Histopathology 3: Breast pathology Flashcards
45 year old lady presents with thick, white nipple discharge and a periareolar lump. Histology shows distended lactiferous duct.
Most likely diagnosis ?
Mammary duct ectasia
- May also cause breast pain, breast mass and nipple retraction
- NB not linked with breastfeeding
Breastfeeding mother presents with a red, painful, swollen breast. Histology shows neutrophils and pus.
Most likely diagnosis and likely organism?
Acute mastitis - S.Aureus
- This is when you get acute inflammation of the breast (glandular tissue)
- Due to milk stasis and cracked skin
60 year old women presents with a painless breast lump. She reports being in a car accident 10 years ago and wonders if the trauma from her seatbelt might have caused it.
Most likely diagnosis ? Other causes ?
Fat necrosis
- Causes: trauma + Radiotherapy, surgery, panniculitis
Aetiology: fat in the breast tissue is attacked by inflammatory cells, and it dies producing a hard lump
A 20 year old lady presents with a breast lump which is well demarcated, mobile and feels rubbery. Histology shows stromal (fibrous tissue) proliferation.
Most likely diagnosis ?
Fibroadenoma
- This is benign neoplasm
- glandular proliferation (of the ducts) and of stroma
- NB usually in younger people
Which breast tumour can originate from Fibroadenomas ?
Phyllodes tumour
- group of potentially aggressive fibroepithelial neoplasms of the breas
- NB they are leaf-like
- Most are benign
A 60 year old lady presents after she noticed her breast lump previously diagnosed as a fibroadenoma has started to increase in size. Histology shows: increased cellularity + Stromal overgrowth and overlapping cells.
most likely diagnosis ?
Phyllodes tumour (Possibly malignant)
- Normally phyllodes tumours are benign
- Arise from fibroadenoma
- Classified as enlarging mass in women > 50 years
45 year old lady presents with bloody nipple discharge. No lump is felt and no mass is seen on mammography.
Histology shows: Large dilated duck with fibrovascular core and stromal vessels.
Most likely diagnosis ?
Duct Papilloma
Histology shows a stellate pattern with central sclerosis/scarring surrounded by proliferating glandular tissue (radiating zone).
Most likely diagnosis ?
Radial scar
A 79 year old lady presents with a hard fixed lump of the breast. Paget’s disease of the breast is present and there are signs of nipple retraction.
Most likely diagnosis ?
Breast carcinoma
Paget’s disease of the breast is eczema affecting the nipple
Histology: Intraductal epithelial proliferation, with pleomorphic cells in the duct and necrotic material in the central lumen.
Mammogram: Microcalcifications
Most likely diagnosis ?
DCIS
Young women presents with multiple small lumps in the breast.
Most likely diagnosis ?
Fibrocystic disease
Histology shows linear arrangement of monomorphic cells in a distribution known as the Indian file pattern.
Most likely diagnosis ?
Lobular carcinoma
List 3 receptors tested for in breast carcinoma ?
Oestrogen
Progesteron
HER2
Which drug is used to treat HER2 positive breast carcinoma?
Herceptin
How does the E cadherin help differentiate between invasive ductal and invasive lobular carcinoma ?
If E cadherin +ve = invasive ductal
if E cadherin -ve = Invasive lobular
Describe normal breast histology
glandular tissue surrounded by stromal tissue
centre = duct surrounded by acini
unit = TDLU (terminal duct lobar unit)
myoepithelial cells help produce milk
USS or mammogram more specific for breast disease?
- USS is slightly more specific than mammogram as it picks up more echos/ shadow in the breast
- NB MRI is good for smaller lesions that the above miss
2 tests for cytopathology and/or histopathology of breast tissue
- Fine need aspiration (aspirated by a 16/18 gauge needle)
- Core biopsy
GOLD STANDARD for the diagnosis of breast cancer
Biopsy
NB takes 24 hours to process
Cytology for duct ectasia
proteinaceous material and inflammatory cells
NB benign condition (no R of malignancy)
Main organism for acute mastitis
What is seen on cytology
staphylococci
Lots of neutrophils + necrotic material with degeneration of cells
Cytology of fat necrosis
- empty spaces are fat tissue
- inflammatory cells (macrophages)
- giant cells formed by histiocytes coming together
Main aetiology of fat necrosis of breast (3)
Trauma, radiotherapy, surgery
Histology of gynaecomastia
Epithelial hyperplasia with finger-like projections extending into the duct lumen
Screening schedule for breast cancer + what Ix is done
47-73 years are screened every 3 years
Done using mammogram - 5% will have an abnormal mammogram and are recalled for further investigation with FNA/biopsy
Coding biopsies in breast cancer (B1-B5)
- B1= normal breast tissue
- B2= benign abnormality
- B3= lesion of uncertain malignant potential
- B4= suspicious of malignancy
- B5= malignant
NOTE: Anything after B3 is often offered excision due to risk of transforming into malignancy
Which breast disease is a plastic intraductal epithelial proliferation in the breast within an inherent risk of progression to breast cancer (has NOT breached the basement membrane)? How do you detect?
Ductal Carcinoma in situ (DCIS) - detected on mammography screening (see microcalcification)
Low grade histology of ductal carcinoma in situ
High grade histology
lumens are very compact and regular - described as cribriform DCIS (punched out appearance)
cells are quite large and there aren’t very many lumens left - have central lumen full of necrotic material + cells are large, pleiomorphic and occlude the duct
Tx of ductal carcinoma in situ
surgical excision with clear margins
MOST IMPORTANT PROGNOSTIC FACTOR in breast cancer
status of the axillary lymph nodes
Have breast lump. Due to fibrosis of the breast tissue along with cystic changes, linked to responses to hormonal influences. What is this? Is there increased R of breast carcinoma?
Fibrocystic Disease - VERY COMMON
No R of carcinoma
Cytology of Fibrocystic Disease
- Ducts are quite dilated
- Ducts may get calcified
Cytology of fibroadenoma
- There are lots of glandular cells and stromal cells
- Smooth monolayers of sheets of cells
Cytology of phyllodes tumour
- The cells are NOT in uniform layers anymore, they are overlapping (it looks more smudged)
benign papillary tumour arising in the duct system of the breast
Intraductal Papilloma
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Two types of intraductal papilloma
- The small terminal ductules- peripheral papillomas
- Larger lactiferous ducts- central papillomas (get nipple discharge with this one)
Tx of intraductal papilloma
Excision
Histology of intraductal papilloma
- large cystically dilated duct with a polypoid mass in the middle
- tends to have a fibrovascular core
What presents as stellate masses on screening mammograms
Tx?
Radial Scar
- A benign sclerosing lesion characterised by a central zone of scarring surrounded by a radiating zone of proliferating glandular tissue
Tx: excision
3 receptors assessed in invasive breast cancer
- Oestrogen receptor (ER)
- Progesterone receptor (PR)
- Her2 receptor
Phenotype of low grade, high grade, and basal-like carcinomas in invasive breast cancers
Low grade
- ER/ PR positive
- Her2 negative
High Grade
- ER/ PR negative
- Her2 positive
Basal-like Carcinomas
- ER/ PR/ Her2 negative (triple negative)
System used to grade invasive breast carcinomas
Nottingham Modification of Bloom-Richardson System
Grades on:
- Tubule formation
- Nuclear pleomorphism
- Mitotic activity
microscopic lesions that usually produce NO symptoms, and that can develop into invasive breast carcinoma - they calcify within the breast
How to Dx?
Proliferative Breast Diseases
Dx: breast tissue removed for other reasons or on screening mammograms if they calcify
Most common cancer in women
Invasive Breast Carcinomas
- Invade through the basement membrane and into the stromal tissue
Genetics for low grade and high grade invasive breast carcinomas
- Low Grade- show 16q loss
- High Grade- show complex karyotypes with many unbalanced chromosomal aberrations
**PLEASE CLOZE DELETE EACH ANSWERS BOTH AS C1**
Histology of invasive ductal carcinoma
Histology of Invasive LOBULAR Carcinoma
Histology of Invasive TUBULAR Carcinoma
Histology of Invasive MUCINOUS Carcinoma
- Cells are pleiomorphic (large, pleiomorphic, nucleated cells)
- have a linear arrangement
- The cells are monomorphic (tend to look like each other)
- The cords of cells is referred to as the Indian File pattern
- elongated tubules of cancer cells which are invading stroma
- All the ‘empty’ spaces contain a lot of mucin
4 types of proliferative breast disease
- Usual Epithelial Hyperplasia
- Flat Epithelial Atypia/ Atypical Ductal Carcinoma
- In situ Lobular Neoplasia
- Basal-like Carcinoma
Sheets and sheets of very atypical pleiomorphic-type cells with prominent lymphocytic infiltrate + central necrosis. Which type of proliferative breast disease?
What is immunohistochemistry?
Basal-like Carcinoma
Positive for basal cytokeratins (CK5/6 and CK14)
