Breast Pathology Flashcards
(99 cards)
1
Q
What is the gold standard assessment of a patient with breast disease?
A
Triple assessment;
Clinical - hx and exam
Imaging - MMG, USS, MRI
Path - cytopathology, histopathology
2
Q
What can give a sample of breast cytopathology?
A
FNA
Fluid
Nipple discharge
Nipple scrape
3
Q
What is the grading of breast FNA cytology?
A
C1 - unsatisfactory C2 - benign C3 - atypia but probs benign C4 - suspicious of malignancy C5 - malignant
4
Q
What are diagnostic breast histopathology mechanisms?
A
Needle core biopsy
Vacuum assisted biopsy
Skin biopsy
Incisional biopsy of mass
5
Q
What are the therapeutic breast histopathology mechanisms?
A
Vacuum assisted excision
Excisional biopsy of mass
Resection of cancer; wide local, mastectomy
6
Q
What is the grading for a needle core biopsy?
A
B1; unsatisfactory B2; benign B3; atypical probs benign B4; suspicious of malignancy B5; malignant (B5a; CIS, B5b; invasive carcinoma)
7
Q
What are developmental anomalies of benign breast disease?
A
Hypoplasia
Juvenile hypertrophy
Accessory breast tissue or nipple
8
Q
What are the common non-neoplastic pathologies of benign breast disease?
A
Gynaecomastia Fibrocystic change Hamartoma Fibroadenoma Sclerosing lesions; sclerosing adenosis or radial scar
9
Q
What are the benign inflammatory pathologies of the breast?
A
Fat necrosis
Duct ectasia
Acute mastitis/ abscess
10
Q
What are the benign tumours of the breast?
A
Phyllodes tumour
Intraductal papilloma
11
Q
What is gynaecomastia?
A
Breast development in the male
Ductal growth without lobular development
12
Q
What can cause gynaecomastia?
A
Exogenous/ endogenous hormones
Cannabis
Prescription drugs
Liver disease - increase in oestrogenic hormones
13
Q
What is the etiology of fibrocystic change of the breast?
A
Women aged 20-50; mostly 40-50
Very common
14
Q
What are risk factors for fibrocystic change of the breast?
A
Menstrual abnormalities
Early menarche
Late menopause
15
Q
What is the presentation of fibrocystic change of the breast?
A
Smooth discrete lumps Sudden pain Cyclical pain Lympiness Incidental finding Screening
16
Q
What is seen in the gross pathology of fibrocystic change of the breast?
A
Cysts; 1mm to several cm Blue domed with pale fluid Usually multiple Assoc with other benign changes Intervening fibrosis
17
Q
What is the microscopic pathology of fibrocystic change of the breast?
A
Cysts; thin walled
Apocrine epithelium
Intervening fibrosis
18
Q
What is metaplasia?
A
Change from one fully differentiated cell type to another fully differentiated cell type
19
Q
What is the management of fibrocystic change of the breast?
A
Exclude malignancy
Reassure
Excise if necessary
20
Q
What is a hamartoma?
A
Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution
21
Q
What is a fibroadenoma?
A
Common
Usually solitary
Commoner in African Women
22
Q
What is the clinical presentation of a fibroadenoma?
A
Painless, firm, discrete, mobile mass Solid on USS Circumscribed Rubbery Grey-white colour Biphasic tumour
23
Q
What is a biphasic tumour?
A
Has epithelium and stroma
24
Q
Tx for fibroadenoma?
A
Diagnose
Reassure
Excise if necessary
25
What is a sclerosing lesion?
Benign, disorderly proliferation of acini and stroma
Can cause mass or calcification
May mimic carcinoma
26
How will sclerosing adenosis present?
Pain
Tenderness
Lumpiness/ thickening
Can be asymptomatic
27
What is the pathology of a radial scar?
```
If 1-9mm = radial scar
If >10mm = complex sclerosing lesion
Stellate architecture
Central puckering
Radiating fibrosis
```
28
What is the histology of a radial scar?
Fibroelastic core
Radiating fibrosis containing distorted ductules
Fibrocystic change
Epithelial proliferation
29
What is the treatment for a radial scar?
Excise or sample extensively via vacuum biopsy
30
Is a radial scar premalignant?
No; but in situ or invasive carcinoma may occur within the lesion
Can mimic carcinoma radiologically
Shows epithelial proliferation
31
What can cause fat necrosis of the breast?
Local trauma; seat belt injury
| Recently stared warfarin therapy
32
What is the pathology of fat necrosis?
Damage and disruption of adipocytes
Infiltration by acute inflammatory cells
Foamy macrophages
Subsequent fibrosis and scarring
33
Tx for fat necrosis of breast?
Confirm diagnosis
| Exclude malignancy
34
What are the clinical features of duct ectasia?
```
Affects subareolar ducts
Pain
Acute episodic inflammatory changes
Bloody +/- purulent discharge
Fistulation
Nipple retraction and distortion
Periductal inflammation and fibrosis
```
35
What environmental factor is assoc with duct ectasia?
Smoking
36
Tx for duct ectasia?
Treat acute infections
Exclude malignancy
Stop smoking
Excise ducts
37
What are the 2 main aetiologies for acute mastitis?
Duct ectasia; mixed organisms, anaerobes
| Lactation; staph aureus, strep pyogenes
38
Mx for acute mastitis/ abscess?
Antibiotics
Percutaneous drainage
Incision and drainage
Treat underlying duct ectasia if present
39
What are the clinical features of a phyllodes tumour?
Slow growing unilateral breast mass
Biphasic tumour
Stromal overgrowth
40
What does the behaviour of a phyllodes tumour depend on?
Stromal features; benign, borderline, malignant (sarcomatous)
41
Does a phyllodes tumour tend to metastasize?
No
| But, prone to local recurrence if not adequately excised
42
What are the different forms of papillary lesion seen in the breast?
Intraductal papilloma
Nipple adenoma
Encapsulated papillary carcinoma
43
What is the presentation of an intraductal papilloma?
Nipple discharge +/- blood
| Asymptomatic at screening; nodules or calcification
44
What are the histological features of an intraductal papilloma?
Papillary fronds containing a fibrovascular core
| Covered by myoepithelium and epithelium which may show proliferative activity
45
What are the miscellaneous malignant tumours of the breast (not carcinomatous)?
```
Malignant phyllodes; sarcomatous stromal
Angiosarcoma; post XRT
Lymphoma; breast +/- lymph nodes
Metastatic tumours
Malignant melanoma
LEiomyosarcoma
```
46
What primary cancers can metastasize to the breast?
Bronchial
Ovarian serous
Clear cell carcinoma of kidney
47
What is the definition of a breast carcinoma?
A malignant tumour of breast epithelial cells
48
Where will a breast carcinoma arise from?
Glandular epithelium of the terminal duct lobular unit (TDLU)
49
What is the precursor lesion to ductal carcinoma of the breast?
Epithelial hyperplasia of usual type
Columnar cell change (+/- atypia)
Atypical ductal hyperplasia
Ductal carcinoma in situ
50
What is the precursor lesion to lobular carcinoma of the breast?
Atypical lobular hyperplasia
Lobular carcinoma in situ
Lobular in situ neoplasia
51
What is an in situ carcinoma of the breast?
Confined within the basement membrane of acini and ducts
| Cytologically malignant but non-invasive
52
Will all in situ carcinomas transform into an invasive carcinoma?
No; they are non-obligate
53
What is the difference between atypical lobular hyperplasia and lobular carcinoma in situ?
ALH; <50% of lobule
| LCIS; >50% of lobule
54
Describe the histopathology of lobular in situ neoplasia
```
Intralobular proliferation of characteristic cells
Small intermediate sized nuclei
Solid proliferation
Intra-cytoplasmic lumens/ vacuoles
ER positive
E-cadherin neg
```
55
What is E-cadherin in terms of breast carcinoma?
Deletion and mutation of the CDH1 gene on chromosome 16
56
What are the clinical features of lobular in situ neoplasia?
```
Multifocal and bilateral
Incidence decreases after menopause
Not palpable, not visible grossly
May calcify; seen on MMG
Incidental finding
```
57
What is the significance of lobular in situ neoplasia?
Marker of subsequent risk
| True precursor lesion
58
Mx for lobular in situ neoplasia?
Discovered on core biopsy; excision or vacuum biopsy to exclude higher grade lesion
Discovered on vacuum or excision biopsy; follow up
59
What is the follow up for lobular in situ neoplasia found on vacuum or excision biopsy?
Annual MMG for 5 years
60
Describe the natural history of intraductal proliferation
```
Epithelial hyperplasia of usual type
Columnar cell change
CCC with atypia
Atypical ductal hyperplasia
Ductal carcinoma in situ
```
61
What is the risk of progression to invasive carcinoma from DCIS (low grade)?
10x RR
| 25% over 10 years
62
How many breast malignancies are DCIS?
15-20%
Arises in TDLU
Characteristically unicentric
63
Describe the histopathology of DCIS?
Cytologically malignant epithelial cells
Confined within BM of duct
Can involve lobules (cancerisation)
Can involve nipple skin (Paget's)
64
What is paget's disease of the nipple?
High grade DCIS extended along ducts to reach the epidermis of nipple
Still in situ
65
How is DSCIS classified?
Cytological grade
Histological type
Presence of necrosis
66
Mx for DCIS?
Diagnosis
Surgery
Adjuvant radiotherapy
Chemoprevention; endocrine therapy
67
What is a microinvasive carcinoma of the breast?
DCIS (high grade) with invasion of <1mm beyond BM
| Treat as high grade DCIS
68
What is the commonest cancer for women?
Breast
69
What is the peak incidence for breast cancer in women?
50-70
70
What are risk factors for carcinoma of the breast?
Age
Repro hx; age at menarche, age at first birth, parity, breastfeeding, age at menopause
Hormones; endogenous, exogenous (OCP, HRT)
Previous breast dx (esp malignant)
Geography
Lifestyle; BMI, physical activity, alcohol, diet, NSAIDs (lowers risk), smoking
Genetics; BRCA
71
Which genetic anomalies increase the risk for breast cancer?
```
BRCA 1 and 2
Tp53
PTEN
STK11/ LKB1
ATM
```
72
What cancer syndrome and associated tumours will the BRCA mutations cause?
BRCA1 = breast, ovarian, bowel, prostate
| BRCA 2 = breast (inc male), ovarian, prostate, pancreatic
73
What cancer syndrome and assoc tumours will the Tp53 mutation cause?
Li Fraumeni Syndrome
| Childhood sarcoma, brain, leukaemia, adrenocortical carcinoma, early-onset breast
74
What cancer syndrome and assoc tumours will the pTEN mutation cause?
Cowden's syndrome
| Breast, GI, thyroid
75
What cancer syndrome and assoc tumours will the STK11/LKB1 mutation cause?
Peutz-Jeghers Syndrome
| Breast, GI, pancreatic, ovarian
76
What cancer syndrome and assoc tumours will the ATM mutation cause?
Ataxia Telangiectasia
Non-hodgkin's lymphoma
Ovarian
Breast (in heterozygous carriers)
77
What percentage of breast cancers are caused by BRCA mutations?
2%
| Present in 0.1% of population; 1 in 450 is a carrier
78
What is the lifetime risk for breast ca with BRCA mutations?
45-64% life-time risk
79
What is the net survival for women with breast cancer; age standardised?
1 yr; 96%
5 yr; 87%
10 yr; 78%
80
How many women will develop breast ca?
1 in 8
81
Describe the natural history of invasive breast ca
```
Local invasion (T); stroma of breast, skin, muscles of chest wall
Lymphatics (N); regional draining lymph nodes
Bloodborne (M); bone, liver, brain, lungs, abdominal viscera, female genital tract
```
82
Where does the majority of lymph from the breast drain to?
Axillary nodes
83
What are the routes for drainage of the breast?
Internal mammary
Intramammary
Axillary
84
What are the sentinel lymph nodes of the breast?
Apical nodes
Infraclavicular nodes
Supraclavicular nodes
85
How is invasive breast cancer classified?
Morphological; type, grade
Gene expression profiling
Hormone receptor; ER, PR, HER2
86
What is the most common histopathological type of breast ca?
Ductal (NST); 70%
| Lobular; 10%
87
What is the grade of a tumour?
Measure of tumour differentation
88
How is breast carcinoma graded?
```
Tubular differentiation (1-3)
Nuclear pleomorphism (1-3)
Mitotic activity (1-3)
Score of 3-5 = grade 1
Score 6-7 = grade 2
Score 8-9 = grade 3
```
89
What is a basal like intrinsic breast cancer sub-type?
ER -ve
HER2 -ve
Basal CK +
90
What is a HER2 intrinsic breast cancer sub-type?`
ER -ve
| HER2 +ve
91
What is a luminal A intrinsic breast cancer sub-type?
ER +ve
| Low proliferation
92
What are luminal B and C intrinsic breast cancer sub-type?
ER +ve
| High proliferation
93
In terms of ER, PgR and HER2 hormone receptors, what percentage of breast ca are positive for them?
80% ER +ve
67% PgR +ve
14% HER2 +ve
94
What will ER positive breast ca respond to in terms of hormonal therapy?
```
Oophorectomy (don't really do anymore)
Tamoxifen
Aromatase inhibitors ( letrozole)
GnRh antagonists (goserelin) - only in pre-menopausal women
```
95
What will HER2 +ve breast ca respond to in terms of hormonal tx?
Trastuzumab (herceptin)
96
In terms of hormone receptors, which subtype of breast cancers have the best outcome?
ER +ve
PR +ve
HER2 -ve
97
In terms of hormone receptors, which subtype of breast ca have worst outcome?
HER 2 +ve
THEN
Triple neg is worst
98
What prognostic indices are used for breast ca?
Nottingham Prognostic Index
| NHS PREDICT
99
How is Nottingham Prognostic Index calculated?
0.2 x tumour diameter (cm)
Tumour grade (1-3)
Lymph node status (1-3)
