Pathology - Breast

Question 1

what three elements are involved in assessing a patient with breast disease?

Answer 1

clinical exam
imaging
pathology

Question 2

what imaging can be done for breast disease?

Answer 2

mammography
USS
MRI

Question 3

what two types of pathology can be done for breast disease?

Answer 3

cytopathology - cells, rarely done

histopathology - tissue, main component

Question 4

what samples can be used for breast cytopathology?

Answer 4

FNA sample
fluids
nipple discharge
nipple scrape

Question 5

what are the possible results for breast cytopathology?

Answer 5

C1 = unsatisfactory 
C2 = benign 
C3 = atypia, probably benign 
C4 = suspicious of malignancy 
C5 = malignant

Question 6

what are the two components of breast histopathology?

Answer 6

diagnostic

therapeutic

Question 7

what are the options for diagnostic breast histopathology?

Answer 7

needle core biopsy
vacuum assisted/large volume biopsy
skin biopsy
incisional biopsy of mass

Question 8

what are the options for therapeutic breast histopathology?

Answer 8

vacuum assisted excision
excisional biopsy of mass
resection of cancer

Question 9

what are the possible results for a needle core biopsy?

Answer 9

B1 = unsatisfactory 
B2 = benign 
B3 = atypia, probably benign 
B4 = suspicious of malignancy 
B5 = malignant

Question 10

what do B5a and B5b mean as results in needle core biopsy?

Answer 10

B5a = carcinoma in situ 
B5b = invasive carcinoma

Question 11

what is gynaecomastia?

Answer 11

breast development in males

Question 12

what growth occurs in gynaecomastia?

Answer 12

ductal growth without lobular development

Question 13

name some causes of gynaecomastia

Answer 13

hormones
cannabis use
prescribed drugs
liver disease

Question 14

who is most commonly affected by fibrocystic change?

Answer 14

women aged 20-50

most are 40-50

Question 15

what menstrual abnormalities can be associated with fibrocystic changes?

Answer 15

early menarche

late menopause

Question 16

when can fibrocystic changes resolve themselves?

Answer 16

often after the menopause

Question 17

how do fibrocystic changes present?

Answer 17

smooth discrete lumps
sudden or cyclical pain
lumpiness

often incidental finding or found at screening

Question 18

what is the gross pathology of fibrocystic changes?

Answer 18

cysts with intervening fibrosis

cysts are blue domed with pale fluid and are usually multiple

Question 19

what lines the cysts seen in fibrocystic changes?

Answer 19

apocrine epithelium

Question 20

how are fibrocystic changes managed?

Answer 20

exclude malignancy
reassure the patient
excise if needed

Question 21

what is a hamartoma?

Answer 21

circumscribed lesion composed of cells types normal to the breast but in an abnormal proportion/distribution

Question 22

which group of women are more commonly affected by fibroadenoma?

Answer 22

african ethnicity

peak incidence in 20’s

Question 23

how do fibroadenomas present?

Answer 23

painless, firm, discrete and mobile masses

Question 24

how are fibroadenomas diagnosed?

Answer 24

often found on screening

solid on USS

Question 25

what are the two types of sclerosing lesions?

Answer 25

sclerosing adenosis complex sclerosing lesions

Question 26

what is another name for a complex sclerosing lesion?

Answer 26

radial scar

Question 27

what are sclerosing lesions?

Answer 27

benign, disorderly proliferations of acini and stroma

Question 28

how does sclerosing adenosis present?

Answer 28

pain tenderness lumpiness can be asymptomatic

Question 29

what is the risk of subsequent carcinoma with sclerosing adenosis?

Answer 29

negligible - these are benign lesions

Question 30

what is the difference between a radial scar and complex sclerosing lesions?

Answer 30

``` RS = 1-9mm CSL = >10mm ```

Question 31

what do radial scars mimic radiologically?

Answer 31

carcinoma

Question 32

what can occur within a radial scar?

Answer 32

in situ or invasive carcinoma

Question 33

how is a radial scar managed?

Answer 33

excise or sample extensively via vacuum biopsy

Question 34

what causes fat necrosis?

Answer 34

local trauma | warfarin therapy

Question 35

what is the pathophysiology of fat necrosis?

Answer 35

damage to adipocytes causes fat leakage = acute inflammatory response this causes subsequent fibrosis and scarring

Question 36

what ducts are affected by duct ectasia?

Answer 36

sub areolar ducts

Question 37

how does duct ectasia present?

Answer 37

pain bloody and/or purulent discharge fistulation nipple retraction and distortion

Question 38

what is a key risk factor for duct ectasia?

Answer 38

smoking

Question 39

how is duct ectasia managed?

Answer 39

treat any infections exclude malignancy stop smoking excise involved ducts

Question 40

what are the two main causes of acute mastitis?

Answer 40

duct ectasia | lactation

Question 41

what organisms are associated with mastitis due to duct ectasia?

Answer 41

mixed organisms | anaerobes

Question 42

what organisms are associated with mastitis due to lactation?

Answer 42

staph aureus | strep pyogenes

Question 43

what age group are most commonly affected by phyllodes tumour?

Answer 43

40-50

Question 44

describe the presentation of phyllodes tumour

Answer 44

a slow growing unilateral breast mass

Question 45

what is another name for phyllodes tumour?

Answer 45

cystosarcoma phyllodes

Question 46

what pathological feature dominates in phyllodes tumour?

Answer 46

stromal overgrowth determines the behaviour of the tumour (benign, borderline or malignant)

Question 47

what is a possible complication of phyllodes tumour?

Answer 47

local recurrence if not adequately excised rarely metastasise

Question 48

what age group are most commonly affected by intraduct papilloma?

Answer 48

35-60

Question 49

how does intraduct papilloma present?

Answer 49

nipple discharge +/- blood asymptomatic at screening

Question 50

what ducts are affected by intraduct papilloma?

Answer 50

sub-areolar ducts

Question 51

what proliferative activity can the epithelium show in intraduct papilloma?

Answer 51

none usual type hyperplasia atypical ductal hyperplasia ductal carcinoma in situ

Question 52

what is breast carcinoma?

Answer 52

a malignant tumour of breast epithelial cells

Question 53

where does breast carcinoma arise?

Answer 53

glandular epithelium of the terminal duct lobular unit (TDLU)

Question 54

what type of cancer is breast carcinoma?

Answer 54

adenocarcinoma

Question 55

what are the two classes of precursor lesions for breast carcinoma?

Answer 55

ductal | lobular

Question 56

what are the ductal precursors of breast carcinoma?

Answer 56

epithelial hyperplasia columnar cell change atypical duct hyperplasia (ADH) ductal carcinoma in situ (DCIS)

Question 57

what are the lobular precursor lesions for breast carcinoma?

Answer 57

atypical lobular hyperplasia (ALH) | lobular carcinoma in situ (LCIS)

Question 58

what is an in situ breast carcinoma?

Answer 58

one that is confined within the basement membrane of the acini and ducts cytologically malignant but non-invasive

Question 59

how is atypical lobular hyperplasia (ALH) defined?

Answer 59

less than 50% of the lobule is involved

Question 60

how is lobular carcinoma in situ (LCIS) defined?

Answer 60

>50% of the lobule is involved

Question 61

when does incidence of LCIS decrease?

Answer 61

after the menopause

Question 62

how can LCIS be found?

Answer 62

not palpable/visible grossly, can be seen on mammography usually an incidental finding

Question 63

how is LCIS managed if found on a core biopsy?

Answer 63

proceed to excision/vacuum biopsy

Question 64

what is there a risk of with DCIS?

Answer 64

progression to an invasive carcinoma

Question 65

where does DCIS arise?

Answer 65

the TDLU

Question 66

how many duct systems are involved in DCIS?

Answer 66

a single duct system - termed unicentric may also involve lobules and nipple skin

Question 67

what is it called when DCIS involves nipple skin?

Answer 67

paget's disease of the nipple

Question 68

what is the classification of DCIS based on?

Answer 68

grade histology presence of necrosis

Question 69

what are the management options for DCIS?

Answer 69

surgery adjuvant radiotherapy chemoprevention or endocrine therapy

Question 70

what is paget's disease of the nipple?

Answer 70

high grade DCIS extending along ducts to reach the epidermis of the nipple still a non invasive disease

Question 71

what is microinvasive carcinoma of the breast?

Answer 71

DCIS with invasion of <1mm

Question 72

what three things are considered and assigned a score of 1-3 when defining the grade of breast cancer?

Answer 72

tubular differentiation nuclear pleomorphism mitotic activity

Question 73

what grade is a breast cancer with a score of 3-5?

Answer 73

grade 1

Question 74

what grade is a breast cancer with a score of 6-7?

Answer 74

grade 2

Question 75

what grade is a breast cancer with a score of 8-9?

Answer 75

grade 3

Question 76

what are the three hormone receptors that a breast cancer can express?

Answer 76

``` oestrogen receptor (ER) progesterone receptor (PR) HER2 ```

Question 77

what specific therapies can ER+ breast cancers respond to?

Answer 77

anti-oestrogen therapies

Question 78

name four possible anti-oestrogens therapies

Answer 78

oophorectomy tamoxifen aromatase inhibitors GnRH antagonists

Question 79

name an aromatase inhibitor

Answer 79

letrozole

Question 80

name a GnRH antagonist

Answer 80

goserilin aka zoladex

Question 81

what drug can HER2+ breast cancers respond to?

Answer 81

trastuzamab aka Herceptin

Question 82

how is breast cancer staged?

Answer 82

TNM staging

Question 83

name a prognostic index that can be used for breast cancer

Answer 83

nottingham prognostic index