour.
A
A group of potentially aggressive fibroepithelial neoplasms of the breast.
Can develop from pre-existing fibroadenomas
NOTE: the majority are benign
25
Which age group does Phyllodes tumour effect? How do they present?
* 50+ years old
* Presents as painless, enlarging lump
26
Describe the histology of Phyllodes tumours.
* Biphasic (consists of 2 cell types - epithelial and stromal)
* **Leaf-like pattern** (phyllodal)
* Whether it is benign or malignant depends degree of stromal proliferation
27
How are phyllodes tumours treated?
* Benign - surgical excision
* Borderline or malignant - CT for metastases
* No mets - wide local excision
* Mets - surgery plus chemotherapy
28
Define intraductal papilloma.
A benign papillary tumour arising within the duct system of the breast.
29
What are the two different types of intraductal papilloma?
* Peripheral papilloma - arises in small terminal ductules
* Central papilloma - arises in large lactiferous ductules
30
Describe the epidemiology of intraductal papilloma?
* Common
* Affects women aged 40-60 yrs old
31
How do intraductal papillomas present?
* Central papillomas present with nipple discharge
* Peripheral papillomas usually remain clinically silent
32
Describe the histology of intraductal papillomas.
* Histology will show a large dilated duct with a polypoid mass in the middle
* The mass tends to have a fibrovascular core
33
How is intraductal papilloma treated?
Excision of involved duct
34
What is a radial scar?
* A benign sclerosing lesion characterised by a central zone of scarring surrounded by a radiating zone of proliferating glandular tissue
* Reasonably common
35
What pathological phenomenon is thought to be responsible for the formation of radial scars?
Exuberant reparative phenomenon in response to areas of tissue damage in the breast
36
How do radial scars present? How are they treated?
Seen as **stellate masses on mammograms** (can mimic carcinoma)
Excision is curative
37
Describe the histological appearance of radial scars.
Central **stellate area** with proliferation of ducts and acini in the periphery
38
Define proliferative breast disease.
A diverse group of **intraductal proliferative lesions** of the breast associated with an **increased risk** of subsequent development of invasive **breast cancer**
39
Describe the presentation of proliferative breast disease.
Microscopic lesions that usually produce no symptoms
Typically diagnosed in breast tissue removed for other reasons or on screening mammograms if they are calcified
40
Describe the appearance of usual epithelial hyperplasia.
Irregular lumens with mildly abnormal cytology and tissue architecture.
41
What is flat epithelial atypia/atypical ductal hyperplasia?
* May be the earliest **precursor to low grade DCIS**
* Frequent secretion and **calcifications**
* There are multiple layers of epithelial cells and the lumens become more regular
* Abnormal cytology and tissue architecture
42
What is *in situ* lobular neoplasia?
A solid proliferation of cells within the acinus
Does not form a palpable mass
43
What is Paget's diease of the nipple and what age group does it affect?
* Carcinoma in situ of the nipple areola epidermis
* Affects women ages 60-70 years old
* Underlying **high-grade DCIS** present in \>95% of patients
44
What is ductal carcinoma *in situ*? How is it diagnosed?
* A **neoplastic intraductal epithelial proliferation** in the breast that has not breached the basement membrane
* Largely asymptomatic - **85% present as microcalcifications** on screening mammogram
* 10% produce symptoms (e.g. lump, discharge, Paget's disease of nipple)
45
Describe the histological appearance of low grade DCIS.
* **Fenestrated proliferation** with multiple, **round, rigid extracellular lumens with punched out** appearance
* Rapid death and proliferation of cells leads to calcification
46
Describe the histological appearance of high grade DCIS.
* Cells are large and few lumens left
* Cells are pleomorphic and occlude the duct
* Comedo necrosis (necrosis of cancer cells in centre of lumen)
47
How is DCIS treated?
Complete surgical excision with clear margins
Recurrance more likely with extensive or high-grade disease
48
List some risk factors for invasive breast carcinoma.
* **Family history (BRCA)**
* Nulliparity
* Early menarche
* Late menopause
* Obesity
* Alcohol
* OCP
49
How does invasive breast cancer present?
* Most present with present lump
* Increasing proportion are detected whilst asymptomatic by screening mammogram
50
What is the most common type of invasive breast cancer?
Invasive ductal carcinoma
51
Describe the histological appearance of:
1. Invasive ductal carcinoma
2. Invasive lobular carcinoma
3. Invasive tubular carcinoma
4. Invasive mucinous carcinoma
1. **Invasive ductal carcinoma** = cells are plaeomorphic and have large nuclei
2. **Invasive lobular carcinoma** = cells have a **l**inear arrangement and are monomorphic. NOTE: cords of cells are sometimes referred to as 'Indian File' pattern
3. **Invasive tubular carcinoma** = elongated **tubule**s of cancer cells invade the stroma
4. **Invasive mucinous carcinoma** = lots of 'empty' spaces containing **mucin**
52
What are basal like carcinomas? Describe their histological appearance
* Recently discovered breast cancer type following genetic analysis of breast cancers
* **Sheets of markedly atypical cells with a prominent lymphocytic infiltrate**
* Central necrosis is common
* Propensitiy for vascular invasion and subsequent metastasis
53
Describe the immunohistochemistry findings in Basal-like carcinoma.
Positive for **basal cytokeratins** (CK5/6 and CK14)
NOTE: basal-like carcinoma is associated **with BRCA mutations**
54
Which histological grading system is used for invasive breast carcinoma?
Nottingham Histologic Score
55
What is histological grading dependent on?
* Tubule/gland formation (more glands = better prognosis)
* Nuclear pleomorphism
* Mitotic activity
Scored out of 9 points. The higher the score, the less differentiated the tumour = worse prognosis
56
Which three receptors are all invasive breast cancers assessed for?
* ER
* PR
* Her2
57
Describe the receptor phenotype of:
1. Low grade invasive breast cancer
2. High grade invasive breast cancer
3. Basal-like carcinoma
1. **Low grade invasive breast cancer**
* ER/PR positive
* Her2 negative
2. **High grade invasive breast cancer**
* ER/PR negative
* Her2 positive
3. **Basal-like carcinoma**
* Triple negative
58
What is the most important prognostic factor in invasive breast cancer?
Status of axillary lymph nodes
(other important factors include tumour type, grade, and size)
59
Which age group is screened in the NHS breast screening programme? What does the mammogram looked for?
50-71 year olds (every 3 years)
Mammogram looks for masses and microcalcifications
60
Outline the coding of histological biopsies for suspicious breast lumps.
* B1 = normal breast tissue
* B2 = benign abnormality
* B3 = lesion of uncertain malignant potential
* B4 = suspicious of malignancy
* B5 = malignancy (a = DCIS; b = invasive carcinoma)
61
How does the structure of the male breast differ to females
Ductal stuctures but no/rare acini
62
Define gynaecomastia. What age group does it tend to affect?
Enlargement of the male breast
Affects pubertal boys and men \>50 years
No increased risk of malignancy
63
What is an important pathological cause of gynaecomastia
Hyperoestrogenism in liver cirrhosis
64
Describe the histology of gynaecomastia.
* Epithelial hyperplasia with finger-like projections extending into the duct lumen
* Periductal stroma is often cellular and oedematous
* Similar to fibroadenoma
