Pathology of the Breast Flashcards
What is inside the lobe of the breast?
Smaller structures called lobules
What is at the end of each lobule of the breast?
Tiny sacs (bulbs) that can produce milk
Definition of fibroadenoma
Circumcised mobile nodule in reproductive age
Fibrocystic changes of the breast involves
Fibrosis Adenosis Cysts Apocrine metaplasia Ductal epithelial hyperplasia (normal or atypical)
Intraduct papilloma involves….
Lactiferous ducts
Nipple discharge
Duct ectasia presentation
Nipple discharge
Peak age for fibroadenomas
3rd decade
What may happen to a fibroadenoma if left untreated?
It may regress with age
Presentation of a fibroadenoma
A mass that is
- well circumcised
- freely mobile
- non-painful
What age is intraduct papillomas usually seen in?
middle aged women
Pathology of fibroadenomas
- ductus distorted elongated
- Slit like structures intracanalicular pattern, ducts not compressed
- Peri canalicular growth pattern
What can fat necrosis stimulate?
Carcinoma, clinically and mammographically
Fat necrosis will have an associated history of…..
Antecedent trauma
Prior surgical intervention
Pathology of intraduct papilloma
Histiocytes with foamy cytoplasm
Lipid filled cysts
Fibrosis, calcifications, egg shell on mammography
Definition of Phyllodes tumour
A fleshy, circumscribed tumour with connective tissue and epithelial elements with cysts on cut surface and a leaf like pattern
Malignancy status of phyllodes tumour
Epithelial component is benign
Stroma component is malignant
Metastases of a phyllodes tumour is by…
Haematogenous spread
What does breast carcinoma show on a mammogram?
Soft tissue opacity
Microcalfication
Presentation of breast carcinoma
Hard lump
Fixed mass
Tethering to skin
Peau d’orange dimpling of skin
Risk factors for breast carcinoma
Gender Increased age Early menarche / late menopause Delayed age of 1st pregnancy (>30 y/o) Radiation Family history Previous cancer Hormonal treatment (HRT, COCP) Genetic factors Obesity Lack of physical activity Alcohol P53 gene mutation Previous surgery for benign breast disease (scar hides mass etc) Non breastfeeding Nulliparity
Breast lesions that require surveillance due to the risks include…
Epithelial proliferation without atypia - 1.5-2x
With atypical ductal or lobar - 4-5x
Lobular carcinoma in situ (LCIS) - 8-10x
Ductal carcinoma in situ (DCIS) - 8-10x
What percentage of breast cancers can be attributed to inherited factors?
5-10%
What are the inherited genes that contribute to breast cancer?
BRCA1 - 20-40% BRCA2 - 10-30% TP53 - <1% PTEN - <1% other genes - 30-70%
Non-invasive carcinomas
Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (LCIS)
Investigations for breast carcinoma
Clinical exam Mammogram USS MRI FNAC Needle core biopsy
Who is screened for breast cancer?
Women aged 50-70 years
How often is breast cancer screening carried out?
every 3 years
What scanning is carried out for breast cancer screening?
Mammogram
Screening for breast cancer reduces mortality by…
30%
The two most important mammographic indications of breast cancer
- Masses
2. Macrocalcifications
What can microcalfications on mammogram indicate?
Possibly an early cancer
What does breast cancer spread to?
Local - skin - pectoral muscles Lymphatic - axillary nodes - internal mammary nodes Blood - bone - lungs - liver - brain
5 year survival prognosis for breast cancer
64%
What is looked at to predict the prognosis in the breast cancer?
Patient related and tumour related Node status (breast prognostic indicator) Tumour size <2cm Type Grade (1,2,3) Age Co-morbidities Lymphovascular space invasion Oestrogen receptors (OR) Progesterone receptors (PR) HER-2 Proliferative rate of tumour Gene expression profiling Nottingham prognostic index (NPI)
What does the Nottingham prognostic index (NPI) base their prognosis on?
Tumour size
Grade
Nodal status
What molecular markers are strong predictors to responses to hormonal therapies in breast cancer?
ER/PR
What molecular marker in breast cancer predicts the response to trastuzumab (Herceptin)?
HER-2
Treatment of breast carcinoma
Surgery - mastectomy - breast conserving surgery (WLE) - +/- lymph nodes Radiotherapy Antihormonal therapy (tamoxifen) Chemotherapy
What is pagets disease of the nipple pathologically a result of?
Intraepithelial spread of intraductal carcinoma
Presentation of pagets disease of the nipple
Large pale staining ells within the epidermis of the nipple limited to the nipple or extend to the areola Pain itching scaling or redness mistaken for eczema ulceration crusting serous or bloody discharge
Gynaecomastia is associated with
hyperthyroidism Cirrhosis of the liver Chronic renal failure Chronic pulmonary disease Hypogonadism Use of hormones (oestrogen, androgrens, spironolactone, marihuana, tricyclic antidepressants)
Who does a galactocele typically occur in?
In women who recently stopped breast feeding
Pathology of galactocele
Occlusion of a lactiferous duct
The build up of milk creates a cystic lesion in the breast
What is lactation mastitis?
A common inflammatory condition of the breast which may be either infectious or non infectious in origin. The main cause is milk status, due to overproduction or insufficient removal.
Most common organism for infectious lactation mastitis
Staph Auerus
Presentation of lactation mastitis
Breast pain (most commonly unilateral)
Erythematous, warm, tender area
Fever
Flu like symptoms
Treatment of lactation mastitis
Analgesia
Encourage removal of milk (continue breastfeeding or expressing) from the affected side in order to prevent further milk status
If symptoms dont improve after 12 - 24 hours of conservative management
- oral flucloxacillin 500mg 4x a day for 14 days
- erythromycin if penicillin allergic
- (second line choice co amoxiclav)
Frequent breastfeeding prpblems
Nipple pain
Blocked duct causing nipple pain when breastfeeding
Nipple candiadis
Can oral flucloxacillin be prescribed during breastfeeding?
Yes
If mastitis is left untreated what can it progress to?
A breast abscess
Presentation of raynauds disease of the nipple
Pain intermittent
Pain during and immediately after feeding
Blanching of the nipple followed by erythema and/or cyanosis
Management of raynauds disease of the nipple
Minimize exposure to the cold
Use of heat packs following a breastfeed
Avoid caffeiene
Stop smoking
If symptoms persist consider oral nifedipine (off license)
If you have breast cancer which is HER-2 positive, what can be used to treat it? What kind of therapy is this?
Herceptin
Biologic therapy
Hormonal treatment of breast cancer in pre and peri menopausal women who are ER +ve
Tamoxifen
Hormonal treatment of post menopausal ER +ve cancer
Aromatase inhibitors (anastrole)
