Histopathology Breast Pathology Flashcards
Anatomy of the Breast Disease
- The breast is a modified sweat gland covered by skin and subcutaneous tissue
- It rests on the pectoralis muscle from which it is separated by a fascia
- Dense connective tissue extends from the underlying pectoralis fascia to the skin of the breast called Cooper’s ligament. These ligaments hold the breast upward.
Histology →
- Histologically breast consists of glandular (parenchymal) and supporting (connective) tissue.
- Glandular element is divided into branching duct system and terminal duct lobular units (TDLU)
• Epithelial element → functional and therefore called parenchymal.
• Accini (collection of lobules (numerous).
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The TDLU Formed by →
The lobule and terminal ductile and represents the secretory portion of the gland.
The TDLU → Connects with the
Sub-segmental duct, which in turn leads to a segmental duct and this to a collecting/lactiferous duct which, empties into the nipple. The latter are 15-30 in number on each side.
Histology of the ductal –lobular system
The breast is lined by two cell types
• The inner epithelial cells
• The outer myoepithelial cells – contraction function to propel fluid.
Histology knowledge is clinically important because
For treatment:
In situ can’t metastisise to maxilla (lymph): excision = cure
Invasive (into BM) can
Gland without myo-epithelial layer means
Pathological as malignant cant build moepithlial layer but can have BM (check this)
Reliable marker of epithelial cells
Various types of cutokeratins and epithelial membrane antigen.
Best marker for myoepitheial cells is
p63
BM stain
Reticulin stains, ultra structurally or with immune-histochemical reactions for laminin or type IV collagen.
Diseases of Breast → Classification
- Inflammatory
- Proliferative
- Neoplasia
Inflammatory
Acute mastitis
Chronic mastitis – lymphocytic lobulitis
Mammary duct ectasia (dilatation)
Fat necrosis – tissue death (various types) (Type 1)
Proliferative
Fibrocystic change
Radial Scar
Lymphocytic Lobulitis definition and histological
Chronic inflammation that presents like cancer → commonly seen in diabetics = hard mass.
Histologically: dese fibrosis and lymphocyte infiltration.
Mammary duct ectasia features
Bloody nipple discharge biopsy reveals inflammation and ectasia
Chronic granulomastitis description and treatment
Collection of epithelial histocytes Cause: 1. TB 2. Leprosie 3. Sarcoidosis 4. Syphilis 5. Idiopathic (common)
Conservative. By operating it triggers a flare
Fat necrosis description
Death of fat cells. Release fat and macrophage eat up = lipid containing. Calcification can occur.
This is similar to cancer as it has irregular density with calcification.
Proliferative:
Radial Scar
Radiologically: exaggerated form of sclerosis adenosis. Fibrosis of epithelial glands produces fibrosheaths (stellate shaped). This looks like a carcinoma as it has an irregular border.
Tubules with 2 cell layers meaning it is benign
Proliferative:
Tubular carcinoma
Biopsy radial scare looks very similar
Proliferative:
Protocol for radial s
carring
Remove all
Neoplastic: Types
Benign
Malignant
Neoplastic: Benign types
Benign
Malignant
Neoplastic: Benign types
Adenoma –epithelial differentiation
Fibroadenoma – mixed glands and neoplastic prolif of fibroelastic element
Papilloma – finger like structures
Malignant types
Carcinoma – epithelial differentiation
Sarcoma – mesenchymal origin
Pagets disease (nipple and vulva)
Phylloides tumour – mixed – prolif or epi + mesenchymal elements
Neoplastic:
Signs and symptoms:
Lump typed and associated underlying pathology
Nipple changes and associated underlying pathology
Breast Pain
Skin features
Micro-calcification
Lump typed and associated underlying pathology
Diffuse – fibrosis/ fibrocystic change Discrete – neoplasm/ cyst/abscess/ hamartoma (dev. malformation Mobile – Benign neoplasm Tethered – Carcinoma * See Pie chat pg 117
Nipple changes and associated underlying pathology
Discharge
• Milky – Pregnancy
• Bloody – duct papilloma/carcinoma
Retraction – invasive arcinoma (due to fibroelastic reaction)
Erythema – Pagets disease or eczema and scaling
Breast Pain
Cyclical – benign breast diseases
On palpation – inflammatory
Skin features
Oedema –peau d’orrange – carcinoma (lymph cells blocked lymph drainage)
Micro-calcification
DCIS or fat necrosis
Adenoma: Fibrocystic change
Different terminology
Common in 25-45 yrs age group
Pathogenesis – hormones
Adenoma: Fibrocystic changes microscopic picture
- TDLU
- Cysts formation
- Fibrosis – surrounding tissue from cyst rupture
- Apocrine metaplasia – epithelial cells modify themselves
- Calcification secretions
Fibroadenoma: Epi
Commonest benign breast tumour
B/W the ages of 20-35 yrs
Fibroadenoma: Morphology
Increases in size during pregnancy
Decrease in size with age
Fibroadenoma:
Composed of both proliferating ducts and connective tissue stroma.
Proliferation of mesenchymal and epithelial cells – no atipia or mitotic activity
Fibroadenoma: Rx
Surgery is not recommended
Phylloides tumour: Description
Phylloides is a Greek word means leaf-like
Phylloides tumour: Epi
Usually occurs in 4th and 5th decade of life.
Phylloides tumour: M/s
It is composed of epithelial and mesenchymal elements
Phylloides tumour: Epithelial cell spread
Takes lymphatic route
Phylloides tumour: Mesenchymal cells spread
Travel via blood and therefore in this don’t excise the lymph nodes therefore this is the malignancy element.
Phylloides tumour: Presentation
It can be benign borderline and malignant
Phylloides tumour: Benign
Circumscribed
Low mitotic activity
Phylloides tumour:
Malignancy
It is the mesenchymal component which is malignant and produce metastasis through haematogenous route.
Phylloides tumour:
Malignant
Irregular margins
High mitotic count
Stromal overgrowth
Phylloides tumour:
Treatment
Wide local excision
Recurrence is common
Carcinoma:Epi
- 20% of all cancers in women
- In the UK 1 in 8 women develop breast cancer
- Commonest cause of death in women in 35-55 yrs age group.
Carcinoma: Risk Factors
• Female sex and age • Reproductive history (increased estrogen exposure) →Early menarche → Late menopause → Nulliparous women → 1st pregnancy after 30 yrs of age • Obesity • Family history in 1st degree relative →1.5-2x if 1 relative
- Geography
- Atypical hyperplasia (increased risk of breast cancer)
Carcinoma: Aetiological mechanisms
• Hormonal Factors • Genetic factors → BRCA 1, ch 17, ovary and breast → BRCA 2, ch 13 • Environmental influences
Carcinoma: Classification
Carcinoma of breast are broadly classified on the basis of two criteria
• Invasion of BM
• Morphology
Carcinoma: Invasion of BM
In-situ
Invasive
Carcinoma:Morphology
Ductal
Lobular
Carcinoma: Insitu Carcinoma
Ductal Carcinoma in situ
Lobular Carcinoma in situ
Carcinoma: Invasive Carcinoma
Invasive ductal carcinoma NST (75-85%)
Invasive lobular carcinoma (10%)
Others (5%)
Carcinoma: DCIS
High grade – invasive disease
Carcinoma: Ductal vs. lobular
Behave differentially
DCIS – develops invasively im
LCIS – can develop into invasive disease (can develop in another breast or other quadrant.
LCIS histology
Lobule w/ epithelial proliferation – myoepithelium containing the cells in accini.
Treatment
Surgery – DCIS, invasive carcinoma
Chemotherapy – reduce in size and clearer margins
Radiotherapy – Conservative
Hormonal treatment – tamoxifen or element X inhib. (post menopause)/ |Herceptin
Prognosis
Size of tumour Grade of the tumour Histological type of tumour Vascular invasion Stage of the tumour – nodal status Receptor status of the tumour
Pagets disease of the nipple: Associated with
Underlying (2%) ductal carcinomas
Pagets disease of the nipple: M/s
There is involvement of epidermis by malignant ductal carcinoma cells.
Pagets disease of the nipple: Clinically there is
Roughing
Reddening and slight ulceration of skin
Pagets disease of the nipple: Histologically
Stratified Squamous – proliferation of neoplastic cells in epidermis
What is the marker for breast cancer →
Micro-calcification
Where do we see this micro-calcification histologically?
It is usually associated with DCIS mostly high grade with central necrosis.
It is always malignant?
No, micro-calcification can be associated with benign fibrocystic change.
Do all breast cancers have micro-calcification?
No
What other mammographic appearances can one have with breast cancers?
Stellate lesion
Circumscribed soft tissue density/mass lesion
Are these appearances specific for breast cancer?
No
What other lesions can mimic breast cancer radio logically?
Micro-calficification
Stellate lesion
Circumscribed soft tissue density
Micro-calcification
Fibrocystic change
Fat necrosis
Calcified eggs of parasites (nearly)
Stellate Lesion
Radial scar
Circumcised soft tissue density
Fibroadenoma and Phylloides tumour
What is Triple Approach?
All breast cases are discussed in a multidisciplinary meeting every week.
Breast Clinicians, Radiologists and thus we use triple approach to triple approach to reach a final diagnosis and decide best management for the patient
