W13 - Breast pathology

Question 1

What breast samples (2) undergo cytology?

Aspirates of breast lumps are coded C1-5 => what does each indicate?

Answer 1

Breast samples: (1) nipple discharge, (2) palpable lumps

—C1 = inadequate

—C2 = benign

—C3 = atypia, probably benign

—C4 = suspicious of malignancy

—C5 = malignant

Question 2

5 different breast FNA cytology - what does each show?

Answer 2

Top right = healthy, benign aspirate = flat sheet of cells of epithelial cells, no overlapping, lots of cytoplasm

Top left = lots of debris, red are RBC, neutrophils = you can’t see the monolayer so inadequate

Bottom left = fat cells = large empty-looking cells with nuclei on outer esges

Bottom right = healthy, benign benign = lots of glandular tissue, monolayer sheet (common in young girls)

Bottom = more structured unit = as compared to top right, this patient has got glandular proliferation and forming branches and staghorn clefts = may have an underlying benign tumour

Question 4

Name 2 pros and 1 con of cytopathology of breast samples

Answer 4

Pros:

1. Good cellular detail
2. Quick to prepare

Cons:

1. No architectural info

Question 5

Name 1 pros and 2 cons of histopathology of breast samples.

Answer 5

Pros: 1. Architectural and cellular detail

Cons: 1. Takes longer (24h) to process

2. Core biopsies requiring surgical excisions

Question 6

Name 3 inflammatory breast diseases

Answer 6

1. Duct ectasia
2. Acute mastitis
3. Fat necrosis

Question 7

What does this breast histological slide show?

Answer 7

This duct is enlarged (maybe x12)

lots of proteinaceous excretion in the lumen

duct ectasia!

Question 8

1. What is duct ectasia?
2. How does it present?
3. What does FNA cytology show?
4. Risk of cancer?

Answer 8

1. inflammation and dilation of large breast ducts
2. nipple discharge +/- breast pain, breast mass, nipple retraction
3. FNA = proteinaceous material + inflammatory cells
4. no increased risk of malignancy

Question 10

What does this breast cytology show?

Answer 10

1. Oval cells are histiocytes
2. Empty spaces are FAT
3. Multinucleated cells are giant cells

= fat necrosis

Question 11

1. What is acute mastitis?
2. How does it present?
3. Causative organism?
4. What does FNA cytology show?
5. Complications
6. Treatment

Answer 11

1. acute inflammation in the breast
2. often in lactating women (due to cracked skin + milk stasis) => painful red breast
3. staphylococci (usually)
4. abundant polymorphonuclear cells, macrophages, lots of debris.
5. breast abscess (1), duct ectasia (2)
6. Warm compression, milk expression, analgesia, increased fluid intake, sometimes abx (dicloxacillin) and sometimes drainage

Question 12

What does this breast histology image show?

Answer 12

normal lobule on left

large calcified cysts on right

fibrocystic disease

Question 13

1. What is fat necrosis?
2. Aetiology?
3. How does it present?
4. What does FNA cytology show?
5. Is it benign?

Answer 13

1. Inflammatory reaction to damaged adipose tissue
2. Caused by trauma (1), surgery (2), radiotherapy (3)
3. A breast mass
4. histiocytes (1), multinucleated giant cells (2) and degenerating adipocytes (3)
5. Benign condition

Question 14

What do these cytology and histology slides show?

Answer 14

histology = monolaye sheet, lots of honeycomb cells, staghorn like arrangement

histology = well circumscribed edge, lots of tissue proliferation = glands compressed

= fibroadenoma

Question 16

What do these cytology and histology show?

Answer 16

cytology = DENSE = lots of CELLS, large nuclei (not like firboadenoma where it’s a monolayer)

histology = lots of stroma, phyllodes = leaf-like moprhology

= phyllodes tumour

Question 17

1. What is fibrocystic disease?
2. How does it present?
3. What does histology show?
4. Is it benign?

Answer 17

1. a group of alterations int he breast which reflect NORMAL, albeit exaggerated, responses to hormonal influences
2. breast lumpiness
3. normal lobules, hypercalcified cysts
4. Completely

Question 18

What do these cytology and histology images show?

Answer 18

cytology => finger-like projections

histology => enlarged, dilated ducts

= intraductal papilloma

Question 20

What does this histology show?

Answer 20

Central fibrous scar with radiating lobules and ductules = radial scar (also known as complex sclerosing lesion if lesion >1cm)

Question 21

1. What is a fibroadenoma?
2. How does it present?
3. What does histology show? What does cytology show?
4. Is it benign?
5. Treatment

Answer 21

1. A benign fibroepithelial neoplasm of the breast
2. Mobile, circumscribed breast lump in young women 20-30s
3. histology = well-circumscribed edge, compressed glands due to high proliferation of tissue

cytology = monolayer sheets, honeycomb sheets, lots of staghorn and antler-like cells

4. yes, very low chance of becoming cancerous
5. Shelling out is curative

Question 23

1. What is a phyllodes tumour?
2. How does it present?
3. What does histology show? What does cytology show?
4. Is it benign?

Answer 23

1. A group of potentially aggressive fibroepithelial neoplasms of the breast
2. enlarging breast lump in women >50y
3. cytology = DENSE = lots of CELLS, large nuclei (not like firboadenoma where it’s a monolayer)

histology = lots of stroma, phyllodes = leaf-like moprhology

4. Vast majority behave benignly, but small proportion could be aggressive!

Question 24

What does this histology slide of the breast show? Risk of cancer?

Answer 24

Multilayering of the epithelium; but nothing has spread outside the duct = epithelial hyperplasia (type of proliferative breast disease)

RR 1.5-2x for subsequent invasive carcinoma

Question 25

What does this histology slide of the breast show? Risk of cancer?

Answer 25

Flat epithelial atypia around the ducts, ducts are dilated and glands are more “blue”, frequent secretions and calcifications within dilated glands = FEA (flat epithelial atypia/atypical ductal carcinoma ; type of proliferative breast disease)

RR 4x of developing cancer

Question 27

1. What is an intrudcutal papilloma?
2. How does it present?
3. What does histology show? What does cytology show?
4. Is it benign?

Answer 27

1. —A benign papillary tumour arising within the duct system of the breast, usually in women 40-60 y.o.
2. IF arising from small terminal ductules (peripheral papilloma) => remain silent if small

IF arising from larger lactiferous ducts (central papilloma) => occlusion of ductal system => nipple discharge/blood

3. cytology => finger-like structures

histology => large, dilated ducts

4. could be in situ tumours that become invasive later = warrants excision

Question 28

What does each histology slide of the breast show?

Answer 28

Left = Atypical ductal hyperplasia, Punched out lesions, calcified, nuclei similar size ro adjacent RBC = low grade DCIS

Right = as above + lots of central necrosis and calcifications = high grade DCIS

Question 30

1. What is a radial scar?
2. How does it present?
3. What does histology show?
4. Is it benign?

Answer 30

1. A benign sclerosing lesion characterised by a central zone of scarring surrounded by a radiating zone of proliferating glandular tissue
2. usually present as stellate masses on screening mammograms which may closely resemble a carcinoma. Ig lstge lesion then pt may present with mass
3. central scar that is fibrous with radiating ducts and lobules
4. can harbour atypical cells = warrants excision

Question 32

A benign breast lesion that most commonly mimicks breast cancer on radiology?

Answer 32

Radial scars

Fat necrosis

Question 33

What do these cytology and histology slides of breast sample show?

Answer 33

Cytology = very large, irregular nuclei with very litle cytoplasm Histology = very irregular cells invading the fat spaces = invasive ductal carcinoma

Question 34

What does this histology of the breast show?

Answer 34

Lobular carcinoma, but you see they also traverse through the stroma in this single-layer trabeculae fashion = **invasive lobular carcinoma**

Question 35

What do each of these histology slides of breast tissues show?

Answer 35

Left = open tubules with dispersed cells = these are associated with radial scars = **inasive tubular carcinoma** Right = nests of tumour cells submerged in mucin (can't see), usually have a glassy-appearance = **invacine mucinous carcinoma**

Question 36

What are proliferative breast diseases? Name 3 types

Answer 36

A diverse group of **intraductal** proliferative lesions of the breast associated with an increased risk, of greatly different magnitudes, for subsequent development of **invasive breast carcinoma** **1. Epithelial hyperplasia** **2. Flat epithelial atypia/atypical ductal carcinoma** **3. In situ lobular neoplasia**

Question 37

What do these histology slides of breast tissue show? What do they have a propensity for?

Answer 37

Very dark cells, little cytoplasm, brown stain on bottom is for basal markers and hence, these arise from basal cells (pick up CK5 and CK14 = basal-like carcinoma Propensity to vascular invasion and distant metastatic spread

Question 38

What are the symptoms of proliferative breast diseases?

Answer 38

Microscopic lesions = usually produce NO symptoms.

Question 41

What is DCIS?

Answer 41

Ductal carcinoma in situ (DCIS) = A neoplastic intraductal epithelial proliferation in the breast with a risk of progression to invasive breast carcinoma. depending on the grade DCIS could either spread or stay in situ. 85% identified on mammograms as microcalcifications

Question 42

How does DCIS present?

Answer 42

- 85% are detected on mammography as areas of microcalcification. - 10% produce clinical findings such as a lump, nipple discharge, or eczematous change of the nipple (Paget’s disease of the nipple). - 5% are diagnosed incidentally in breast specimens removed for other reasons.

Question 43

Is there a risk of malignancy with gynaecomastia?

Answer 43

No - it is fully benign and is epithelial hyperplasia with typical finger-like projections extending into the duct lumen. Periductal stroaml is often CELLULAR and OEDEMATOUS

Question 45

What is the treatment for DCIS?

Answer 45

- Surgical excision = complete excision with clear margins is curative. Recurrence more likely with extensive disease + high grade DCIS

Question 46

What are invasive breast carcinomas? Lifetime risk in women?

Answer 46

Invasive breast carcinomas are a group of malignant epithelial tumours which infiltrate within the breast and have the capacity to spread to distant sites. lifetime risk of 1 in 8.

Question 47

RFs (7) for invasive breast carcinoma

Answer 47

1. Early menarche 2. Late menopause 3. Increased wieght 4. High alcohol consumption 5. OCP 6. Family history 7. BRCA mutation = 85% lifetime risk of developing invasive breast carcinoma

Question 48

How does invasive breast carcinoma usually present?

Answer 48

- Most cases with a breast lump

Question 52

What is the most common malignant breast tumour?

Answer 52

Invasive ductal carcinoma (IDC)

Question 54

What 3 parameters are used to histologically grade invasive breast cancers? How many scores is each given? Total score?

Answer 54

1. Tubule formation 2. Nuclear pleomorphism 3. Mitotic activity each parameter is scores from 1-3. Total scores from 3-9. 3-5 = grade 1 (well differentiated), 6-7 = grade 2 (moderately differentiated), 8-9 = grade 3 (poorly differentiated)

Question 55

How are invasive breast carcinomas treated? Describe properties of low-grade, high-grade tumours, and basal-like carcinomas related to treatment

Answer 55

1. All are assesed for oestrogen receptor (ER), progesterone receptor (PR), and Her2 status Low grade tumours tend to be ER/PR + and Her2 - High grade tumours tend to be ER/PR - and Her2 + Basal-like carcinomas are often ER/PR/Her2 - (triple negative)

Question 56

The single most important prognostic factor for invasive breast carcinomas is \_\_\_\_\_\_\_\_\_\_\_? Name some other prognostic factors (3)

Answer 56

Infiltration into axillary LNs 1. Tumour size 2. Histological type 3. Histological grade

Question 57

Describe the aim of the NHS Breast Screening Programme Who is included?

Answer 57

- pick up DCIS or early invasive carcinomas - women aged 47-73 are invited for screening every 3 years - mammogram looking for abnormal areas of calcification or a mass within the breast

Question 58

What % of women have an abnormal mammogram? They are then invited for further testing, such as having a core biopsy taken. These are scored by B1 =\> B5. Describe each

Answer 58

5% ## Footnote B1 = normal breast tissue. B2 = benign abnormality. _B3_ = lesion of uncertain malignant potential. _B4_ = suspicious of malignancy. _B5_ = malignant (B5a = DCIS, B5b = invasive carcinoma).