Histopathology 3: Breast pathology Flashcards by .. ...

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Histology shows a stellate pattern with central sclerosis/scarring surrounded by proliferating glandular tissue (radiating zone).

Most likely diagnosis ?

Radial scar

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Histology: Intraductal epithelial proliferation, with pleomorphic cells in the duct and necrotic material in the central lumen.

Mammogram: Microcalcifications

Most likely diagnosis ?

DCIS

How well did you know this?

Not at all

Perfectly

Young women presents with multiple small lumps in the breast.

Most likely diagnosis ?

Fibrocystic disease

How well did you know this?

Not at all

Perfectly

Histology shows linear arrangement of monomorphic cells in a distribution known as the Indian file pattern.

Most likely diagnosis ?

Lobular carcinoma

How well did you know this?

Not at all

Perfectly

List 3 receptors tested for in breast carcinoma ?

Oestrogen
Progesteron
HER2

How well did you know this?

Not at all

Perfectly

Which drug is used to treat HER2 positive breast carcinoma?

Herceptin

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

2 tests for cytopathology and/or histopathology of breast tissue

Fine need aspiration (aspirated by a 16/18 gauge needle)
Core biopsy

How well did you know this?

Not at all

Perfectly

GOLD STANDARD for the diagnosis of breast cancer

Biopsy

NB takes 24 hours to process

How well did you know this?

Not at all

Perfectly

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 *

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)