Pathology - Breast Flashcards
what three elements are involved in assessing a patient with breast disease?
clinical exam
imaging
pathology
what imaging can be done for breast disease?
mammography
USS
MRI
what two types of pathology can be done for breast disease?
cytopathology - cells, rarely done
histopathology - tissue, main component
what samples can be used for breast cytopathology?
FNA sample
fluids
nipple discharge
nipple scrape
what are the possible results for breast cytopathology?
C1 = unsatisfactory C2 = benign C3 = atypia, probably benign C4 = suspicious of malignancy C5 = malignant
what are the two components of breast histopathology?
diagnostic
therapeutic
what are the options for diagnostic breast histopathology?
needle core biopsy
vacuum assisted/large volume biopsy
skin biopsy
incisional biopsy of mass
what are the options for therapeutic breast histopathology?
vacuum assisted excision
excisional biopsy of mass
resection of cancer
what are the possible results for a needle core biopsy?
B1 = unsatisfactory B2 = benign B3 = atypia, probably benign B4 = suspicious of malignancy B5 = malignant
what do B5a and B5b mean as results in needle core biopsy?
B5a = carcinoma in situ B5b = invasive carcinoma
what is gynaecomastia?
breast development in males
what growth occurs in gynaecomastia?
ductal growth without lobular development
name some causes of gynaecomastia
hormones
cannabis use
prescribed drugs
liver disease
who is most commonly affected by fibrocystic change?
women aged 20-50
most are 40-50
what menstrual abnormalities can be associated with fibrocystic changes?
early menarche
late menopause
when can fibrocystic changes resolve themselves?
often after the menopause
how do fibrocystic changes present?
smooth discrete lumps
sudden or cyclical pain
lumpiness
often incidental finding or found at screening
what is the gross pathology of fibrocystic changes?
cysts with intervening fibrosis
cysts are blue domed with pale fluid and are usually multiple
what lines the cysts seen in fibrocystic changes?
apocrine epithelium
how are fibrocystic changes managed?
exclude malignancy
reassure the patient
excise if needed
what is a hamartoma?
circumscribed lesion composed of cells types normal to the breast but in an abnormal proportion/distribution
which group of women are more commonly affected by fibroadenoma?
african ethnicity
peak incidence in 20’s
how do fibroadenomas present?
painless, firm, discrete and mobile masses
how are fibroadenomas diagnosed?
often found on screening
solid on USS
what are the two types of sclerosing lesions?
sclerosing adenosis
complex sclerosing lesions
what is another name for a complex sclerosing lesion?
radial scar
what are sclerosing lesions?
benign, disorderly proliferations of acini and stroma
how does sclerosing adenosis present?
pain
tenderness
lumpiness
can be asymptomatic
what is the risk of subsequent carcinoma with sclerosing adenosis?
negligible - these are benign lesions
what is the difference between a radial scar and complex sclerosing lesions?
RS = 1-9mm CSL = >10mm
what do radial scars mimic radiologically?
carcinoma
what can occur within a radial scar?
in situ or invasive carcinoma
how is a radial scar managed?
excise or sample extensively via vacuum biopsy
what causes fat necrosis?
local trauma
warfarin therapy
what is the pathophysiology of fat necrosis?
damage to adipocytes causes fat leakage = acute inflammatory response
this causes subsequent fibrosis and scarring
what ducts are affected by duct ectasia?
sub areolar ducts
how does duct ectasia present?
pain
bloody and/or purulent discharge
fistulation
nipple retraction and distortion
what is a key risk factor for duct ectasia?
smoking
how is duct ectasia managed?
treat any infections
exclude malignancy
stop smoking
excise involved ducts
what are the two main causes of acute mastitis?
duct ectasia
lactation
what organisms are associated with mastitis due to duct ectasia?
mixed organisms
anaerobes
what organisms are associated with mastitis due to lactation?
staph aureus
strep pyogenes
what age group are most commonly affected by phyllodes tumour?
40-50
describe the presentation of phyllodes tumour
a slow growing unilateral breast mass
what is another name for phyllodes tumour?
cystosarcoma phyllodes
what pathological feature dominates in phyllodes tumour?
stromal overgrowth
determines the behaviour of the tumour (benign, borderline or malignant)
what is a possible complication of phyllodes tumour?
local recurrence if not adequately excised
rarely metastasise
what age group are most commonly affected by intraduct papilloma?
35-60
how does intraduct papilloma present?
nipple discharge +/- blood
asymptomatic at screening
what ducts are affected by intraduct papilloma?
sub-areolar ducts
what proliferative activity can the epithelium show in intraduct papilloma?
none
usual type hyperplasia
atypical ductal hyperplasia
ductal carcinoma in situ
what is breast carcinoma?
a malignant tumour of breast epithelial cells
where does breast carcinoma arise?
glandular epithelium of the terminal duct lobular unit (TDLU)
what type of cancer is breast carcinoma?
adenocarcinoma
what are the two classes of precursor lesions for breast carcinoma?
ductal
lobular
what are the ductal precursors of breast carcinoma?
epithelial hyperplasia
columnar cell change
atypical duct hyperplasia (ADH)
ductal carcinoma in situ (DCIS)
what are the lobular precursor lesions for breast carcinoma?
atypical lobular hyperplasia (ALH)
lobular carcinoma in situ (LCIS)
what is an in situ breast carcinoma?
one that is confined within the basement membrane of the acini and ducts
cytologically malignant but non-invasive
how is atypical lobular hyperplasia (ALH) defined?
less than 50% of the lobule is involved
how is lobular carcinoma in situ (LCIS) defined?
> 50% of the lobule is involved
when does incidence of LCIS decrease?
after the menopause
how can LCIS be found?
not palpable/visible grossly, can be seen on mammography
usually an incidental finding
how is LCIS managed if found on a core biopsy?
proceed to excision/vacuum biopsy
what is there a risk of with DCIS?
progression to an invasive carcinoma
where does DCIS arise?
the TDLU
how many duct systems are involved in DCIS?
a single duct system - termed unicentric
may also involve lobules and nipple skin
what is it called when DCIS involves nipple skin?
paget’s disease of the nipple
what is the classification of DCIS based on?
grade
histology
presence of necrosis
what are the management options for DCIS?
surgery
adjuvant radiotherapy
chemoprevention or endocrine therapy
what is paget’s disease of the nipple?
high grade DCIS extending along ducts to reach the epidermis of the nipple
still a non invasive disease
what is microinvasive carcinoma of the breast?
DCIS with invasion of <1mm
what three things are considered and assigned a score of 1-3 when defining the grade of breast cancer?
tubular differentiation
nuclear pleomorphism
mitotic activity
what grade is a breast cancer with a score of 3-5?
grade 1
what grade is a breast cancer with a score of 6-7?
grade 2
what grade is a breast cancer with a score of 8-9?
grade 3
what are the three hormone receptors that a breast cancer can express?
oestrogen receptor (ER) progesterone receptor (PR) HER2
what specific therapies can ER+ breast cancers respond to?
anti-oestrogen therapies
name four possible anti-oestrogens therapies
oophorectomy
tamoxifen
aromatase inhibitors
GnRH antagonists
name an aromatase inhibitor
letrozole
name a GnRH antagonist
goserilin
aka zoladex
what drug can HER2+ breast cancers respond to?
trastuzamab aka Herceptin
how is breast cancer staged?
TNM staging
name a prognostic index that can be used for breast cancer
nottingham prognostic index
