Theme 6: Breast pathology

Question 1

What is screening?

Answer 1

the process of identifying people who appear healthy but may be at an increased risk of a disease or condition

Question 2

Who is eligible for breast screening and how often are they screened?

Answer 2

• Eligible women: 50-up to 71st birthday (age extension 47-73 in some areas)
• invited every 3 years

Question 3

What does a breast screen consist of?

Answer 3

• Clinical examination
• Mammograms (2 X-rays of each breast) or USS
• Biopsy - corecut or FNAC

Question 4

How might a patient present with breast cancer?

Answer 4

• 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

Question 5

What is FNAC?

Answer 5

Fine needle aspiration cytology - only undertaken for cystic lesions or used when a biopsy is contra-indicated

Question 6

How are breast lumps graded in triple assessment?

Answer 6

Clinical - P1-P5
Radiology - R1-R5
Pathology - B1-B5

P1-normal
P2 - benign lesion
P3 - atypical
P4 - atypical, probably malignant 
P5 - malignant

Question 7

what is a mammogram looking for?

Answer 7

calcification

Question 8

What is the procedure (i.e next steps) for each grades on biopsy (e.g B1-B5)

Answer 8

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

Question 9

What is DCIS?

Answer 9

Ductal carcinoma in situ

Question 10

What are the anatomical differences in male and female breasts?

Answer 10

• no lobules
• no TDLU’s
• no cooper’s ligaments
• no fibroadenomas
• no cysts (arising from breast stroma)
• can occasionally get breast carcinomas

Question 11

What are breast lobes drained by?

Answer 11

a lactiferous duct

Question 12

What do all lobes converge towards?

Answer 12

areola

Question 13

What is a breast?

Answer 13

• 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

Question 14

What disorders can arise from the terminal duct lobular units (TDLUs) ?

Answer 14

• cysts
• sclerosing adenosis
• small duct papilloma
• hyperplasia
• atypical hyperplasia
• carcinoma

Question 15

What disorders can arise from the lobular stroma?

Answer 15

• fibroadenoma

- phyllodes tumor

Question 16

What disorders can arise from the large ducts and lactiferous sinuses?

Answer 16

• duct ectasia
• recurrent subareolar abscess
• solitary ductal papilloma
• pagets disease

Question 17

What disorders can arise from the interlobular stroma?

Answer 17

• fat necrosis
• lipoma
• fibrous tumour
• fibromatosis
• sarcoma

Question 18

Is a fibroadenoma benign or malignant?

Answer 18

benign

Question 19

What is the most common breast disorder of the nipple

Answer 19

Pagets –> arises from large ducts

Question 20

What is fibrocystic change?

Answer 20

• affects women 20-45 years of age
• usually bilateral and multifocal
• no increase risk for subsequent carcinoma development

Question 21

What is fibrocystic disease?

Answer 21

a constellation of benign, hormonally mediated breast changes which include cyst formation, stromal fibrosis and mild epithelial hyperplasia without atypia

Question 22

How might a patient with fibrocystic disease present?

Answer 22

lumpy, pre menstrually painful breasts

symptoms generally cease 1-2yrs after menopause

Question 23

Who is at risk of fibroadenoma?

Answer 23

• incidence - common
• usually in women 20-30 years
• more common in afro-caribbean women

Question 24

What are the signs of fibroadenoma?

Answer 24

mobile, painless, well-defined breast lump

Question 25

What is the treatment of fibroadenoma?

Answer 25

surgical excision, some may recur

Question 26

What is a prevalent screen and what is an incident screen?

Answer 26

prevalent screen - first visit
incident screen
incident screen - not first visit

Question 27

What is DCIS?

Answer 27

• 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)

Question 28

Explain how we grade breast cancer

Answer 28

T-tubule formation (1-3)
N-nuclear pleomorphism (1-3)
M-mitosis (1-3)

Question 29

Would a grade 1 tumour be well or poorly differentiated?

Answer 29

well differentiated

Question 30

What is breast cancer

Answer 30

a common cancer that arises anywhere in breast parencyma or accessory breast tissue

Question 31

What are the risk factors associated with breast cancer?

Answer 31

• oestrogen
• early menarche
• late menopause
• obesity in post menopausal women
• OCPs
• hormone therapy for menopause
• alcohol

Question 32

What should a pathology report of a malignant breast cancer show?

Answer 32

• 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

Question 33

What is the most common breast cancer?

Answer 33

invasive ductal carcinoma

Question 34

What are the important prognostic indicators when it comes to diagnosing breast cancer?

Answer 34

1. grading
the higher the grade, the higher the chance of recurrence 
2. vascular invasion 
3. nottingham prognostic index (NPI)
4. Margins

Question 35

Name some hormone targeted therapies for breast cancer

Answer 35

tamoxifen
aromatase inhibitors
bisphosphonates
her-2 targeted approach –> trastuzumab

Question 36

How is the molecular classsification of breast cancer decided?

Answer 36

classified into luminal A or B based on their ER and Her2 positivity