Breast Pathology

Question 1

Define carcinoma

Answer 1

Malignant tumour of epithelial origin
A subtype of carcinoma depends on the organ or tissue of origin

Question 2

Define sarcoma

Answer 2

Malignant tumour arising from mesenchymal tissue

Question 3

Define lymphoma

Answer 3

Malignancy arising in lymphoid tissue

Question 4

Define leukaemia

Answer 4

Malignancy arising from haematopoietic cells

Question 5

Define malignant melanoma

Answer 5

Malignant tumour of melanocyte origin

Question 6

What is an excision biospy

Answer 6

Excise the area of abnormality with clear margins
Different to a diagnostic biospy

Question 7

What is an adenocarcinoma?

Answer 7

Gland forming/mucin producing tumour
GIT, Breast, endometrium, prostate

Question 8

What is the relationship between ducts and lobules in the mammillary breast?

Answer 8

Progressively branching ducts leads to terminal ductular lobular units
Terminal ducts branch into lobules

Question 9

Describe the normal breast histology

Answer 9

Grape like clusters of acini = lobules
Lobules connect into ducts -> more tube-like in structure.

Question 10

What is the epithelium like in normal breast histology?

Answer 10

Luminal epithelial cells
Overly myoepithelial cells on basement membrane.

Question 11

What are the key benign pathologies of the breast?

Answer 11

1. Epithelial hyperplasia - neoplasia (inc cell mass)
2. Papilloma - wart like growth in milk ducts
3. Fibroadenoma - neoplastic stromal cells and reactive epithelium
4. Hemangioma - of blood vessels
5. Fibrocystic disease -

Question 12

What are the different malignant pathologies can commonly affect the breast?

Answer 12

1. Ductal/lobular carcinoma in situ
2. Invasive ductal/lobular carcinoma
3. Phyllodes tumour - malignant counterpart of fibroadenoma - stromal.
4. Angiosarcoma

Question 13

What is the key feature of an in situ carcinoma?

Answer 13

Not invaded/breached the basement membrane

Question 14

What are the key inflammatory breast diseases?

Answer 14

Breast abscess/mastitis

Question 15

What are the key pathological features of a breast abscess?

Answer 15

Usually an infection acquired during breast feeding
Staphylococcus aureus from skin
Formation of a lacatation abscess

Question 16

What is the recommended treatment for a breast abscess?

Answer 16

Treated with antibiotics, continued expression of milk
Rarely - incision and drainage (can cause misshapen breast)

Question 17

What are the key histopathological features of fibrocystic breast changes?

Answer 17

Dilated and cystic ducts (large hollow spaces)- lined by single epithelium
Prominent apocrine metaplasia - outgrowths into ducts
No cytological atypia or mitoses

Question 18

What is the key history of fibrocystic breast disease?

Answer 18

Most common benign breast disease
Common in 30-5oyrs
Benign cystic typically mobile and rubbery on examination
Prone to hormonal alteration
Skin - dimpled or orange appearance, lumpy, thickened

Question 19

Do fibrocystic changes inc risk of breast cancer?

Answer 19

Not associated with an increased risk of malignancy

Question 20

What is the relevant histopathology of a fibroadenoma?

Answer 20

Growth of stroma compressing nearby glandular structures
No stromal atypica
Intact myoepithelial cell layer
Well defined/circumsided edge surrounded by background normal breast tissue

Question 21

What is the relevant history of a fibroadenoma disease?

Answer 21

Most common benign tumour of the female breast
Round, smooth, firm, mobile singular mass
Can occur at any age, most commonly 25yrs

Question 22

What is the key pathology underpinning a fibroadenoma?

Answer 22

Well-circumscribed, unencapsulated
Biphasic tumour - proliferation of glandular and stromal elements
No risk of malignancy

Question 23

What is the typical treatment for a fibroadenoma?

Answer 23

mage risk factors, patient preference
Conservative - follow up
Local surgical excision

Question 24

What are the key risk factors for breast carcinoma?

Answer 24

Age = 75% greater than 50yrs old
FH = up to 10% germline mutation in BRCA1/2
Reproductive history - early menarche, nulliparity, absence of breast feeding
Geographic = Europe and N America (diet, reproductive patterns and attitudes to breast feeding)

Question 25

What is the most common categoriy of breast malignancy?

Answer 25

Adenocarcinoma

Question 26

What is the difference between the in situ and invasive carcinoma stage of breast pathology?

Answer 26

In situ - neoplastic proliferation limited to ducts and lobules by basement membrane Invasive - penetrated the BM into stroma - potential for lymphovascular invasion and metastatic spread

Question 27

What are the key features of this close up look at normal breast pathology?

Answer 27

Single later of epithelial cells Basement membrane - pink line underneath - still in tact

Question 28

What is the key difference between ductal and lobular carcinoma in situ?

Answer 28

Cell of origin - ducts v lobules Ductal - in expression of e-cadherin, more likely to show calcification on mammography Lobular - dec expression of e-cadherin, less likely to show calcification on mammography (can still be present)

Question 29

What are the key features of ductal carcinoma in situ of low grade histopathology?

Answer 29

Atypical epithelium proliferation into the ducts (commonly excludes lumen) Intact basement membrane Darker areas of calcification Pink central areas of comedo necrosis

Question 30

What are the features of ductal cell carcinoma in situ in high grade histopathology?

Answer 30

Mitoses Abnormal muclear features Variation in nuclea shape and size Overlapping nuclei or cramped appearance

Question 31

What is the key risk of DCIS breast disease?

Answer 31

Precursor for invasive carcinoma

Question 32

What is the most common histological classification of breast cancer?

Answer 32

Invasive ductal carcinoma (70-80%)

Question 33

What are the key pathological features of the pathology of invasive ductal cell carcinoma?

Answer 33

Penetrated though BM and invaded stroma Can can lymphatic/vascular invasion and metastases Is an adenocarcinoma - mucin producing

Question 34

How does invasive ductal carcinoma appear on mammography?

Answer 34

Radiodense mass

Question 35

What skin changes can indicated invasive ductal carcinoma of the beast?

Answer 35

If central - nipple retraction Blocked lymphatics - peau d orange

Question 36

What are the gross histological features of ductal cell carcinoma of the breast?

Answer 36

Haphazard outline - not clear, projecting into nearby tissue Haphazard malignant glands - infiltrating stroma - different shape and size May also just have abnormal cells in stroma/adipose tisse as invades - single or indian files (lines of cells with large and darkened, circular nuclei)

Question 37

What is removed in a radical mastectomy? What are the consequences of this?

Answer 37

mammary glands Both pectoral muscles Entire axillary lymphatic tissue Causes - permanent disfigurement, shoulders caved, arm swelling (elephantiasis)

Question 38

What are the different treatment options that exist for breast cancer today?

Answer 38

Surgery - mastectomy, breast conserving (wide local excision) SLN biopsy - followed by axillary LN if positive Radiotherapy Chemotherapt Endocrine therapy - esotrgen antagonists Tissue targeted therapy - anti ERBB2 trastuzumab

Question 39

Who is invited to the NHS Breast Screening Programme?

Answer 39

All women aged 50 to 70 yrs - regerested with a GP every 3 years

Question 40

What is the role of pathology in breast cancer?

Answer 40

Biospy diagnosis - confirming benign or malignant Grade tumours - give prognostic value Identifying surface receptors

Question 41

What factors contribute to breast cancer tumour grading by Bloom Richardon System?

Answer 41

Tubule Formation (score from 1 -3) Nuclear Pleomorphism (1-3) Mitotic Activity(1-3) Combined 3-5 is grade 1 (well differentiated) 6-7 Grade 2 (moderately differentiated) 8-9 Grade 3 (poorly differentiated)

Question 42

For what treatments is hormone receptor status important in breast cancer?

Answer 42

Tamoxifen - must be ER or PGR positive Traztuzumab - targets HER2

Question 43

How does the receptor status of the tumour affect its prognosis?

Answer 43

Triple negative - more liekly to reoccur early on peak 2 years after diagnosis, risk then decreases HER2 positive - less risk, bipeak at 2 years and 7 years Luminal - lowest overall risk, relatively constant with small peak at 3 years *NOT YEAR IMPORTANT*

Question 44

What are the different methods of spread of an invasive carcinoma? Why are these important?

Answer 44

Direct spread Lymphocvascular space invasion Metastasis - locoregional lymph nodes, distant metastasis These are important prognostic factors

Question 45

What is the key lymphatic drainage of the breast?

Answer 45

Axillary up to 75/90% Parasternal lymph nodes Inferior phrenic lymph nodes

Question 46

What is the role of pathological sentinel lymph node biopsies?

Answer 46

Between one and 3 lymph nodes are sampled Axillary lymph node only is sentinel are positive If positive consider chemotherapy or radiotherapy alongside surgical treatment

Question 47

What are the TNM stages for breast cancer?

Answer 47

T 1 - less than2cm 2 - less than 5cm 3 - greater than 5cm 4 - skin or chest wall N 1 - ipsilatareal moveable axillary LN 2 - i fixed axillary or internal mammary LN 3 - infraclavicular, supracilvacule LN M 1 - distant metastasis

Question 48

What is the use of personalised medicine in breast pathology?

Answer 48

Oncotype DX - quantifies risk of breast cancer recurrence to give a recurrence score Low score are unlikely to benefit from additional chemotherapy alongside required hormonal therapy