Pathology Flashcards
What are the 2 main imaging modalities used to diagnose breast pathologies?
1) Mammogram
2) Ultrasound
What are the 2 main biopsy techniques used for laboratory testing of suspected breast cancers?
1) Fine needle aspiration biopsy
2) 14 gauge needle core biopsy
On a xray, a premenopausal breast appears (more/less) radiodense than a post-menopausal breast.
More
Why are inflammatory conditions of the breast most common in lactating women?
More milk
→ proliferation of Staphylococci in stagnant milk
→ Acute inflammation w neutrophils
→ Acute abscess formation
(Acute mastitis)
What are 4 examples of inflammatory conditions affecting the breast?
1) Acute mastitis
2) Periductal mastitis
3) Idiopathic granulomatous mastitis
4) Duct ectasia
5) Fat necrosis (usually trauma caused)
6) Inflammatory breast cancer
What are 3 Rx for a breast abscess?
1) Antibiotics
2) Excision
3) Incision and drainage
What is idiopathic granulomatous mastitis?
Rare inflammatory condition in parous women
- unknown etiology (might be HS rxn)
What are 2 Ddx of idiopathic granulomatous mastitis?
1) Malignancy
2) TB
What are 3 Rx for idiopathic granulomatous mastitis?
1) Steroids
2) Immunosuppressives
3) Surgery
What is a possible complication of breast augmentation such as paraffin injections, implants or autologous tissue?
Paraffinoma
- foreign-body type multinucleate giant cell reaction
What is an example of a common non-proliferative breast lesion?
Fibrocystic changes
Fibrocystic breast changes EPC:
Symptomatic in only _____% of women
Occurs during ______ age
Fibrocystic breast changes EPC:
Symptomatic in only 10% of women
Occurs during reproductive age
How does a breast with fibrocystic change present?
Surgeon: Lumpy bumpy breast on palpation
Radiologist: Dense breast with cysts
Characteristic microscopic findings:
1) Fibrosis
2) Cysts
3) Apocrine metaplasia
4) Epithelial hyperplasia
What is the main determinant of malignancy risk for a breast with fibrocystic change?
Degree of epithelial hyperplasia
(also look at:
i) proliferative/non-proliferative
ii) atypia
iii) Carcinoma in Situ)
What are the characteristic histological findings of fibrocystic changes in the breast?
1) Fibrosis
2) Cysts
3) Apocrine metaplasia
4) Epithelial hyperplasia
What are 2 epithelial tumours of the breast?
1) Papilloma
2) Carcinoma
What an example of a myoepithelial tumours of the breast?
Adenomyoepithelioma
What is an example of a mesenchymal tumour of the breast?
Lipoma
What are 2 examples of fibroepithelial tumours of the breast?
1) Fibroadenoma
2) Phyllodes
What is an example of a tumour of the nipple?
Paget’s
What are 2 examples of tumours in the male breast?
1) Gynaecomastia
2) Carcinoma
What are 3 examples of benign epithelial tumours of the breast?
1) Intraduct papilloma
2) Fibroadenoma
3) Phyllodes tumour
4) Nipple adenoma
Fibroadenoma EPC:
- (Common/Rare) benign lesion
- Highest prevalence in (young/old) women
- Peak prevalence around ____y
Fibroadenoma EPC:
- Common benign lesion
- Highest prevalence in young women
- Peak prevalence around 25y
What are the gross features of a breast fibroadenoma?
1) Firm, well-defined mobile lump
2) 1-6cm
3) May be multiple or bilateral
4) Can recur or regress spontaneously
What is the histological feature of a breast fibroadenoma?
Proliferation of glandular and stromal elements
What are 3 differences between a fibroadenoma and a phyllodes tumour?
1) Phyllodes have frond/leaf like architecture
2) Phyllodes can be malignant; fibroadenoma only benign
3) Phyllodes usually bigger and stromal proliferation is more common
What is the most common non-skin malignancy in women?
Breast carcinoma
What are 5 risk factors for developing breast cancer?
1) Caucasian/Jew/Parsi race
2) Perimenopausal age
3) High SES
4) Obesity
5) Previous breast disease
6) Family Hx
7) Early menarche/late menopause
What are 4 clinical/EPC characteristics of familial breast cancer?
1) Usually have several affected family members
2) Early onset
3) Bilateral breast cancers
4) Both breast and ovarian cancers
5) Germline mutations (eg. BRCA1/2, p53, PTEN)
How do breast cancers present on physical exam?
1) Palpable mass
2) Nipple discharge
3) Mammographic density
4) Mammographic calcification
What are 2 examples of non-invasive/in-situ carcinomas of the breast?
1) Ductal carcinoma in-situ
2) Lobular carcinoma in-situ
What are 3 examples of invasive carcinomas of the breast?
1) NST (no special type)
2) Special type (eg. mucinous, tubular, medullary, micropapillary, metaplastic, etc.)
3) Lobular carcinoma
What are 5 examples of malignant epithelial tumours of the breast?
Non-invasive:
1) Ductal carcinoma in-situ
2) Lobular carcinoma in-situ
Invasive:
3) NST (no special type)
4) Special type (eg. mucinous, tubular, medullary, micropapillary, metaplastic, etc.)
5) Lobular carcinoma
Others:
6) Paget’s
What are the common gross appearances of breast carcinoma?
Sites:
Upper outer > Subareolar > others
Growth pattern:
- comedo, circumscribes, infiltrating
Consistency:
- scirrhous, encephaloid, mucinous
Paget’s (nipple)
How are ductal and lobular carcinoma in-situ differentiated?
1) Location:
D: ducts
L: lobules
2) Cell size
D: M to L
L: S
3) Pattern
D: comedo, cribiform, micropapillary, papillary, solid
L: solid
4) Calcifications
D: present/absent
L: usually absent
5) Risk of subsequent invasive cancer
D: higher
L: lower
6) Location of metastasis
D: Ipsilateral
L: Ipsi/Contralateral
What is the distinctive feature of lobular carcinoma?
1) Loss of cellular adhesion
2) Characteristic arranged in discohesive or single file pattern
3) E-cadherin mutation
What is Paget’s disease?
Proliferation of malignant glandular epithelial cells (in-situ carcinoma) in nipple areolar epidermis
What are 5 prognostic factors of breast cancer?
1) Staging (TNM)
2) Grading (1-3)
3) Histological type (eg. NST, Special type, lobular)
4) ER/PR
- if +ve can use:
i) Tamoxifen → block tumours use of circulating estrogen
ii) Aromatase inhibitors → ↓estrogen in body
5) CerbB2/HER2
- can use Herceptin
6) Vascular invasion
When is breast screening for breast cancer recommended?
40-49y → 1 per year
>50y → once every 2 years
What are 3 determinants of breast cancer grading?
1) Tubule formation
2) Nuclear pleomorphism
3) Mitotic count
How is the staging of breast carcinomas done?
T:
<1cm → T1
2-5cm → T2
>5cm → T3
N:
no palpable → N0
ipsilateral axillary movable → N1
ipsilateral axillary movable → N2
ipsilateral internal mammary → N3
M:
M0 or M1
What are the typical molecular subtypes of breast carcinoma?
1) ER/PR
2) HER2
3) Proliferation gene (Ki67)
What are 5 causes of gynaecomastia?
Pubertal cause:
1) Hormonal imbalance (estrogen»_space; androgen)
Other:
2) Testicular atrophy (Klinefelter)
3) Cirrhosis
4) Estrogen secreting tumours of testes/adrenal gland
5) ↑Prolactin level
6) Drugs (eg. digoxin, anabolic steroids, etc.)
Carcinoma:
7) Any type (NST, special, lobular
BPH EPC:
(M/F)
Age:______
Men >50y
What is the definition of benign prostate hyperplasia?
Nodular hyperplasia of prostatic stromal and epithelial cells
What is the pathophysiology/pathogenesis of BPH?
1) Type 2 5α-reductase in the stromal cells convert testosterone into DHT
2) DHT bind to androgen receptors in epithelial and stromal cells → induce production of growth factors
3) ↑growth factors → ↑proliferation of stromal cells + ↓death of epithelial cells
Which part of the prostate does BPH occur?
Transitional zone
Why does BPH lead to urinary obstruction?
1) Enlarged prostate gland compress on prostatic urethra
2) ↑Prostatic smooth muscle tone (mediated via α1-adrenergic receptors)
What are 2 common clinical presentations of BPH?
Lower urinary tract symptoms:
1) Filling/storage problems
- frequency, urgency, nocturia
2) Voiding/obstructive symptoms
- hesitancy, terminal dribbling, incomplete voiding, urinary retention, overflow incontinence
How does BPH present on PE?
Enlarged rectal examination
- usually symmetrical and smooth
What is the histological appearance of BPH on (i) low power (ii) high power?
Low power:
- proliferation of both glandular and stromal tissue in nodular configuration
High power:
- hyperplastic prostatic glands w intact basal cell layer
What are 4 complications of BPH?
1) Acute urinary obstruction
2) Chronic urinary obstruction
3) Recurrent UTIs
4) Urolithiasis
5) Bladder hypertrophy, diverticulum, distension
6) Hydronephrosis, hydroureter
7) CKD
What are 3 forms of treatment for BPH?
1) Non-pharmacological:
- ↓fluid intake (esp before bedtime)
- ↓alcohol and caffeine intake
2) Medical:
- 5α-reductase inhibitors
- α-blockers
3) Surgical
- transurethral resection of prostate
Prostatic cancer EPC:
Age:
Top 3 cancers in M in SG
Men >50y
True or false: More men die with prostate cancer than from it as it has a wide range of biological behaviors.
True.
- from indolent to widely metastatic, fatal tumours
What is the most common form and type of prostatic malignancy?
Adenocarcinoma
- acinar adenocarcinoma (95%)
- ductal adenocarcinoma less common
What are 5 presentations of prostatic cancer?
1) Asymptomatic
2) Urinary symptoms
3) Symptoms of metastasis (eg. back pain)
4) Constitutional symptoms
5) DRE (enlarged, hard prostate)
6) ↑PSA levels
True or false: Clinically significant high of PSA is indicative of prostate cancer.
False.
Does not correlate with presence/absence of prostatic cancer
- can be elevated in eg. prostatitis
How is prostate cancer staged and graded?
Staging
i) confined to prostate
ii) invasion beyond prostate (eg. extraprostatic extension, seminal vesicle, bladder)
Grading:
i) Based on architecture
ii) Gleason grading and scoring
What is the histological appearance of prostatic cancer?
Infiltrative/malignant glands/cells with nuclear atypia and absent basal cell layers
How is the Gleason score of prostatic cancer calculated?
Most predominant Gleason pattern + Most common Gleason pattern
What is a “grade group” of prostatic cancer?
Prognostic category based on Gleason score
What are 3 Rx for prostatic cancer?
1) Radical prostatectomy
- good for localised (low stage)
2) Radiotherapy
- good for localised or locally advanced (low stage)
3) Androgen deprivation therapy
- for advanced, metastatic disease
i) Medication (eg. synthetic analogues of LHRH, androgen receptor blockers)
ii) Surgical castration (orchidectomy)
What is condyloma acuminatum?
Sexually transmitted wart caused by HPV (commonly low risk types HPV-6, HPV-11) that occurs on external genitalia or perineal area
What is the gross appearance of condyloma acuminatum?
Pedunculated or sessile papillary tumours
- on external genitalia or perineal area
- on penis, most commonly (i) around coronal sulcus (ii) inner surface of prepuce
What is the histological appearance of condyloma acuminatum?
1) Papillary proliferation of thickened epidermis (acanthosis)
2) a/w Koilocytosis (squamous cells w enlarged irregular hyperchromatic nuclei w perinuclear haloes)
What genital pathology is caused by HPV 6 and 11?
HPV 6 and 11 → Low risk
→ Condyloma acuminatum
What genital pathology is caused by HPV 16 and 18?
Squamous cell carcinoma
What are 3 a/w of penile SCC?
1) HPV 16 or 18 infection
2) Poor genital hygiene
3) Smoking
(Circumcision in early life a/w lower risk)
Penile SCC is usually (fast/slow) growing and (locally/widely) invasive.
Slow growing, locally invasive
- so metastasis to inguinal/iliac lymph nodes → grim prognosis
Penile SCC may be preceded by a non-invasive precursor lesion known as ____________________.
Penile intraepithelial neoplasia (PeIN)
Both invasive penile SCC and PeIN can be classified into ________________ via ____________________.
HPV-associated and HPV-independent
- by p16 IHC
How does HPV act as a carcinogenic virus?
1) E6 oncogene:
- targets p53 → degradation → loss of tumour suppression
2) E7 oncogene:
- targets Rb → inactivation → uninhibited cell proliferation
What is the appearance of penile SCC?
Same as most other SCCs:
- nests of malignant squamous cells
- nuclear pleomorphisms and mitotic figures
- keratin pearls
Cryptorchidism:
Presentation:
Treatment:
Histology if untreated:
Cryptorchidism:
Presentation: empty scrotal sac
Treatment: orchidopexy (by 1y)
Histology if untreated: (i) arrest of germ cell development (ii) testicular atrophy
What are the 3 common sites of cryptorchidism?
1) High Scrotal (60%)
2) Inguinal canal (25%)
3) Abdominal (15%)
A hydrocoele is caused by the accumulation of serous fluid between the _________________ of the ___________________.
Visceral and parietal layers of tunica vaginalis
What are 3 causes of hydrocoele?
1) Primary/idiopathic
Secondary:
2) Patent processus vaginalis
3) Infections (eg. filariasis, epididymorchiditis)
4) Tumour
5) Iatrogenic (eg. disruption of lymphatics after hernia repair)
How does a hydrocoele present?
1) Painless
2) Enlarged testis/scrotum
3) Transilluminative scrotum
What are 4 complications of hydrocoele?
1) Rupture
2) Infection → pyocoele
3) Acute haemorrhage → haematocoele
4) Testicular atrophy (long-standing)
How is hydrocoele usually treated?
Most spontaneously resolve
- if need, treat underlying secondary cause
- SOME cases require surgical treatment
What is the clinical definition of testicular torsion?
Twisting of spermatic cord that cuts off venous drainage of testis
What is the typical presentation of testicular torsion?
Adolescent males presenting with sudden onset testicular pain
True or false: Testicular torsion is a medical emergency.
True.
Torsion <6 hours probably will not cause infarct
Torsion >24 hours will certainly cause an infarct
What are 4 risk factors for testicular torsion?
1) Larger testes
2) Cryptorchidism
3) Trauma/exercise
Congenital factors:
4) Bell-clapper abnormality (90%)
5) Horizontal lie of testes
6) Spermatic cord w long intrascrotal component
What is Bell-clapper abnormality?
Abnormally high insertion of the tunica vaginalis on spermatic cord
→ ↑mobility of testes
- usually bilateral and orchidopexy will be done during surgical correction to ↓risk of reccurence
What are the common causative organisms for UTIs in male children?
Gram neg rods
- a/w congenital genitourinary abnormalities
What are the common causative organisms for UTIs in male <35/sexually active young men?
STDs (eg. chlamydia, gonorrhoea)
What are the common causative organisms for UTIs in male >35?
Common UTI pathogens (eg E. coli, pseudomonas)
How does gonorrhoea usually spread to the testis?
Only in late stage
Urethra → prostate, seminal vesicles → epididymis → testes
Mumps usually affects ______________ and acute orchiditis usually follows __________________.
School-aged children
Acute orchiditis follows 1wk after onset of parotid gland swelling
Tuberculous orchiditis usually starts in the ____________ before spreading to the testes.
Epididymis
In syphilitic orchiditis, the testes are usually involved (before/after) the epididymis.
Before
- epididymis may be spared
What are 5 germ cell testicular tumours?
Seminomatous:
1) Seminoma
2) Spermatocytic seminoma
Non-seminomatous
3) Embryonal carcinoma
4) Yolk sac tumour
5) Choriocarcinoma
6) Teratoma
7) Neuroendocrine tumour
Testicular tumours are mostly ___________, less commonly _______ and least commonly _______________.
Germ cell (95%) > Sex cord stromal tumours > Lymphomas (in older px) > Epithelial tumours (very rare)