Histopathology 3 - Breast pathology Flashcards
In which type of breast cancer is MRI most useful?
Lobular
What guage needle is used for core biopsy in breast cancer investigiation?
16/18 guage
Recall the C1-C5 code that is used to grade fine needle aspirate in breast cancer investigation
C1 - Inadequate sample
C2 - Benign
C3 - Atypia, probably benign
C4 - Suspicious of malignancy
C5 - Malignant
Recall some symptoms of duct ectasia
Pain, mass, nipple inversion and discharge (thick, white)
What would be seen upon cytological analysis of nipple discharge in duct ectasia?
Proteinaceous material and inflammatory cells only
What is the most common pathogen identified in acute mastitis?
Staphylococcus aureus
What is the cause of fat necrosis of the breast?
Trauma–> inflammatory reaction
also: radiotherapy, surgery, nodular panniculitis
What is the cause of fibrocystic disease of the breast?
Normal, but exaggerated, response to hormonal influences
How can fibroadenoma be cured?
‘Shelling out’
**you take it all out in one go without any margins (i.e. not wide local excision)
Which breast tumours can be described as ‘leaf like’?
Phyllodes tumours
What is a phyllodes tumour?
Potentially aggressive fibroepithelial neoplasm of the breast - but usually benign
How do phyllodes tumours tend to present?
Usually as an enlarging breast mass in women >50 - often in pre-existing fibroadenomas
In what ways are intraductal papillomas comparable to polyps?
They have a fibrovascular core
How can radial scars of the breast be cured?
Excision
What is the key histopathological feature of usual epithelial hyperplasia of the breast?
Irregular lumens
**almost counterintuitive- usual vs irregular**
What is another name for flat epithelial atypia?
Atypical ductal carcinoma
How much is risk of malignancy increased by flat epithelial atypia?
4 times
What is the main histopathological features of flat epithelial atypia?
Cribiform spaces (punched out areas)
**instead of being completely infiltrated with cancer cells** like a less severe version of invasive carcinoma
How much is risk of malignancy increased by in situ lobar neoplasia?
7-12 times increased risk
How will the lumens often appear in DCIS?
Calcified
How should DCIS be managed?
Complete excision with surgical margins
What is the biggest risk factor for invasive breast carcinoma?
Osetrogen exposure
Which genetic change is seen in low grade invasive ductal carcinoma of the breast?
16q loss
What is the histological appearance of invasive ductal carcinoma vs lobular carcinoma?
Ductal: Large pleiomorphic cells with huge nuclei. E CADHERIN POSITIVE
Lobular: Linear, MONOmorphic cells. E CADHERIN NEGATIVE
Which type of breast pathology would show an “Indian file pattern” of cells under the microscope?
Invasive lobular carcinoma
**file pattern = linear
Which type of breast carcinoma has the worst prognosis?
Basal-like carcinoma
How can basal-like breast carcinomas be identified using immunohistocheistry?
Positive for ‘basal’ cytokeratins eg CK5/6/14
What 3 features of a breast malignancy are examined to decide its histological grading?
Tubule formation
Nuclear pleiomorphism
Mitotic activity
Which receptors are tested for in breast cancer diagnosis, and why?
ER
PR
HER2
Gives therapeutic and prognostic value
ER/PR receptor positive associated with good prognosis because it predicts response to tamoxifen.
HER 2 positive associated with bad prognosis.
What age group is invited to breast cancer screening in the UK?
47 to 73yr
Recall the B1-B5 code used for core biopsies of breast masses
B1 = normal B2 = benign B3 = uncertain B4 = suspicious B5 = malignant
What are the 3 inflammatory breast conditions?
- acute mastitis
- mammary duct ectasia
- fat necrosis
What is acute mastitis?
Presentation: painful, red breast, hot to touch and fever
• Either lactational (more common) or non-lactational
• Lactational is usually secondary to staphylococcal infection (often polymicrobial) via cracks in the nipple & due to stasis of milk • FNA cytology shows an abundance of neutrophils • Tx: continued expression of milk + antibiotics +/- surgical drainage • Non-lactational – keratinising squamous metaplasia block
lactiferous ductsleading to peri-ductal infalmation and rupture.
What is mammary duct ectasia?
Inflammation and dilatation of large breast ducts
What is the biggest risk factor for mammary duct ectasia?
smoking
Pathophysiology of mammary duct ectasia
Inflammation and dilatation of large breast ducts
• Poorly defined palpable periareolar mass with thick, white nipple
secretions.
• Dilatation in one or more of the larger lactiferous ducts, which fill with a
stagnant brown or green secretion. This may discharge. These fluids then set up an irritant
reaction in surrounding tissue leading to periductal mastitis or even abscess and fistula
formation.
• In some cases, a chronic indurated mass forms beneath the areola, which
mimics a carcinoma. Fibrosis eventually develops, which may cause slit-
like nipple retraction
What does mammary duct ectasia look like on mammography?
Mimics breast cancer
Typical demographic affected by fat necrosis?
(typically obese, middle-
aged women
Cytology of fat necrosis?
empty fat spaces , histiocytes and giant cells
**histiocyte - tissue resident macrophage
What are the benign neoplastic conditions?
- Fibroadenoma
- intraductal papilloma
- radial scar
- phyllodes tumour
- fibrocystic disease
What is the most common benign tumour of the breast?
Fibroadenoma
Clinical features of fibroadenoma
Spherical, freely mobile, variable size and rubbery.
Cytology and histology of fibroadenoma
branching sheets of epithelium, bare bipolar nuclei and stroma
What are the two types of intraductal papilloma?
Peirpheral: arise in small terminal ductules
Central: arise in large lactiferous ducts
Clinical features of intraductal papilloma
Bloody discharge
not seen on mammogram
Cytology and histology of intraductal papilloma
Cytology of nipple discharge – branching papillary groups of epithelium • Histology – papillary mass within a dilated duct lined by epithelium
Key features of radial scar
Key features of phylloides tumour
Arise from interlobular stroma (like fibroadenomas – can arise within existing
fibroadenomas) with increased cellularity and mitoses.
• Present >50yrs as palpable mass
• Low grade or high grade lesions. Mostly relatively benign, but can be aggressive therefore
excised with wide local excision/mastectomy to limit local recurrence.
• Mets very rare
Key features of fibrocystic disease
What are the proliferative breast conditions?
- usual epithelial hyperplasia - not a precursor lesion. growth of galndular tissue and epithelial cells forming FRONDS
- flat epithelial atypia/ atypical ductal carcinoma- precurosr to low grade DCIS
- in situ lobular neoplasia - precurosr to lobular carcinoma??
What is the precurosr lesion of low grade DCIS?
flat epithelial atypia (atypical ductal carcinoma)
Histology of in situ lobular neoplasia
solid proliferation of aplastic cells with little space with small
residue areas where you can still see lumen
*solid proliferation of cells within acinus*
What are the malignant neoplastic breast conditions?
1) Carcinoma in situ
- ductal carcinoma in situ
- lobular carcinoma in situ
2) invasive carcinoma
- ductal
- lobular
- tubular
- basal
Presentation of breast cancer
Presentation: hard fixed lump, Paget’s disease (eczema of the nipple first then areola –
normal eczema never affects the nipple), peau d’orange, nipple retraction.
What % of malignant breast tumours are in situ vs invasive?
70% invasive
30% in situ
What changes are detected on mammography?
Calcification and masses
**that’s why it only picks up the tumours that show calcification
Main difference between LCIS and DCIS
DCIS shows calcification - picked up on mammography
LCIS no calcification
Histology of DCIS
ducts filled with atypical epithelial cells
Two grades of DCIS
low grade
high grade
categories of invasive breast carcinoma
which is the most common?
- ductal
- lobular
- tubular
- mucinous
**ductal carcinoma is the most common
Histology of invasive ductal carcinoma
Big, pleiomorphic cells – invasive cells move intro stroma
Histology of invasive lobular carcinoma
cells aligned in single file chains/strands.
Histology of tubular carcinoma
well-formed tubules with low grade nuclei. Rarely palpable as
<1cm.
Histology of mucinous carcinoma
Mucinous carcinoma cells produce abundant quantities of extracellular mucin which
dissects into surrounding stroma.
MOst important prognostic factor for breast cancer
status of axillary lymph nodes
drugs for breast cancer
Tamoxifen = mixed agonist/antagonists of oestrogen at its receptor. Herceptin/trastuzumab = monoclonal Ig to Her2 (direct toxic effect on myocardium, must monitor LVEF)
histology of basal like carcinoma
Histologically - sheets of markedly atypical cells with lymphocytic infiltrate
often associated with BRCA
In familial cases of male breast cancer, what value does BRCA have?
BRCA2 carriers are at higher risk
not BRCA 1
Calcification: is that a distinguishing feature of in situ caricnoma or invasive carcinoma?
Distinguishes DCIS from LCIS - only DCIS shows calcification and ish ence picked up on mammography
Not a feature of invasive ductal or lobular carcinoma
Is fibrocystic disease more common in pre-menopausal or post-menopausal women?
What about fibroadenoma?
Phylloides?
Pre-menopausal
Pre-menopausal
Post-menopausal
Breast tumour also known as ‘no specific type (NST)
invasive ductal carcinoma
What is the most common breast cancer?
invasive ductal carcinoma
Which tumour is associated with e-cadherin?
invasive ductal carcinoma
