Week 5 - Breast Pathology Flashcards
Factors that Increase Risk of Breast Cancer
Women who are received HRT, especially the combined oestrogen and progesterone preparations
Women on OCP
Obesity
Alcohol
Factors that Decrease Risk of Breast Cancer
High parity
Age at first childbirth
Breast feeding
Late menarche
Early menopause
Embryonic Breast Development
Gestational week 5-6: Primitive milk streak develops from the ectoderm
Gestational week 7-8: Thickening of the mammary tissue, invagination into the mesoderm
Gestational week 12-16: Mesenchymal cells differentiate into the smooth muscle of the nipple/areola
Gestational week 16-20: Tips of breasts buds become secretory alveoli, secondary mammary tissue differentiates into hair follicles & sebaceous & sweat glands
Gestational week 20-32: Breast buds develop and become lactiferous mammary ducts
Gestational week 32-40: Parenchymal differentiation, where lobules and alveoli develop, proliferation of mesenchyme forms the nipple/areolar complex, pigmentation of the nipple areola complex
Clinical Presentation of Breast Disease - Pain
Most common
Diffuse pain has no pathologic correlation
Non-cyclical pain is usually assoc with a focal/localised site in the breast
Causes can include ruptured cysts, infections
Clinical Presentation of Breast Disease - Discrete Palpable Lesions
2nd most common
Palpable breast lesions usually become palpable when they are ~2cm in diameter
These are common in post menopausal women and become less frequent with age
The risk that a palpable mass is malignant increases with age
Clinical Presentation of Breast Disease - Discharge
D/C produced when manipulating breast = not likely associated with a pathological condition
- milky D/C (galactorrhoea) is associated with an increase in prolactin and associated with hypothyroidism, or endocrine anovulatory syndromes
- bloody or serous D/C can occur during pregnancy, due to rapid formation of new lobules
Triple Test for Breast Cancer
Includes:
- clinical breast examination and history
- imaging
- non-excisional biopsy
The triple test is positive if any of the three approaches are positive
Negative if all the approaches are negative
Advantages of the Triple Test
To maximise diagnostic accuracy in breast tissue
To maximise the preoperative diagnosis of cancer
To minimise the proportion of excisional biopsies for diagnostic purposes
To minimise the proportion of benign excisional biopsies for diagnostic purposes
Benign Breast Lesions - Acute Mastitis
Occur during pregnancy and lactational change
During breast feeding, the breast is vulnerable to bacterial infection because of cracks and fissures of the nipples
This allows entry of commonly, Staphylococcus aureus, or less commonly Streptococci infection
Staphylococcus infections:
- present as a localised area of acute inflammation
- may develop into abcesses
Streptococcal infections:
- involve diffuse infection that involves the entire breast
- may eventually become necrotic and demonstrates areas of neutrophilic infiltration
Benign Breast Lesions: Duct Ectasia
Often occurs in the 5th or 6th decade
Patients present with a poorly defined palpable peri areolar mass, occasionally skin retraction is noted accompanied with white thick nipple D/C
Pain and erythema are not common
Morphology:
- dilation of ducts filled with granular debris that may display lipid laden macrophages and a predominance in plasma cells
- occasionally, cholesterol deposits are noted
- fibrosis may result in skin and nipple retraction
Benign Breast Lesions: Fat Necrosis
Occurs as a painless palpable mass lesion, as a result of a trauma to fat as part of an inflammatory response,
- lump may be present with bruising
Morphology:
- focal haemorrhage in the early stages of trauma, followed by central liquefactive necrosis of fat
- it may appear as an ill defined nodule of grey-white, firm tissue
- central foci of necrosis/haemorrhage is initially surrounded by macrophages and a neutrophilic infiltration
- fibroblastic proliferation and increased vascularisation is evident
- replacement of scar tissue or collagenous tissue forms
Benign Epithelial Breast Lesions
Commonly arise in ducts and lobules
Most are found on mammographic screening and as incidental findings
Benign epithelial breast lesions can be divided into:
- non-proliferative breast changes
- proliferative breast disease
- atypical hyperplasia
Benign Epithelial Breast Lesions - Non-proliferative
This group involves predominantly the lesions termed ‘fibrocystic’ in type
Patient’s may present with ‘lumpy’ breasts on physical examination
Only a concern when their morphology on imaging is not smooth, or there are calcifications
Morphology:
- small cysts form by the dilation and unfolding of lobules
- when cystic lobules coalesce, larger cysts are formed
- unopened cysts are brown to grey in colour due to contained semi translucent turbid fluid
- breast cysts are usually lined by a flattened atrophic epithelium or by cells undergoing apocrine metaplasia
Benign Epithelial Breast Lesions - Proliferative
These lesions rarely form palpable masse
They are often identified on mammography, such as complex sclerosing adenosis, calcifications or as incidental findings
Most present with nipple DC
Papilloma may undergo torsion of the stalk resulting in bloody nipple DC
This group of disorders include; florid epithelial hyperplasia, sclerosing adenosis, complex sclerosing lesions, papillomas and Complex FA
Benign Epithelial Breast Lesions - Epithelial Hyperplasia
Hyperplasia in normal breast tissue is defined by the presence of >2 cell layers
Moderate to florid hyperplasia is >4 cell layers
The proliferating epithelium including both the luminal and myoepithelial cells, fill and distend the ducts and lobules
Benign Epithelial Breast Lesions - Fibroadenoma
Can occur at any age, but more commonly within the reproductive age and most commonly in women <30yrs
Usually multiple and bilateral in occurrence
Present as firm, movable mass that does not adhere to chest wall or skin of the breast
Occur under the influence hormones and usually increase in size towards the end of each menstrual cycle or as a result of lactational change
Fibroadenoma Microscopy
Well circumscribed, non encapsulated
Biphasic tumour, proliferation of both glandular and stomal elements
Glands are compressed into linear structures by proliferating stroma
Peri canalicular - glands retain open lumens but separated by expanding stoma
Stroma is uniform with collagen and spindle stromal cells with oval or elongated nuclei
Benign Epithelial Breast Lesions - Gynaecomastia
Enlargement of the male breast
Occurs as a result of hormonal changes of fluctuations of oestrogens/progesterone compared to male androgens
Can be as a result of hypertrophy and hyperplasia of the glandular and parenchymal breast tissue
Morphology:
- proliferation of stroma and epithelium
- epithelial hyperplasia with papillary projections
Frozen Sections and Applications
Urgent biopsy reporting
Establishing whether the tissue obtained contains diagnostic material or whether additional sampling is required
Used for demonstration of soluble substances
- enzymes, lipid, some carbohydrates
Frozen Sections Theory
Frozen tissue is supported/embedded in frozen tissue fluid/ice
Consistency dependent on T
- reducing the temp will harden the block
- section at -10 to -25 depending on tissue e.g. fatty tissue at cooler T
- fixed tissue requires higher temp to section -10°
Cryostat Technique
Fresh tissue
Rapid freezing - cabinet temperature -15° to -23°
Liquid Nitrogen (-190 ), Isopentane cooled by liquid Nitrogen (-150°C), CO2 gas (-70), aerosol sprays (-50)
Tissue support medium - OCT
What are Clean Slides for Frozen Sections Coated with?
Poly-l-lysine
Albumin
