Reproductive Pathology: Female 1 Flashcards
Benign Breast Disease
- Heterogenous group of lesions including developmental abnormalities, inflammatory lesions, epithelial and stromal proliferations, and neoplasms. About 90% of referrals have a benign disease.
- Common and increases in frequency towards menopause then decreases. It can be difficult to distinguish clinically from breast cancer. Causes a variety of histological changes.
- Vast majority of lesions that occur in the breast in benign. With the use of mammography, ultrasound, MRI of the breast and the extensive use of needle biopsies, the diagnosis can be accomplished without surgery in most patients. Which is great as most lesions end up being benign.
- Important for pathologists, radiologists and oncologists to recognise benign lesions, both to distinguish them from in situ and invasive breast cancer to assess a patient’s risk of developing breast cancer, so that most appropriate treatment modality can be established in each case.
Identifying Benign VS. Malignant Lumps of Breast on US
- Benign: Shape is oval/ellipsoid. Alignment is wider rather than deep and aligned parallel to tissue planes. Margins are smooth/thin and echogenic pseudocapsule with 2-3 gentle lobulations. Echotexture is variable to intense hyperechogenicity. Homogeneity of internal echoes is uniform. Lateral shadowing is present. Minimum attenuation/posterior enhancement.
- Malignant: Shape is variable. Alignment is deeper rather than wide. Margins are irregular or spiculated; echogenic halo. Echotexture is low-level, marked hypoechogenicity. Homogeneity of internal echoes is non-uniform. Lateral shadowing is absent. Attenuation with obscured posterior margin. Other signs include calcification, microlobulation, intraductal extension, infiltration across tissue planes and increase echogenicity of surrounding fat.
Normal VS Malignant Breast Cell Cytology
- Normal - large cytoplasm, single nucleus, single nucleolus, fine chromatin.
- Cancer - small cytoplasm, multiple nuclei, multiple and large nucleoli, coarse chromatin.
Normal breast architecture
- Adolescent breast - large and intermediate-size ducts are seen with dense fibrous stroma. No lobular units are present.
- Postpubertal breast - the terminal duct lobular unit consists of small ductules arrayed around an intralobular ducts. The two-cell-layered epithelium shows no secretory or mitotic activity. The intralobular stroma is dense and confluent with the interlobular stroma.
- Lactating Breast - The terminal duct lobular units are conspiculousy enlarged, with inapparent interlobular and intralobular stroma. The individual terminal ducts, now termed acini, show prominent epithelial secretory activity (cytoplasmic vacuolisation). The acinar lumina contain secretory material.
- Postmenopausal breast - terminal duct lobular units are absent. Remaining intermediate ducts and larger ducts are commonly dilated.
Fibrocystic Change (FCC)
- Exaggerated physiologic response.
- Fibrocystic change is a nonproliferative change that includes gross and microscopic cysts, apocrine metaplasia, mild epithelial hyperplasia, adenosis and an increase in fibrous stroma.
- Affects over 1/3 of women 20-50 years old, then declines after menopause. Most are asymptomatic but some present with nodularity and pain. Typically multifocal and bilateral.
- FCC doesn’t increase risk of cancer but makes it harder to identify potentially cancerous lumps.
Proliferative Breast Disease
- Proliferative breast lesions without atypia entails a 2 fold increase risk of developing carcinoma over 5-15 years and is classified simply as proliferative breast disease.
- Proliferative breast lesions with atypia involve even greater relative risk (5-fold). Such patients require close clinical monitoring.
Breast Carcinogenesis
Normal epithelium -> Proliferative disease without atypia -> atypical hyperplasia -> Ductal Carcinoma In Situ (DCIS) -> invasive breast cancer
Gynaecomastia
Gynaecomastia is hyperplasia of the male breast stromal and ductal tissue. It is usually caused by a relative increase in the oestrogen to androgen ratio in the circulation or breast tissue. The most common cause is secondary to drugs. In older patients, it involves cardiovascular and prostate drugs, and in younger patients; cannabis, anabolic steroids, anti-ulcer drugs and anti-depressants. It can also be physiological and present spontaneously in a trimodal age pattern; neonates, pubertal and senescence (these cases are usually self-limiting). Other pathological causes include undiagnosed hyperprolactinaemia, liver failure, alcohol excess, obesity and malignancy (in lungs and/or testes).
Fibroadenomas
Arise from breast lobules and are composed of fibrous and epithelial tissue. They are well circumscribed and highly mobile, because of the encapsulation and pliability of young breast tissue. Clinically, fibroadenomas are difficult to differentiate from Phyllodes Tumours, which is a distinct pathology. Fibroadenomas appear as a well-defined, smooth, oval-shaped lump, distinctly mobile and easily identified on ultrasound.
Phyllodes Tumours
Phyllodes Tumours are sarcomas which rapidly enlarge and have variable degrees of malignant potential. They are larger than fibroadenomas and tend to occur in an older age group.
Fat Necrosis
Fat necrosis presents as a soft, indistinct lump that develops a few weeks after a traumatic incident, and often in older women with fatty breasts. On imaging, some are difficult to distinguish from breast cancer and a core biopsy is often indicated.
Breast Carcinoma
- 20% of all cancers in women. 1% of tumours occur in men. In the UK, lifetime risk for women in one in nine. It is the commonest cause of death for women aged 35-55. Commonest cancer in the UK except for Scotland with lung cancer beating it there.
- Invasive Carcinoma of the Breast - most are of “no special type”/Ductal (75-90%). Infiltrating lobular carcinoma (10%) may be multifocal. There are some special types (less common).
Risk factors of Breast Cancer
- Decreases risk - breastfeeding, body fatness (pre-menopausal), physical activity.
- Increases risk - digoxin, oestrogen HRT, ethylene oxide, shiftwork involving circadian disrubtion, smoking, adult attained height (pre-menopausal), greater birth weight (pre-menopausal), abdominal fatness (post-menopausal), adult weight gain (post-menopausal), total dietary fat (post-menopausal), alcohol, diethylstilbestrol, oestrogen-progesterone contraceptives, oestrogen-progesterone HRT, X radiation and gamma radiation, body fatness (post-menopausal), adult attained height (post-menopausal).
Non-invasive Precursors
Usually identified coincidentally. Tumour cells confined to ducts or acini. Two forms; Ductal Carcinoma In Situ (DCIS) which is often unilateral or Lobular Carcinoma In Situ (LCIS) which is often bilateral and can be multifocal.
Paget’s Disease of the Nipple
- Leads to erosion of the nipple that resembles eczema.
- Associated with underlying in situ or invasive carcinoma.
