Histopathology 3 - Breast pathology

Question 1

In which type of breast cancer is MRI most useful?

Answer 1

Lobular

Question 2

What guage needle is used for core biopsy in breast cancer investigiation?

Answer 2

16/18 guage

Question 3

Recall the C1-C5 code that is used to grade fine needle aspirate in breast cancer investigation

Answer 3

C1 - Inadequate sample
C2 - Benign
C3 - Atypia, probably benign
C4 - Suspicious of malignancy
C5 - Malignant

Question 4

Recall some symptoms of duct ectasia

Answer 4

Pain, mass, nipple inversion and discharge

DEFINITION: Inflammation and dilation of large breast ducts (BENIGN no increased chance of malignancy)

Question 5

What would be seen upon cytological analysis of nipple discharge in duct ectasia?

Answer 5

Proteinaceous material and inflammatory cells only

DEFINITION: acute inflammation of the breast (glandular tissue)

Question 6

What is the most common pathogen identified in acute mastitis?

Answer 6

Staphylococcus aureus

Often seen in lactating women due to cracked skin and stasis of milk

Question 7

What is the cause of fat necrosis of the breast?

Answer 7

Trauma - An inflammatory reaction to damaged adipose tissue

Question 8

What is the cause of fibrocystic disease of the breast?

Answer 8

Normal, but exaggerated, response to hormonal influences

presents as breast lumpiness

Question 9

How can fibroadenoma be cured?

Answer 9

‘Shelling out’

Benign fibroepithelial neoplasm of the breast

Question 10

Which breast tumours can be described as ‘leaf like’?

Answer 10

Phyllodes tumours

Question 11

What is a phyllodes tumour?

Answer 11

Potentially aggressive fibroepithelial neoplasm of the breast - but usually benign

Question 12

How do phyllodes tumours tend to present?

Answer 12

Usually as an enlarging breast mass in women >50 - often in pre-existing fibroadenomas

Question 13

In what ways are intraductal papillomas comparable to polyps?

Answer 13

They have a fibrovascular core

benign papillary tumour arising in the duct system of the
breast (40-60y old)

Question 14

How can radial scars of the breast be cured?

Answer 14

Excision

A benign sclerosing lesion characterised by a central zone of
scarring surrounded by a radiating zone of proliferating glandular tissue

stellate masses on screening mammograms (may closely
resemble carcinoma)

Question 15

What is the key histopathological feature of usual epithelial hyperplasia of the breast?

Answer 15

Irregular lumens

Question 16

What is another name for flat epithelial atypia?

Answer 16

Atypical ductal carcinoma

Question 17

How much is risk of malignancy increased by flat epithelial atypia?

Answer 17

4 times

Question 18

What is the main histopathological features of flat epithelial atypia?

Answer 18

Cribiform spaces

Question 19

How much is risk of malignancy increased by in situ lobar neoplasia?

Answer 19

7-12 times increased risk

Question 20

How will the lumens often appear in DCIS?

Answer 20

Calcified

Question 21

How should DCIS be managed?

Answer 21

Complete excision with surgical margins

a neoplastic intraductal epithelial proliferation in the breast
within an inherent risk of progression to breast cancer (has NOT breached the
basement membrane)

Question 22

What is the biggest risk factor for invasive breast carcinoma?

Answer 22

Osetrogen exposure

Question 23

Which genetic change is seen in low grade invasive ductal carcinoma of the breast?

Answer 23

16q loss

Question 24

What is the histological appearance of invasive ductal carcinoma vs lobular carcinoma?

Answer 24

Ductal: Large pleiomorphic cells with huge nuclei
Lobular: Linear, MONOmorphic cells

Question 25

Which type of breast pathology would show an “Indian file pattern” of cells under the microscope?

Answer 25

Invasive lobular carcinoma

Question 26

Which type of breast carcinoma has the worst prognosis?

Answer 26

Basal-like carcinoma

Sheets and sheets of very atypical pleiomorphic-type cells with
prominent lymphocytic infiltrate

Question 27

How can basal-like breast carcinomas be identified using immunohistocheistry?

Answer 27

Positive for ‘basal’ cytokeratins eg CK5/6/14

Question 28

What 3 features of a breast malignancy are examined to decide its histological grading?

Answer 28

Tubule formation
Nuclear pleiomorphism
Mitotic activity

Nottingham Modification of Bloom-Richardson System

Each parameter is scored from 1-3 and the three values are added together to
produce total scores from 3-9
o Grade 1= 3-5 points (well differentiated)
o Grade 2= 6-7 points (moderately differentiated)
o Grade 3= 8-9 points (poorly differentiated)

Question 29

Which receptors are tested for in breast cancer diagnosis, and why?

Answer 29

ER
PR
HER2
Gives therapeutic and prognostic value

Phenotype
o LOW grade = ER/ PR positive and Her2 negative
o HIGH grade = ER/ PR negative and Her2 positive
o Basal-like Carcinomas = ER/ PR/ Her2 negative (triple negative)

Question 30

What age group is invited to breast cancer screening in the UK?

Answer 30

50-73

Question 31

Recall the B1-B5 code used for core biopsies of breast masses

Answer 31

B1 = normal
B2 = benign
B3 = uncertain
B4 = suspicious
B5 = malignant

B5a= DCIS
B5b= invasive carcinoma

Question 32

How does Acute mastitis present/ how is it treated

Answer 32

painful (tender to touch), red breast, lumpy

Often have an abscess

Treatment: drainage and antibiotics

Question 33

Whether the breast tumour is benign or malignant is determined based on?

Answer 33

the cellularity of the stroma:
high cellularity + stromal overgrowth = malignant

Benign- no stromal overgrowth or cellularity
Malignant- very pleiomorphic and atypical cells and
overgrowth

Question 34

What are the proliferative breast disease

Answer 34

DEFINITION: A diverse group of intraductal proliferative lesions of the breast
accompanied with an increased risk of subsequent development of invasive breast carcinoma

Usual epithelial hyperplasia
Flat epithelial atypia
In site Lobular Neoplasia

Question 35

Most important prognostic factor in breast cancer

Answer 35

The status of the axillary lymph nodes

Question 36

What are the Invasive breast carcinomas

Answer 36

invaded through the basement membrane and into the stromal
tissue

Invasive ductal/lobular/tubular/mucinous carcinoma
Basal-like carcinoma

(NB: DCIS is malignant but has not breached the basement membrane)

Question 37

Histology of gynaecomastia

Answer 37

-Epithelial hyperplasia with finger-like projections extending into the
duct lumen
-Periductal stroma is often cellular and oedematous
-There is concentric fibrosis of the stroma
-Similar to fibroadenoma