Breast pathology 2

Question 1

what are the types of breast malignancy

Answer 1

Malignant phyllodes tumour

angiosarcoma

lymphoma

metastatic tumours

breast carcinoma

Question 2

what types of tumour tends to metastasise to the lungs

Answer 2

carcinoma

• bronchial
• ovarian serous carcinoma
• clear cell carcinoma of the kidney

malignant melanoma

soft tissue tumours
-leiomyocarcoma

Question 3

what is a breast carcinoma

Answer 3

a malignant tumour of Brest epithelial cells

arises in the glandular epithelium of the terminal duct lobar unit

its an adenocarcinoma but just called a breast carcinoma

Question 4

what precursor lesions are there for breast carcinoma in the ducts

Answer 4

epithelial hyperplasia
columnar cell change
atypical ductal hyperplasia
ductal carcinoma in situ

Question 5

what precursor lesions are there for lobular breast carcinoma

Answer 5

lobular in situ neoplasia

• atypical lobular hyperplasia (<50% of lobule involved)
• lobar carcinoma in situ (>50% of lobule involved)

Question 6

what is an in-situ carcinoma

Answer 6

carcinoma confined within basement membrane of acini and ducts

cytologically malignant however non-invasive

precursor of invasive carcinoma

Question 7

types of carcinoma in situ

Answer 7

lobar

ductal

Question 8

what does lobular in situ neoplasia look like under a microscope

Answer 8

intra-lobular proliferation of characteristic cells

• small nuclei
• solid proliferation
• intra-cytoplasmic lumens/vacuoles
• ER positive
• E-cadherin negative

Question 9

how does lobular in situ neoplasia present

Answer 9

incidental finding
not palpable or visible grossly
may calcify - mammography needed

Question 10

what is the significants of a lobular in situ neoplasia

Answer 10

marker of subsequent risk

true precursor lesion

Question 11

management of lobular in situ neoplasia

Answer 11

excision or vacuum biopsy to exclude higher grade lesion

Question 12

what are the types of intraductal proliferation

Answer 12

epithelial hyperplasia of usual type

columnar cell change (lesion)

columnar cell change with atypic

atypical ductal hyperplasia

ductal carcinoma in situ

Question 13

what are the features of ductal carcinoma in situ

Answer 13

15-20% of malignancies

Aries in the terminal ductal lobular unit

usually just effect a single duct system

Question 14

what is a ductal carcinoma in situ

Answer 14

malignant epithelial cells

confined to basement membrane of dict

may involve lobules (cancerisation)

may involve nipple skin (pages)

Question 15

what is a ductal carcinoma in situ involving nipple skin called

Answer 15

Paget’s disease of the nipple

high grade DCIS extending along ducts to reach the epidermis of the nipple

Question 16

what is ductal carcinoma in situ involving lobules called

Answer 16

cancerisation

Question 17

what is the significance of DCIS

Answer 17

risk for development of invasive carcinoma

true precursor lesion for invasive carcinoma

Question 18

how do you manage DCIS

Answer 18

surgery
adjuvant radiotherapy
chemoprevention
endocrine therapy

Question 19

what is a microinvasive carcinoma

Answer 19

rare
DCIS (high grade) with invasion of <1mm

treat as high grade DCIS

Question 20

what is an invasive breast carcinoma

Answer 20

malignant epithelial cells which have breached the BM

infiltration of normal tissues

risk of metastasis and death

Question 21

risk factors for invasive breast carcinoma

Answer 21

age

reproductive history

• age at menarche
• age at first birth
• parity
• breast feeding
• age at menopause

Hormones

• endogenous
• exogenous (OCP, HRT)

Previous breast disease

Geography

lifestyle

• body weight
• physical activity
• alcohol consumption
• diet
• NSAIDs (lowers risk)
• smoking

Genetics

• affected first degree relative doubles risk
• BRCA 1&2 (2% of all breast cancers)
• Other cancer syndromes

Question 22

what is the life time risk of breast cancer if you have BRCA 1 or 2

Answer 22

45-64%

Question 23

what’s the 1, 5 and 10 year survival rates for invasive breast carcinoma

Answer 23

1 year - 96%
5 year - 87%
10 year - 78%

Question 24

what is the pathway for invasive breast carcinoma to spread

Answer 24

Local invasion (T)

• stroma of breast
• skin
• muscles of chest wall

Lymphatics (N)
-regional draining lymph nodes

Blood-borne (M)

• bone
• liver
• brain
• lungs
• abdominal viscera
• female genital tract

Question 25

how is lymph drained from the breasts

Answer 25

intramammary nodes internal mammary nodes sentinel nodes drain into axillary nodes, apical nodes, intraclavicular nodes, supraclavicular nodes

Question 26

what are the different types of invasive breast carcinoma

Answer 26

``` Ductal (70%) Lobular (10%) Mucinous (2%) Medullary (3%) Tubular (2%) Cribriform (1%) Papillary (<1%) Mixed (10%) ```

Question 27

how are breast carcinomas graded

Answer 27

assessment of (graded 1-3) - tubular differentiation (1-3) - nucleuar pleomorphism (1-3) - mitotic activity (1-3) (measure of how different it the tumour is to the parent tissue) total score: 3-5 = grade 1 6 or 7 = grade 2 8 or 9 = grade 3

Question 28

what hormone receptors can breast cancers have (the hormones make the cancer grow more)

Answer 28

Oestrogen receptors (ER) Progesterone receptors (PhR) Human epithelial growth hormone receptors (HER2)

Question 29

what re the 3 major types of breast cancers divided by hormone receptors

Answer 29

ER+ HER2- (Most common, basal like) ER- HER2+ (HER2 carcinoma) ER- HER2- (normal breast like)

Question 30

what does ER receptor expression predict the response to

Answer 30

anti-oestrogen therapy - oophrectomy - tamoxifen - aromatase inhibitors - GnRH antagonists

Question 31

how are breast carcinomas staged

Answer 31

TNM T0-4 - local tumour growth N0-3 - regional lymph nodes M0-M1- blood born spread

Question 32

what are predictive and prognostic factors for invasive carcinoma

Answer 32

ER PgR HER2