Breast Pathology

Question 1

How does breast pathology usually present?

Answer 1

• Painful breast
• Palpable mass
• Nipple discharge

Question 2

How can one classify different breast pathologies?

Answer 2

• Inflammatory conditions
• Benign proliferative conditions
• Benign neoplastic conditions
• Malignant neoplastic conditions

Question 3

Name some inflammatory pathologies of the breast

Answer 3

• Mammary duct ectasia
• Acute mastitis
• Fat necrosis

Question 4

What is mammary duct ectasia? What is the epidemiology? Symptoms? Cytology?

Answer 4

It is granulomatous inflammation and dilatation of the breast ducts.

It usually affects women ages 40-60.

It presents with a periareolar mass, and thick white nipple secretions.

On cytology, there are large dilated ducts, with proteinaceous material and inflammatory cells.

Question 5

What is acute mastitis? What is the epidemiology? Symptoms? Cytology? How is it treated? Are there any other variations?

Answer 5

This is an acute infection of the breast.

It most commonly occurs during lactation or breastfeeding, as a result of staphylococcus infection through cracks in the nipple.

It presents as a painful, tender red breast and fever.

On cytology, the breast tissue is necrotic, and infiltrated with neutrophils.

It is treated with antibiotics and drainage.

There is also periductal mastitis, associated with smoking (not lactation) that shows keratinising squamous epithelium extending deep into nipple duct orifices.

Question 6

What is fat necrosis? What is the epidemiology? Symptoms? Cytology?

Answer 6

This is an inflammatory reaction to damaged adipose tissue.

It is usually caused by trauma, radiotherapy or surgery.

It presents as a painless breast mass.

Question 7

Name some benign proliferative conditions of the breast

Answer 7

• Fibrocystic disease/fibroadenosis
• Phyllodes tumour
• Gynaecomastia
• Epithelial hyperplasia
• Flat epithelial hyperplasia
• In situ lobular neoplasia

Question 8

How does one investigate any breast pathology?

Answer 8

• Clinical history and examination
• Imaging (mammogram, US or MRI)
• Cytology/histopathology (fine needle aspirate or core biopsy)

Question 9

What is the gold standard in diagnosing malignancy in the breast?

Answer 9

Histopathology

Question 10

How is cytological evaluation of breast tissue divided to summarise the suspicion of malignancy?

Answer 10

C1-5

• C1 = inadequate sample
• C2 = benign
• C3 = atypical but benign
• C4 = suspicion of malignancy
• C5 = malignant

Question 11

What is fibrocystic disease? What is the epidemiology? Symptoms? Cytology?

What is fibroadenosis

Answer 11

This is fibrous and cystic tissue changes within the breast, caused by an exaggerated normal response to hormones.

This is very common.

It presents as a ‘lumpy breast’.

On cytology, one can see small cysts which contain fluid, and inflammation and fibrosis secondary to cyst rupture.

Fibroadenosis involved fibrous changes with an increased number of acini per lobule.

Question 12

What is phyllodes tumour? What is the epidemiology? Symptoms? Cytology?

Answer 12

This is a leaf-like tumour arising from the interlobular stroma. They are mostly benign, but can be aggressive and malignant.

They usually affect those above the age of 50.

They usually present as a palpable mass.

Question 13

What is gynaecomastia? What is the epidemiology? Symptoms? Histology?

Answer 13

This is unilateral/bilateral enlargement of the male breast, usually caused by a hyperoestrogenic state (alcohol, liver damage, testicular tumour).

It most commonly affects prepubertal boys and men over the age of 50.

It presents as enlargement of the breast tissue.

On histology, there is epithelial hyperplasia and finger like projection into ducts.

Question 14

Name some benign neoplastic conditions of the breast

Answer 14

• Fibroadenoma
• Duct papilloma
• Radial scar

Question 15

What is a fibroadenoma? What is the epidemiology? Symptoms? Cytology?

What is the treatment?

Answer 15

This is a benign tumour from the stroma.

It can occur at any age, but most commonly affects those in reproductive age. They can increase in size during pregnancy, and calcify after menopause.

They usually present as a painless, mobile hard lump.

On cytology, there is an overgrowth of collagenous mesenchyme.

Treat by surgical removal.

Question 16

What is a duct papilloma? Symptoms? Cytology?

Answer 16

This is a benign papillary tumour arising anywhere within the ductal system of the breast.

It usually presents with bloody discharge and no lump.

On cytology, some duct dilation is seen with a central papillary growth.

Question 17

What is a radial scar? Cytology?

Answer 17

This is a benign sclerosing lesion.

On cytology, there is a central scarring with surrounding proliferating glandular tissue in a stellate pattern.

Question 18

Name some malignant neoplastic conditions of the breast

Answer 18

• Carcinoma in situ

- Invasive carcinoma

Question 19

What is the epidemiology surrounding breast cancer?

Answer 19

It is the most common cancer in women, affecting 1 in 8.

It usually affects those aged over 75 (younger in afro-Caribbean’s)

There is a ethnic predilection to Caucasian women.

Question 20

What are the risk factors associated with breast cancer?

Answer 20

Genetic:

• BRCA1 or 2 mutations
• Also susceptible to other gynaecological cancers
• Up to 85% of women with a BRCA mutation will develop cancer

Hormonal:

• Oestrogen exposure
• Early menarche/late menopause
• Nulliparity
• Obesity/alcohol
• COCP

History:

• Age
• Family history
• Ethnicity

Question 21

What is carcinoma in situ? What types exist?

Answer 21

This is a neoplastic proliferation of cells that is limited to the ducts or lobules by a basement membrane.

They can be ductal or lobular.

Ductal:

• Higher incidence since screening programme
• Increased risk of progression to invasive cancer
• Surgical removal is curative

Lobular:
- Always incidental as no calcification

Question 22

What is invasive carcinoma? What types exist?

Answer 22

This is neoplastic proliferation of cells that has infiltrated within the breast, with the capacity to spread to distal sites.

They can be ductal, lobular, tubular, mucinous or basal-like.

Ductal:

• Cannot be classified into another group
• Most common

Lobular:
- Cells aligned in chains/strands

Tubular:

• Cells arranged into tubules
• Rarely palpable as very small

Mucinous:
- Abundant quantities of mucin

Basal-like:

• Sheets of atypical cells with lymphocytic infiltrate
• Positive for CK 5, 6 and 14
• Negative for ER/PR/HER2 receptors

Question 23

How are neoplastic conditions graded?

Answer 23

They are given a score out of 3 for their:

• Nuclear polymorphism
• Tubule formation
• Mitotic activity

Scores 3-5: Grade 1
Scores 6-7: Grade 2
Scores 8-9: Grade 3

Question 24

What is the significance of hormone receptor activity with neoplastic conditions?

What treatments are available to these?

Answer 24

They are all assessed for their oestrogen, progesterone and HER2 receptor status.

Oestrogen/Progesterone receptor positive: good prognosis

HER2 receptor positive: poor prognosis

Treatments:

• ER/PR +ve: tamoxifen [mixed agonist/antagonist of oestrogen at receptor]
• HER2 +ve: Herceptin/trastuzumab [monoclonal Ig to HER2] (cardiotoxic, monitor LVEF)

Question 25

What is the current screening programme for breast cancer in the UK?

Answer 25

Women aged 47-73 invited for mammogram every 3 years

Question 26

What is the triple assessment?

Answer 26

- Examination - Imaging (mammogram, US or MRI) - Cytology (fine-needle aspirate or biopsy)

Question 27

Describe the epidemiology surrounding male breast cancer. How does it present? Cytology?

Answer 27

This is a very rare cancer, accounting for 0.2% of all cancers. It usually affects males above the age of 65. It presents as a palpable mass. On cytology, it can show the same types of breast carcinoma as in females.