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

Smoking is the biggest risk factor

Question 5

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

Answer 5

Proteinaceous material and inflammatory cells only

Smoking is a big risk factor

Question 6

What is the most common pathogen identified in acute mastitis?

Answer 6

Staphylococcus aureus

Question 7

What is the cause of fat necrosis of the breast?

Answer 7

Trauma, Surgery, Radiation

Often presentation in clinic is of a obese middle-aged woman presenting with a painless breast mass

Question 8

What is the cause of fibrocystic disease of the breast?

Answer 8

Normal, but exaggerated, response to hormonal influences

Common around period time

Question 9

How can fibroadenoma be cured?

Answer 9

‘Shelling out’

Common disease in young woman, benign, often referred to as breast mouse

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

Question 14

How can radial scars of the breast be cured?

Answer 14

Excision, same with intraductal papillomas- remove the ductal structures

Question 15

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

Answer 15

Irregular lumens-frond like growths

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 (Ductal carcinoma in situ)?

Answer 20

Calcified

Can also cause Paget’s disease of the nipple if the ducts below the skin of the nipple are involved

Detected incidentally on mammograms with calcification- this is what the screening for breast cancer looks for

can progress to aggressive invasive carcinoma

Question 21

How should DCIS be managed?

Answer 21

Complete excision with surgical margins

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- indian file pattern

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

Commonly associated in BRCA patients

Question 27

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

Answer 27

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

Basal-like carcinoma common in BRCA patients

Called basal-like carcinoma because these cells stain for basal markers and originate from those cells.

Question 28

Nottingham grading of breast tumours:

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

Answer 28

Tubule formation
Nuclear pleiomorphism
Mitotic activity

Question 29

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

Answer 29

ER
PR
HER2
Gives therapeutic and prognostic value

Low-grade tumours tend to be ER/PR+ve and HER2 -ve (Treated with tamoxifen)
High grade tumours tend to be ER/PR-ve and HER2 +ve (treated with HER2 drugs)
Very aggresive tumours, e.g basal-cell like or BRCA+ve: triple negative so very hard to treat

Question 30

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

Answer 30

47-73

Those at risk e.g BRCA mutations are called earlier and after 73 people can opt-in for screening, unlike cervical screening where you cannot opt-in screening

Mainly to identify DCIS

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

Question 32

Which benign breast lesions most commonly mimic breast cancer on radiology?

Answer 32

Fat necrosis

Radial scars

Question 33

What are three kinds of proliferative breast diseases

Answer 33

1) Usual epithelial hyperplasia x2 risk- frond like growth
2) Flat epithelial atypia/atypical ductal carcinoma x4 risk
3) In-situ lobular neoplasia x12 risk

They are a group of intraductal proliferations of the breast which lead to an increased risk of developing malignancy.

Typically microscopic lesions that produce no symptoms

Diagnosed on breast tissue removed for other reasons or on a mammogram if they calcify

Question 34

Most common breast cancer?

Answer 34

Invasive ductal carcinoma

Question 35

What are the benign breast pathologies?

Answer 35

1) Fat necrosis-trauma, surgery, radiation
2) Duct ectasia, Pain, mass, nipple inversion and discharge. Smoking is the biggest risk factor. Proteinaceous and inflammatory cells on cytology.
3) Mastitis/abscess
4) Fibrocystic disease- due to hormones, uncommon in post-menopausal
5) Fibroadenoma- due to hormones (breast mouse), uncommon in post-menopausal
6) Phyllodes tumour- “leaf like” on histology, can become malignant so should excise
7) Intraductal pappiloma- bloody discharge but benign
8) Radial scar- presents as a stellate mass, benign central scarring surrounded by proliferating glandular tissue

Question 36

Peau d’orange sign

Answer 36

sign of breast cancer

Question 37

4 types of invasive breast carcinoma:

Answer 37

DCIS is not invasive- but still malignant

1) Invasive ductal (most common subtype- progresses on from DCIS)
2) Invasive lobular- hard to see on mammo, do MRI
3) Tubular
4) Mucinous