Flashcards in Breast Pathology Deck (87):
What imaging is used in the assessment of breast disease?
What pathology testing is carried out in breast disease assessment?
How are samples taken for breast cytopathology?
What are the categories in breast FNA cytology?
C3- Atypia, probably benign
C4- Suspicious of malignancy
What Ix are carried out in breast histopathology?
(Needle) core biopsy
Vacuum assisted biopsy (large volume, mammotome)
Incisional biopsy of mass
What therapeutic interventions are carried out in breast histopathology?
Excisional biopsy of mass
Resection of cancer- wide local excision/mastectomy
What are the categories in breast needle core biopsy?
B1 - Unsatisfactory / normal
B2 - Benign
B3 - Atypia, probably benign
B4 - Suspicious of malignancy
B5 - Malignant
B5a - carcinoma in situ
B5b - invasive carcinoma
What are some developmental anomalies in breast growth?
Accessory breast tissue
What are some non-neoplastic breast diseases?
Sclerosing lesions- sclerosing adenosis, radial scar/complex sclerosing lesions
What are some inflammatory benign breast diseases?
What are some benign tumours of the breast?
What is gynaecomastia?
Breast developmental in the male
Ductal growth without lobular development
What are some causes of gynaecomastia?
When do fibrocystic changes usually occur?
20-50yo, majority 40-50
What are the clinical features of fibrocystic change?
Often resolve or diminish after menopause
How do fibrocystic changes present?
Smooth discrete lumps
What is the usual appearance of cysts related to fibrocystic changes?
1mm to several cm
Blue domed with pale fluid
Associated with other benign changes
How do cysts related to fibrocystic changes appear microscopically?
Thin walled, but may have fibrotic wall
Lined by apocrine epithelium
How are cysts managed?
Excise if necessary
What is a hamartoma?
Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution
How do fibroadenomas usually present?
Common- found through screening
Usually solitary (10% multiple)
Commoner in African women
When is the peak incidence of fibroadenomas?
How will fibroadenomas feel?
How will fibroadenomas appear on US?
How will fibroadenomas appear grossly and microscopically?
Biphasic tumour/lesion- epithelium/stroma
How is fibroadenoma managed?
Describe sclerosing lesions
Benign, disorderly proliferation of acini and stroma
Can cause a mass or calcification
May mimic carcinoma
How will sclerosing adenosis present?
Pain, tenderness of lumpiness/thickening
How will radial scar present?
Wide age range
Common- 67% multicentric, 43% bilateral
How is a radial scar and complex sclerosing lesion differentiated?
Describe the appearance of a radial scar
What are the histological characteristics of a radial scar?
Radiating fibrosis containing distorted ductules
Are radial scars malignant?
Mimic carcinoma radiologically
Likely not premalignant
In situ or invasive carcinoma may occur within lesion
What can cause fat necrosis?
Local trauma- seat belt trauma, frequently no Hx
What occurs in fat necrosis?
Damage and disruption of adipocytes
Infiltration by acute inflammatory cells
Subsequent fibrosis and scarring
How is fat necrosis managed?
What are the clinical features of duct ectasia?
Affects sub-areolar ducts
Acute episodic inflammatory changes
Bloody and/or purulent D/C
Nipple retraction and distortion
What is duct ectasia associated with?
Does fibrosis occur in duct ectasia?
Yes- Periductal fibrosis
How is duct ectasia managed?
Treat acute infections
What are the 2 main causes of acute mastitis/abscess?
Duct ectasia- mixed organisms, anaerobes
Lactation- staph aureus, strep pyogenes
How is acute mastitis/abscess managed?
Incision & drainage
Treat underlying cause
What are the clinical features of phyllodes tumour?
Slow growing unilateral breast mass
Describe the growth of phyllodes tumour
Behaviour depends on stromal features
Benign, borderline, malignant (sarcomatous)
What is the behaviour of phyllodes tumour?
Pathology helps to predict
Prone to local recurrence if not adequately excised
What are the papillary lesions of the breast?
Encysted papillary carcinoma
What are the symptoms and signs of intraduct papilloma?
Nipple discharge +- blood
Asymptomatic at screening- nodules, calcification
What age group is effected by intraduct papilloma?
What are the pathological and clinical features of intraduct papilloma?
Papillary fronds contained a fibrovascular core, covered by myoepithelium and epithelium
Epithelium may show proliferate activity
What are the categories of epithelial proliferation in intraduct papilloma?
Usual type hyperplasia-benign
Atypical ductal hyperplasia
Ductal carcinoma in situ
What tumours often metastasise to the breast?
Carcinoma- bronchial, ovarian serous carcinoma, clear cell carcinoma of kidney
Soft tissue tumours- leiomysarcoma
Where does breast carcinoma arise from?
Glandular epithelium of the terminal duct lobular unit (TDLU)
What are some ductal precursor lesions of breast carcinoma?
Epithelial hyperplasia of usual type
Columnar cell change
Atypical ductal hyperplasia
Ductal carcinoma in situ
What are some lobular precursor lesions of breast carcinoma?
Lobular in situ neoplasia- atypical lobular hyperplasia, lobular carcinoma in situ
Where is in situ carcinoma confined within?
Basement membrane of acini and ducts
What is in situ carcinoma on cytologically?
Malignant but non-invasive
What is the difference between atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS?
ALH <50% of lobule involved
LCIS >50% of lobule involved
What are the pathological findings in lobular in situ neoplasia?
Small-intermediate sized nuclei
E-cadherin -ve (deletion & mutation of CDH1 on Ch 16)
What are the clinical features of lobular in situ neoplasia?
Frequently multifocal and bilateral
Incidence 0.5-4% in benign biopsies
Incidence decreases after menopause
Not palpable, not visible grossly
May calcify – mammography
Usually an incidental finding
What is the management of lobular in situ neoplasia?
LN on core biopsy- proceed to excision or vacuum biopsy to exclude higher grade lesion
LN on vacuum or excision biopsy- follow up, clinical trials
What is the risk of progression to invasive carcinoma of epithelial hyperplasia of usual type?
What is the risk of progression to invasive carcinoma of atypical ductal hyperplasia?
What is the risk of progression to invasive carcinoma of ductal carcinoma in situ (low grade)?
10x RR (25% over following 10y)
What % of breast malignancies are DCIS?
Where does DCIS arise?
What is characteristic about DCIS?
Unicentric (single duct system)
What are the pathological features of DCIS?
Cytologically malignant epithelial cells
Confined within basement membrane of duct
May involve lobules (cancerisation)
May involve nipple skin (Paget's)
What is Paget's disease of the nipple?
High grade DCIS extending along ducts to reach epidermis of nipple
Still in situ carcinoma (non invasive)
What is used to classify DCIS?
Presence of necrosis (comedo)
Describe microinvasive carcinoma
DCIS (high grade) with invasion of <1mm
Treat as high grade DCIS
Why is DCIS significant?
RF for development of invasive carcinoma
True precursor lesion
75% progress to invasion following incisional biopsy only
How is DCIS managed?
Surgery- trials of mammographic follow-up in low risk DCIS
What is the definition of an invasive carcinoma?
Malignant epithelial cells which have breached the BM
What are the RFs for breast carcinoma?
Reproductive history- age at menarche/first birth/menopause, parity, breast feeding
Hormones- endogenous, exogenous- OCP, HRT
Previous breast Hx
Lifestyle- bodyweight, physical activity, alcohol, diet, NSAID (lower risk), smoking
By how much is the RR increased if a first degree relative is affected by breast cancer?
Describe the incidence and risk of BRCA 1/2
Each present in 0.1% of population (approx 1 in 450 carry mutation in one of these genes)
2% of all breast cancers
45-64% lifetime risk
What is the 1,5,10,20y survival rate for breast cancer?
How can invasive breast carcinoma be classified histologically?
What is tumour grade a measure of?
If a tumour is very similar to the parent tissue, is it well or poorly differentiated, and thus a good or poor prognosis?
Well differentiated, therefore good prognosis
What is assessed in breast carcinoma grading?
Tubular differentiation (1-3)
Nuclear pleomorphism (1-3)
Mitotic activity (1-3)
How is tumour grade scored from it's assessment?
Score 3,4,5= Grade 1
6 or 7= Grade 2
8 or 9= Grade 3
What does ER expression in invasive carcinoma predict?
Response to anti-oestrogen therapy: oophorectomy, tamoxifen, aromatase inhibitors, GnRG antagonists
What does HER2 overexpression or amplification in invasive carcinoma predict?
Response to trastuzamad (Herceptin)
Seen in ~15%
What hormone receptors will usually be +ve in invasive carcinoma?
What is the Nottingham Prognostic Index?
Histopathology based (grade and stage)