Week 7 - B - Breast Pathology - Triple assessment, Cyto/histopathology, Benign - Non-neoplastic, inflammatory and tumours

Question 1

Management of Breast Disease • Multi-Disciplinary Team (MDT) – Surgeon – Radiologist – Pathologist – Oncologist – Breast Care Nurse In a person presenting with breast disease, what is the triple assessment that is often carried out?

Answer 1

Clinical, Imaging and Pathology assessment

Question 2

What is done in the clinical assessment? What is done in the imaging assessment? What is done in the pathology assessment?

Answer 2

Clinical assessment of breast disease - history and breast examination Imaging assessment of breast disease - Mammography, Ultrasound and MRI are the options Pathology assessment of breast disease - cytopathology and histopathology

Question 3

Clinical assessment - history and examination Imaging - Mammography, Ultrasound and MRI As this is a pathology lecture, shall be focusing more on the cytopathology and histopathology What is the difference between cytopathology and histopathology? Which ways can you obtain cytopathology samples of the breast?

Answer 3

Cytopathology involves studying the cells at a cellular level Cytopathology is generally used on samples of free cells or tissue fragments, in contrast to histopathology, which studies whole tissues. Obtaining cytopathology samples * Fine needle aspiration * Fluid * Nipple dischare * Scrape

Question 4

The cytology of the breast fine needle aspiration is graded from C1-C5 What are these 5 grades?

Answer 4

C1 - unsatisfacory C2 - Benign C3 - Atypia - probably benign C4 - Suspicious of malignancy C5 - Malignant

Question 5

What were the different methods of collecting samples for cytopathology again? What was the other part for looking at pathology in the triple assessment?

Answer 5

Different methods

• * Fine needle aspiration
• * Fluid
• * Nipple discharge
• * Nipple scrape

C1 - unsatisfactory C2 - bengin C3 - atypia, probably benign C4 - Suspicious of malignancy C5 - Malignant

The other part is histopathology - look at large sample of tissue under the microscope

Question 6

There are two different ways at looking at the histopathology of the breast cancer Diagnostic and therapeutic are the two categories Which ways can you obtain samples for a diagnostic histopathology?

Answer 6

Diagnostic histopathology - * core biopsy * Vacuum assisted biopsy * Skin biopsy * Incisional biopsy of mass

Question 7

Diagnostic histopatologies Core biopsy Vacuum assisted biopsy Skin biopsy Incisional biopsy of mass What are the options for carrying out therapeutic histopthaology?

Answer 7

Excisional biopsy of mass Resection of cancer - wide local biopsy or mastectomy

Question 8

One more time, name both the diagnostic and therapeutic histoathology procedures

Answer 8

Diagnostic

• * Core biopsy
• * Vacuum assisted biopsy
• * Skin biopsy
• * Incisional biopsy of mass

Therapeutic

• * Excisional biopsy of mass
• * Resection of cancer
  
  • * Wide local excision
  • * Mastectomy

Question 9

As the cytopathology fine needle aspiration results can be graded from C1 to 5, how can the needle core biopsy results be graded?

Answer 9

Histopathology results

• * B1 - unsatisfactory/normal
• * B2 - benign
• * B3 - Atypia, probably benign
• * B4 - Suspicious of malignancy
• * B5 - Malignant
  
  • * B5a - carcinoma in situ
  • * B5b - invasive carcinoma

Question 10

State the gradings for DNA cytopathology? and for Needle core biopsy histopathology?

Answer 10

Cytopathology results C1 - unsatisfactory C2 - benign C3 - atypia, probably benign C4 - suspicious of malignany C5 - malignant

Histopathology results

• B1 - unsatisfactory/normal B2 - benign B3 - Atypia, probably benign B4 - Suspicious of malignancy B5 - Malignant
  
  • * B5a - carcinoma in situ
  • * B5b - invasive carcinoma

Question 11

What result on needle core biopsy distinguishes a carinoma in situ from an invasive carcinoma?

Answer 11

B5a needle core biopsy - this is a carcinoma in situ B5b needle core biopsy - this is an invasive carcinoma

Question 12

Pathology of benign breast disease Can be due: Developmental anomalies Non neoplastic change Inflammatory Tumours Name 4 different causes of developmental anomalies of the breast?

Answer 12

* Hypoplasia of the breast * Juvenile hypertrophy of the breast * Accessory breast tissue * and Accessory nipple

Question 13

Non-neoplastic breast changes are another causes of benign breast disease pathology What is gynaecomastia? What gender does it affect?

Answer 13

Gynaecomastia is breast development in the male which is due to ductal growth without lobular development

Question 14

Gynaecomastia is breast development in males where there is ductal growth without lobular development What are some of the causes of gyaecomastia?

Answer 14

* Exogenous/endogenous hormones * Cannabis * Prescription drugs * Liver disease

Question 15

Why can liver disease cause gynaecomastia? What is usually the treatment of gynaecomastia?

Answer 15

Liver disease can cause increased oestrogens which can lead to gynaecomastia Oestorgen causes ductal development (ie remember in pregnant mothers oestrogen causes ductal development whereas progesterone causes lobular development) Usually no treatment but if persistent embarrassment, can give tesosterone if hypogonadism or tamoxifen (oestrogen receptor modulator)

Question 16

Another causes of non-neoplatic benign breast disease is fibrocystic change What is fibrocystic change?

Answer 16

This is where there is the excess of fibrous tissue in the breast and the presence of multiple small cysts usually

Question 17

Who gets fibrocystic change of the breast? What age group as well? When does the fibrocystic change often resolve by?

Answer 17

Usually women ages 20-50 It is more common in women with menstrual abnormalities ie woman who had an early menarche or late menopause It usually resolves after menopause

Question 18

What is thought to be the cause of the fibrocystic change?

Answer 18

It is usually thought to be associated with the cyclical change in a women - the symptoms usually tend to fluctuate with the menstrual cycle

Question 19

How does fibrocystic change tend to present?

Answer 19

It is usually presents with Smooth discrete lumps of the breast with sudden pain and tenderness that fluctuates with the menstrual cycle - the pain tends to worsen around menses The pain usually presents before and during menses and the lumps are often multiple and bilateral

Question 20

How are the fibrocystic breasts described on gross pathology? What is the tenderness and breast pain that is often cyclical known as?

Answer 20

On gross pathology it is described as mutliple blue domed cysts with pale fluid that usually range from 1mm to several cm in size Mastalgia

Question 21

What does the fibrocystic change look like on micropathology of the breast? (ie if a needle core biopsy has been taken?

Answer 21

Usually the cysts are thin walled but may have a fibrotic wall and are lined by apocrine endothelium There is also intervening fibrosis in the breast

Question 22

Summarise what you know about fibrocystic change of the breast

Answer 22

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Question 23

Define metaplasia?

Answer 23

This is where this is change from one fully differentiates cell type to another fully differentiated cell type

Question 24

Histological findings that confirm fibrocystic breasts are apocrine metaplasia and hyperplasia, gross and microscopic cysts, and fibrosis. Apocrine glands are typically odour secreting sweat glands (Dermatology remember) What is the management of fibrocytisc change?

Answer 24

Exclude malignancy - can USS/Xray dependent on age, FNA or Biopsy dependent on palpating cystic or solid lump Reassure Excise if necessary

Question 25

What is a hamartoma?

Answer 25

A mammary hamartoma is a benign circumscribed lesion composed of all cell types normal to the breast but present in an abnormal proportion o distribution Basically a collection of benign disorganized cells indigenous to its site

Question 26

What is a fibroadenoma?

Answer 26

A fibroadenoma is a benign overgrowth of the collagenous mesenchyme of one breast lobule resulting in the formation of a lump

Question 27

What ethnicity are fibroadenomas more common in and what age group do they usually occur in?

Answer 27

They are commoner in african women and typically present in women <30 years of age but can occur up until menopause

Question 28

Fibroadenomas tend to be found on screening How does it usually present if symptomastic?

Answer 28

Fibroadenomas usually present as firm, smooth, mobile breast masses which are painless They can present as multiple masses

Question 29

Why are they often known as breast mice? As they are firm, smooth mobile lumps usually in patients below 30, what scan is mostly used for imaging of the lump? How do the lumps appear on this imaging?

Answer 29

They are often known as breast mice due to their high mobility in the breast Unlike typical lumps from breast cancer, fibroadenomas are easy to move, with clearly defined edges. Usually USS is used and the lumps appear solid on ultrasound

Question 30

Fibroadenomas are well circumscribed and rubbery with a grey/white colour WHat type of proliferation describes the fibroadenoma?

Answer 30

The fibroadenoma has biphasic proliferation of the epithelium and stroma

Question 31

How is the fibroadenoma managed? As the mass is solid on ultrasound, what is usually carried out next?

Answer 31

Usually after seeing the solid mass on ultrasound, fibroadenomas are managed by a needle core biopsy to confirm the benign mass and then reassure the patient it is not malignant Excision of the fibroadenoma is an option

Question 32

Sclerosing lesions • Sclerosing adenosis • Radial scar / Complex sclerosing lesion What is a sclerosing lesion of the breast?

Answer 32

A sclerosing lesion of the breast is the hardening of the breast that occurs as age does and may mimic a carcinoma

Question 33

Sclerosing adensosis is one of the types of sclerosing lesions of the breast It is due to the benign, disorderdly proliferation of the breast acini and stroma What do the breast acini contain? How does sclerosing adenosis usually present?

Answer 33

Breast acini contains the secretory epithelium of the breast - the acini line the lobules of the breast Sclerosing adenosis usually presents as lump that is painful, tender of lumpiness that is thickening It can be asymptomatic and found on routine scans Occurs in patients aged 20-70

Question 34

Sclerosing adenosis can be difficult to diagnose as it can occasionally look like breast cancer on a mammogram. Because of this, a biopsy may be needed to make a firm diagnosis. What is a radial scar sclerosing lesion?

Answer 34

A radial scar is a benign hyperplastic proliferative disease of the breast.

Question 35

WHat is the difference between a radial scar nd complex sclerosing lesions?

Answer 35

Radial scars and complex sclerosing lesions are benign (not cancer) conditions. They are the same thing but are identified by size Radial scars on pathology are less than 1cm - 1to9mm Complex sclerosing lesions are greater than 1cm - >10mm

Question 36

Radial scars mimic invasive carcinomas of the breast and therefore are very difficult to distinguish based on immaging Describe the cell structure in a radial scar?

Answer 36

There is a stellate architecture - star like appearance with central puckering and radiating fibrosis

Question 37

Histologically, the radial scar has a fibroelastic core, radiating fibrosis containing distorted ductule and fibrocystic change How is the architecture of a radial scar described again?

Answer 37

It is described as a stellate architecture In oncology, a spiculated mass is a lump of tissue with spikes or points on the surface. It is suggestive but not diagnostic of malignancy, This spiculated mass is seen with radial scars on the xray - can see the spikes

Question 38

Radial Scar • Mimic carcinoma radiologically • Probably not premalignant per se • Often show epithelial proliferation • In situ or invasive carcinoma may occur within these lesions Even though the diagnosis can usually be made on a core biopsy, what may be offered as treatment?

Answer 38

Excision biopsy or a vacuum assisted biopsy as this takes a large sample of tissue

Question 39

Inflammatory lesions • Fat necrosis • Duct ectasia • Acute mastitis/abscess How does fat necrosis occur?

Answer 39

This occurs when here is injury to the breast tissue causing damage to the adipocytes in the breast

Question 40

When there is damage and disruption of the adipocytes, what happens? What causes the injury to the breast tissue?

Answer 40

When there is damage to the breast tissue, there is infiltration by acute inflammatory cells eg foamy macrophages and these cells cause subsequent firbossis and scarring Fat necrosis can be due to local trauma and warfarin therapy is also a cause of fat necrosis

Question 41

What is the management of fat necrosis of the breast?

Answer 41

Tripe assessment of the breast is required as the scarring results in a firm lump formation

• History and examination
• Xray/USS dependent on age
• Probably core biopsy next

Question 42

What is duct ectasia?

Answer 42

Duct ectasia is a condition in which the lactiferous ducts became blocked or clogged

Question 43

Which lactiferous ducts are typically affected by duct ectasia? What is the presenting features of duct ectasia?

Answer 43

It is usually the sub-areolar lactiferous ducts that are blocked in duct ectasia Presents with pain and nipple discharge - green/brown/bloody, nipple retraction and a lump often

Question 44

What is duct ectasia associated with? Why does this condiiton potenitally mimic cancer?

Answer 44

Duct ectasia * • Associated with smoking * • Sub-areolar duct dilatation * • Periductal inflammation * • Periductal fibrosis * • Scarring and distortion Cancer can often cause nipple retraction/inversion and and an odd discharge with a lump

Question 45

When does duct ectasia typically occur? What is the management plan?

Answer 45

Typically occurs around menopause Confirm diagnosis and exclude malignancy And stop smoking

Question 46

Acute mastitis/abscess is the other cause of breast inflammation (after fat necrosis and duct ectasia) What are the usual two ways in which acute mastitis / abscess can occur in women? Which organisms can affect the breast in both etiologies?

Answer 46

Duct ectasia - mixed organsisms Lactation - staph aureus most commonly but also maybe strep pyogenes

Question 47

Tender spot, redness, sore lump without fever – blocked duct A tender spot or lump and a low grade fever – breast infection When are antibiotics considered in mastitis?

Answer 47

Antibiotics are considered if symptoms of the mastitis haven’t improved 24 hours after pain relief and expressing before feeds

Question 48

What is a breast abscess?

Answer 48

This is a localised collection of pus that forms in a breast due to a blocked duct usually - it presents as a painful hot swelling of a breasts egement and requires draining before antibiotic treatment

Question 49

What is the management of acute mastitis / abcess? Mastitis can occur with or without fever/infection (without fever/infection - blocked duct, with - infection) Acute mastitis is another term for infective mastitis

Answer 49

The management is to treat with antibiotics usually flucloxacillin If abscess Then percutaenous drainage or open incision and drainage

Question 50

What are the antibiotics given for the treatment of acute maastitis/abscess?

Answer 50

Flucloxacillin is given for 7 days If pen allergic give clindamycin

Question 51

Benign breast pathology Tumours • Phyllodes tumour • Intraduct papilloma What is phyllodes tumour?

Answer 51

This is a slow growing unilateral breast mass that forms from the periductal stromal cells of the breast

Question 52

What age group do phyllodes tumours tend to affect? Phyllodes comes form greek - phyllos meaning leaf Why is named this?

Answer 52

Usually affects those aged 40-50 The tumour is said to appear leaf like on histology

Question 53

Once excised, will a phyllodes tumour come back? What is the type of excision commonly carried out for a Phyllodes tumour?

Answer 53

Once excised, it is prone to local recurrence if it is not adequately excised But rarely metastasis The type of excision carried out is usually a wide local excision of the tumour

Question 54

Papillary lesions * • Intraduct papilloma * • Nipple adenoma * • Encysted papillary carcinoma These are the three main types of benign papillary lesions of the breast A papilloma is a benign epithelial tumor outwardly projecting What are the common symptoms of an intraductal papilloma?

Answer 54

It usually presents middle aged with nipple discharge from one breast that is often bloody

Question 55

What is an intraductal papilloma?

Answer 55

It is a benign papillary proliferation (epithelial growth) of growth within the lactiferous ducts of the breast that commonly produces bloody nipple discharge and is found middle aged

Question 56

As the intraductal papilloma is due to epithelial proliferation, what are the different categories of the epithelial proliferation in intraductal papillary lesions?

Answer 56

None Usual type proliferation Atypical ductal proliferation Ductal carcinoma in situ