L33 - PATHOLOGY OF BREAST CANCER Flashcards
List typical clinical presentations of breast cancer? (6)
1) lump or thickening in breast
2) change in size or shape of a breast
3) nipple retraction
4) bloody nipple discharge
5) A rash on a nipple or surrounding area
6) Dimpling of the skin, skin appears inflamed
Pathogenesis of Paget’s disease of the breast?
Underlying intraductal or invasive carcinoma
> > Invasion of epidermis by Paget’s cells
> > erosion of the nipple and areola
Morphology of Paget’s cells?
large, round to oval, clear cytoplasm (clear halo) and eccentric, hyperchromic nuclei
contain mucin.
Clinical presentation of Paget’s disease?
Nipple and areola: red and weeping, occasionally dry, scaly and psoriatic
What causes puckering of skin with red, warm, peau d’orange appearance on breasts?
Inflammatory breast cancer
> > blockage of lymph vessels in the skin by cancer cells
List 2 non-invasive breast carcinoma
- Ductal carcinoma-in-situ (DCIS): High grade comedo or Non-comedo Low grade
- Lobular carcinoma in-situ (LCIS)
List Invasive breast carcinoma.
- Invasive carcinoma of no special type (NST)
- Special subtypes :
- Invasive lobular carcinoma
- Tubular carcinoma
- Mucinous carcinoma
Define the anatomical location of Ductal Carcinoma-in-situ of breasts? Ddx location with LCIS?
confined within the ductal basement membranes
50% are centrally situated, palpable mass
LCIS = Medial + Lateral Upper quadrants
Compare the effectiveness of mammography in finding DCIS and LCIS?
DCIS = detectable due to microcalcification and confined involvement
LCIS = easily missed due to no calcification and multicentric involvement
Compare the prognosis of high grade and low grade DCIS of breast? How to ddx the two?
High = large pleomorphic cells and central comedo necrosis
High grade = 50% evolve into invasive carcinoma within 5 years
Non-comedo low grade = 30% will develop invasive carcinoma within the next 10-15 years.
Describe the extent of involvement of Lobular carcinoma-in-situ?
Multicentric, sometimes bilateral
concentrated within 5 cm of the nipple
@ OUTER + INNER UPPER QUADRANT
Prognosis and progression of Lobular carcinoma in situ of the breast?
10 times higher risk of invasive carcinoma: can be ductal or lobular
What is the most common type of breast carcinoma?
INVASIVE BREAST CARCINOMA OF NO SPECIAL TYPE (NST):
70% of invasive breast cancers
Gross morphology and clinical presentation of Invasive breast carcinoma of no special type (NST)?
FEELS LIKE CRAB!!!!!!!
poorly defined, hard, yellow-grey mass with radiating fibrous trabeculae
Touch = gritty feel and chalky streaks
Pathohistology of Invasive lobular carcinoma of breast?
SINGLE CELL INFILTRATION
in single file (INDIAN FILING)
or
arranged as concentric rings around a duct (TARGET-LIKE LESION) of small to medium-sized tumour cells
Extent of involvement of Invasive lobular carcinoma of breast?
multifocal and bilateral
poorly circumscribed mass
DCIS = Central LCIS = Medial + Upper lateral quadrant
Histological feature of Tubular carcinoma of breast? Prognosis?
open tubules lined by single layer of cells
excellent prognosis in the pure form
Distant metatastasis are unlikely
Histological feature of Mucinous carcinoma of breast?
islands of tumour cells floating in large lakes of mucin
Clinical presentation of mucinous carcinoma of breast? Prognosis?
slow growing** circumscribed mass
bulky, soft**, gelatinous material
excellent prognosis in the pure form
2 main modes of breast cancer spread?
Lymphatic and Haematogenous
Define the 2 paths of breast cancer spread along lymph nodes.
Lateral tumours»_space; Level I to III Axillary nodes (at outer, upper quadrant)»_space; Supraclavicular LN
Medial and deep carcinoma»_space; Internal mammary chain (medial quadrant)
Which organs are most susceptible to breast cancer spread? Triple negative tumours?
Haematogenous spread:
- Bone most common
- Lung
- Liver
- Ovary and adrenals
- Brain
VISCERAL METASTASIS is common for TRIPLE NEGATIVE tumours: negative for estrogen receptors, progesterone receptors, and excess HER2 protein
Define Sentinel lymph nodes and it’s clinical implications in breast CA?
first lymph node(s) to which cancer cells are most likely to spread from a primary tumor
Negative finding:
- breast CA not able to spread to nearby LN or organ
- Indication for LN removal as prevention
List 7 prognostic factors for breast carcinoma?
- Size
- Histological type and grade
- Presence of DCIS
- Margins of excision
- Lymph node status
- Vascular invasion
- Hormone receptor and HER2 status
List types of breast cancer with excellent prognosis?
Mucinous carcinoma
Tubular carcinoma
List types of breast cancer with poor prognosis?
Invasive carcinoma of no special type (NST)
Pleomorphic invasive lobular carcinoma
High grade comedo DCIS
LCIS
Define the criteria for histological grading of invasive carcinoma?
assessed on
– tubule formation
– nuclear grade
– mitotic rate
Grade I > 80% survival in 16 years
Grade II < 60% survival in 16 years
Grade III < 50% survival in 16 years
Classification of DCIS?
Assess:
- Margin, size, pathological subtype
Classify into Low, intermediate and High nuclear grade DCIS
How is prognosis of breast CA linked to lymph nodes?
Prognosis related to the overall number of nodes involved and the level of nodal involvement
Which genetic marker indicates use of Herceptin and Doxorubicin-based chemotherapy in breast CA?
HER2 Oncogene expression
2 lab dx tests to confirm HER2 status?
Immunohistochemical assay
Fluorescent in-situ hybridization (FISH)
Define the size of breast cancer for in each TNM stage?
pTis = DCIS (including Paget’s disease)
pT1:
pT1a < or = 5 mm
pT1b 5 - 10 mm
pT1c 10 - 20 mm
pT2 = tumour 20 - 50 mm
pT3 = tumour > 50 mm
pT4 = tumour with direct extension to skin or chest wall
List different approaches to classify tumours.
- Traditional pathologic prognostic and predictive features
- Clinical outcome (prognostic)
- Response to therapy (predictive)
- Gene expression profiling
Define the major breast cancer subtypes based on gene profiling?
Classify by traditional immunomarkers ER, PR and HER2
- Luminal A/B
- HER2
- Basal-like
Compare the treatment options indicated by Luminal, HER2 and Basal-like breast CA?
Luminal = Endocrine treatment
HER 2 = Herceptin, Anthracycline based chemo
Basal- like = Platinum, PARP inhibitors
Which major breast cancer subtypes based on gene profiling accounts for the most breast cancers?
Luminal = 70%
HER2 and Basal-like = 15% each
