Pathology of Breast Disease Flashcards
What is contained in the normal structure of breasts?
- Epithelial: ducts and lobules (glandular)
- Mesenchymal: fat and fibrous tissue
- Hormone dependent
- Physiological changes with age and pregnancy
What is the basic structure of a breast?
- Made up of 8 to 10 lobes that are arranges like petals of a daisy
- Inside each lobe are smaller structures called lobules
- At the end of each lobule and tiny sacs (bulbs) that can produce milk
Where does branching of lobules start and what is it dependent on?
- Branching of the lobules starts from the nipple and it is hormonally responsive
What is the role of the lymph ducts of the breasts?
- Drain fluid that carries WBCs from the breast tissues to the lymph nodes in the axilla and behind the sternum
- [they filter harmful bacteria and play key role in fighting infection]
What are some benign breast conditions?
Fibrocystic change: fibrosis, adenosis, apocrine metaplasia
Fibroadenoma: circumsised mobile nodule of reproductive age
Intraduct papilloma: lactiferous ducts, nipple discharge
Fat necrosis: traumatic
Duct ectasia: nipple discharge
What are the features of fibroadenoma?
- Proliferation of epithelial and stromal elements
- MOST COMMON breast tumour in adolescent and young adult women
- Well circumscribed, freely mobile, non painful mass
- May regress with age
- Ducts distorted elongated slit-like structures intracanalicular pattern, ducts not compressed
pericanalicular growth pattern
Two other types of adenoma?
- Tubular adenoma: far less common, discrete freely moveable mass, young women
- Lactating adenoma: enlarging masses during lactation/pregnancy
Features of intraduct papilloma?
- Usually middle aged women
- Nipple discharge
- [can show epithelial hyperplasia, which may be atypical]
What effect can fat necrosis have on breast tissue? And its features?
- Can simulate carcinoma clinically and
mammographically
- History of antecedent trauma, prior surgical
intervention
- Histiocytes with foamy cytoplasm
- Lipid–filled cysts
Epidemiology of breast carcinoma
- Affects 1 in 8 females
- 1 in 870 males
- Commonest cause of female cancer death (1/3
of affected women will die from disease)
What can be seen on mammogram for breast carcinoma?
- Soft tissue opacity
- Microcalcification
What can be seen macroscopically of breast cancer?
- Hard lump, fixed mass, tethering to skin, peau d’orange dimpling of skin
RF for breast carcinoma?
- Gender
- Age
- Menstrual history
- Age at first pregnancy
- Radiation
- Family history
- Personal history
- Hormonal treatment
- Genetic factors
- Other: obesity, lack of exercise, alcohol
How can some breast lesions effect risk of breast cancer ?
- Epith proliferation without atypia: RF 1.5/2x
- With atypia ductal or lubular: RF 4/5x
- Lobar carcinoma in situ (LCIS): 8-10x
- Ductal carcinoma in situ (DCIS): 8-10x
List the genes related to inherited breast cancer disease and their relative contributions to hereditary carcinoma.
- BRCA1: 20-40%
- BRCA2: 10-30%
- TP53: <1%
- PTEN: <1%
Name the histological classifications of invasive and non-invasive breast cancers.
Non-invasive
- Ductal carcinoma in situ (DCIS)
- Lobular carcinoma in situ (LCIS)
Invasive
- Invasive ductal carcinoma (75%)
- Invasive lobular carcinoma and its variants (5-15%)
What are the features of the in situ carcinomas?
- preinvasive - does not form a palpable tumor
- not detected clinically (only X-ray in DCIS–screening)
- multicentricity and bilaterality (LCIS)
- no metastatic spread (basement membrane)
- risk of invasion depending on grade
What are the risks of progression in situ cancer?
- Low grade DCIS - 30% in 15 years
- High grade DCIS - 50% in 8 years
- LCIS - 19% in 25 years and bilaterality
What are the ‘special’ types of breast cancer?
- Tubular carcinoma
- Mucinous carcinoma
- Carcinoma with medullary features (This is the type you get with BRCA1 mutations)
- Metaplastic carcinoma
What are the diagnostic procedures for finding breast cancer?
- Clinical examination
- Radiology (Mammogram, ultrasound, MRI)
- Fine needle aspiration cytology FNA
- Needle core biopsy
- Wide local excision with adequate margins
How is breast cancer screening carried out and what are the benefits?
- Mammogram every 3 years for women between the age of 50 and 70
- 30% reduction of mortality
- Over 80% (1,406 cases) of cancers detected were invasive, of which over half were less than 15mm in size
Explain microcalcifications
- Tiny deposits of calcium can appear anywhere in the breast and often show up on a mammogram
- Most women have one or more areas of microcalcifications of various sizes
- Majority of calcium deposits are harmless
- A small percentage may be in precancerous or cancerous tissue
On mammography, what are the two most important mammographic indicators of breast cancer?
- Masses
- Microcalcifications
What info will be gained from a histology report?
- Invasive vs non-invasive
- Histological type: ductal (85%) or lobular
- Grade (estimate of how aggressive the cancer is)
- Size
- Margins
- Lymph nodes
- Eostrogen/progesterone receptor
- HER2 gene
Where can breast cancer spread and via what route?
- Local: skin and pectoral muscles
- Lymphatic: axilla and internal mammary nodes
- Blood: bone, lungs, brain, liver
What factors have an effect on the prognosis of breast cancer?
- Patient + tumour related
- Node status
- Tumour size
- Type
- Grade
- Age
- Lymphovascular invasion
- Oestrogen/progestrogen receptors
- HER-2
- Proliferative rate of tumour
- Overall there is a 64% 5 year survival
What molecular markers can we use?
- ER /PR strong predictors of response to hormonal therapies
- ER/PR negative tumours do not respond
- HER-2 : about 20-30% positive- predicts response to trastuzumab ( Herceptin )
Theres some stuff on molecular classification in the lectures although I’m unsure if we need to know it: it’s on this card anyway if you’re feeling keen
Molecular Classification
- Gene expression technology
- 5 subtypes : ER + luminal A, luminal B, Basal, Her 2+ and normal breast-like
- Biologically diverse disease
- Predictive gene signatures/ potential to improve therapy
- Complement current clinicopathological features
What is the management of breast cancer?
- Staging
- Surgery: mastectomy, breast conserving surgery ± lymphnodes
- Radiotherapy
- Antihormonal therapy (tamoxifen)
- Chemotherapy
What is pagets disease of the nipple? Signs and symptoms?
- Results from intraepithelial spread of intraductal carcinoma
- Large pale staining cells within the epidermis of the nipple
- Limited to the nipple or extend to the areola
- Pain or itching, scaling and redness, mistaken for eczema
- Ulceration, crusting, and serous or bloody discharge
Most common pathology of the male breast?
Gynecomastia
- increase in subareolar tissue
- in 30 to 40 percent of adult males, both breasts are affected in many cases
- Associated with hyperthyroidism, cirrhosis of the liver, chronic renal failure, chronic pulmonary disease and hypogonadism
