Theme 6: Breast pathology Flashcards
What is screening?
the process of identifying people who appear healthy but may be at an increased risk of a disease or condition
Who is eligible for breast screening and how often are they screened?
- Eligible women: 50-up to 71st birthday (age extension 47-73 in some areas)
- invited every 3 years
What does a breast screen consist of?
- Clinical examination
- Mammograms (2 X-rays of each breast) or USS
- Biopsy - corecut or FNAC
How might a patient present with breast cancer?
- a lump or thickening in the breast
- a change in the nipple - morphology, rash, blood or fluid
- a change in how the breast feels or looks
- pain or discomfort in the breast or armpit
- swelling or lump in the armpit
What is FNAC?
Fine needle aspiration cytology - only undertaken for cystic lesions or used when a biopsy is contra-indicated
How are breast lumps graded in triple assessment?
Clinical - P1-P5
Radiology - R1-R5
Pathology - B1-B5
P1-normal P2 - benign lesion P3 - atypical P4 - atypical, probably malignant P5 - malignant
what is a mammogram looking for?
calcification
What is the procedure (i.e next steps) for each grades on biopsy (e.g B1-B5)
B1 –> return to screening
B2 –> reassure, return to screening
B3 –> uncertain malignant potential = excision
B4 –> suspicion of malignancy = rebiopsy or excision
B5 –> surgical excision (WLE or mastectomy)
B5a - DCIS
B5b - invasive
What is DCIS?
Ductal carcinoma in situ
What are the anatomical differences in male and female breasts?
- no lobules
- no TDLU’s
- no cooper’s ligaments
- no fibroadenomas
- no cysts (arising from breast stroma)
- can occasionally get breast carcinomas
What are breast lobes drained by?
a lactiferous duct
What do all lobes converge towards?
areola
What is a breast?
- breast is a modified sweat gland composed of lobes and lobules of glands within fibroadipose stroma
- composed of specialised epithelium and stroma
- ductules drain into intralobular duct, which moves out to become the extralobular duct, which all converge to form the interlobular duct
What disorders can arise from the terminal duct lobular units (TDLUs) ?
- cysts
- sclerosing adenosis
- small duct papilloma
- hyperplasia
- atypical hyperplasia
- carcinoma
What disorders can arise from the lobular stroma?
- fibroadenoma
- phyllodes tumor
What disorders can arise from the large ducts and lactiferous sinuses?
- duct ectasia
- recurrent subareolar abscess
- solitary ductal papilloma
- pagets disease
What disorders can arise from the interlobular stroma?
- fat necrosis
- lipoma
- fibrous tumour
- fibromatosis
- sarcoma
Is a fibroadenoma benign or malignant?
benign
What is the most common breast disorder of the nipple
Pagets –> arises from large ducts
What is fibrocystic change?
- affects women 20-45 years of age
- usually bilateral and multifocal
- no increase risk for subsequent carcinoma development
What is fibrocystic disease?
a constellation of benign, hormonally mediated breast changes which include cyst formation, stromal fibrosis and mild epithelial hyperplasia without atypia
How might a patient with fibrocystic disease present?
lumpy, pre menstrually painful breasts
symptoms generally cease 1-2yrs after menopause
Who is at risk of fibroadenoma?
- incidence - common
- usually in women 20-30 years
- more common in afro-caribbean women
What are the signs of fibroadenoma?
mobile, painless, well-defined breast lump
What is the treatment of fibroadenoma?
surgical excision, some may recur
What is a prevalent screen and what is an incident screen?
prevalent screen - first visit
incident screen
incident screen - not first visit
What is DCIS?
- ductal carcinoma in situ
- malignant clonal proliferation of cells within breast parenchymal structures
- a precursor of invasive carcinoma (pure DCIS cannot produce a metastasis but has the potential to progress to invasion if left)
Explain how we grade breast cancer
T-tubule formation (1-3)
N-nuclear pleomorphism (1-3)
M-mitosis (1-3)
Would a grade 1 tumour be well or poorly differentiated?
well differentiated
What is breast cancer
a common cancer that arises anywhere in breast parencyma or accessory breast tissue
What are the risk factors associated with breast cancer?
- oestrogen
- early menarche
- late menopause
- obesity in post menopausal women
- OCPs
- hormone therapy for menopause
- alcohol
What should a pathology report of a malignant breast cancer show?
- in situ or invasive?
- what type of tumour?
- grade?
- size?
- evidence of vascular invasion?
- nodal status?
- relationship of tumour wrt margins?
- molecular marker status: ER, PR, HER2
What is the most common breast cancer?
invasive ductal carcinoma
What are the important prognostic indicators when it comes to diagnosing breast cancer?
1. grading the higher the grade, the higher the chance of recurrence 2. vascular invasion 3. nottingham prognostic index (NPI) 4. Margins
Name some hormone targeted therapies for breast cancer
tamoxifen
aromatase inhibitors
bisphosphonates
her-2 targeted approach –> trastuzumab
How is the molecular classsification of breast cancer decided?
classified into luminal A or B based on their ER and Her2 positivity
