Breast Pathology I

Question 1

What does the triple assessment of a patient with a breast condition involve?

Answer 1

Clinical = history, examination
Imaging = mammography, US, MRI
Pathology = cytopathology, histopathology

Question 2

What are the methods of gaining samples for breast cytopathology?

Answer 2

Fine needle aspiration, fluid, nipple discharge, nipple scrape

Question 3

What is the cytology of FNA?

Answer 3

C1 = unsatisfactory       
C2 = benign
C3 = atypia, probably benign
C4 = suspicious of malignancy
C5 = malignant

Question 4

What are the diagnostic methods used for breast histopathology?

Answer 4

Needle core biopsy, vacuum assisted biopsy, incisional biopsy

Question 5

What are the therapeutic methods used for breast histopathology?

Answer 5

Vacuum assisted excision, excisional biopsy, resection of cancer (wide local excision, mastectomy)

Question 6

What is the cytology of a needle assisted biopsy?

Answer 6

B1 = unsatisfactory/normal        B2 = benign
B3 = Atypia, probably benign
B4 = suspicious of malignancy
B5a = carcinoma in situ             B5b = invasive carcinoma

Question 7

What are some benign developmental anomalies of the breast?

Answer 7

Hypoplasia, juvenile hypertrophy, accessory breast tissue, accessory nipple

Question 8

What are some non-neoplastic benign breast diseases?

Answer 8

Gynaecomastia, fibrocystic change, hamartoma, fibroadenoma, sclerosing adenosis, radial scar (complex sclerosing lesion)

Question 9

What are some benign inflammatory breast diseases?

Answer 9

Fat necrosis, duct ectasia, acute mastitis/abscess

Question 10

What are some benign tumours of the breast?

Answer 10

Phyllodes tumour, intraduct papilloma

Question 11

What is gynaecomastia?

Answer 11

Breast development in males = ductal growth without lobular development

Question 12

What are some causes of gynaecomastia?

Answer 12

Exogenous/endogenous hormones, cannabis, prescription drugs, liver disease

Question 13

What age group is most affected by fibrocystic changes?

Answer 13

Women aged 20-50 = most are aged 40-50

Question 14

What is the prognosis of fibrocystic changes?

Answer 14

Very common = often resolve or diminish after menopause, may be incidental finding at screening

Question 15

What is the presentation of fibrocystic changes?

Answer 15

Smooth discrete lumps, sudden pain, cyclical pain, lumpiness

Question 16

What is the gross pathology of fibrocystic change?

Answer 16

Cysts = blue domed with pale fluid, usually multiple, associated with other benign changes
Intervening fibrosis

Question 17

What is the microscopic pathology of fibrocystic change?

Answer 17

Thin walled but may have fibrotic wall, lined by apocrine epithelium

Question 18

What is the management of fibrocystic changes?

Answer 18

Exclude malignancy, reassure, excise if necessary

Question 19

What is a hamartoma?

Answer 19

Circumscribed lesion composed of all cell types normal to the breast but present in an abnormal proportion

Question 20

What is the epidemiology of fibroadenomas?

Answer 20

Common = more common in African women
Peak incidence in 30s
May need excised

Question 21

How do fibroadenomas present?

Answer 21

Usually solitary but multiple in 10%
Painless, firm and discrete mobile mass
Solid on US

Question 22

What are the features of fibroadenomas?

Answer 22

Circumscribed, rubbery and grey/white coloured

Biphasic lesion = epithelium and stroma

Question 23

What causes sclerosing lesions?

Answer 23

Benign disorderly proliferation of acini and stroma = can cause mass or calcification that can mimic carcinoma

Question 24

What are some features of sclerosing adenosis?

Answer 24

Peak incidence age 20-70
Negligible risk of subsequent carcinoma
Pain, tenderness, lumpiness or asymptomatic

Question 25

What is the epidemiology of radial scars/complex sclerosing lesions?

Answer 25

Wide age range and usually incidental finding on mammogram = common, with 67% being multicentric and 43% being bilateral

Question 26

What is the classification of radial scars and complex sclerosing lesions?

Answer 26

Radial scar if 1-9mm | Complex sclerosing lesion if >10mm

Question 27

What are the features of radial scars/complex sclerosing lesions?

Answer 27

Stellate architecture with central puckering and radiating fibrosis Often show epithelial proliferation and may mimic carcinoma radiologically

Question 28

What is the histology of radial scars/complex sclerosing lesions?

Answer 28

Fibroelastic core, radiating fibrosis containing distorted ductules, fibrocystic change, epithelial proliferation

Question 29

Can radial scars/complex sclerosing lesions be precursor lesions?

Answer 29

Yes = in situ or invasive carcinomas may occur within lesions

Question 30

What is the treatment of radial scars/complex sclerosing lesions?

Answer 30

Excise or sample extensively by vacuum biopsy

Question 31

What are some causes of fat necrosis?

Answer 31

Local trauma or warfarin therapy

Question 32

What occurs in fat necrosis?

Answer 32

Damage and disruption of adipocytes | Infiltration of acute inflammatory cells = foamy macrophages subsequent fibrosis and scarring

Question 33

How is fat necrosis managed?

Answer 33

Confirm diagnosis and exclude malignancy

Question 34

What part of the breast is affected by duct ectasia?

Answer 34

Sub-areolar ducts

Question 35

What is the presentation of duct ectasia?

Answer 35

Pain, acute inflammatory changes, bloody discharge and/or purulent discharge, fistulation, nipple retraction and distortion

Question 36

What is duct ectasia associated with?

Answer 36

Smoking

Question 37

What occurs in duct ectasia?

Answer 37

Sub-areolar duct dilation and periductal inflammation leads to periductal fibrosis and scarring/distortion

Question 38

How is duct ectasia managed?

Answer 38

Treat acute infection, stop smoking, excise ducts

Question 39

What are the two main aetiologies of acute mastitis/abscess?

Answer 39

Duct ectasia = mixed organisms and anaerobes | Lactation = staph aureus, strep pyogenes

Question 40

What is the management of acute mastitis/abscess?

Answer 40

Antibiotics, percutaneous drainage, incision and drainage, treat underlying cause

Question 41

What is a Phyllodes tumour?

Answer 41

Biphasic tumour with stromal overgrowth = due to cystosarcoma phyllodes

Question 42

What age group is most commonly affected by Phyllodes tumours?

Answer 42

Patients aged 40-50

Question 43

What are some features of Phyllodes tumours?

Answer 43

Slow growing unilateral breast mass | Can be benign, borderline or malignant

Question 44

What does the behaviour of Phyllodes tumours depend on?

Answer 44

Stromal features and is predicted by pathology

Question 45

Do Phyllodes tumours metastasise commonly?

Answer 45

No = prone to local recurrence if not excised adequately but rarely metastasise

Question 46

What are some examples of breast papillary lesions?

Answer 46

Intraduct papilloma, nipple adenoma, encapsulated papillary adenoma

Question 47

What age group is most commonly affected by intraduct papillomas?

Answer 47

Age 35-60 = affects sub-areolar ducts

Question 48

How do patients with intraduct papillomas present?

Answer 48

Nipple discharge +/- blood | Asymptomatic at screening = nodules or calcification seen

Question 49

How do intraduct papillomas present?

Answer 49

2-20mm in diameter with papillary fronds containing a fibro-vascular core = covered by myoepithelium and epithelium

Question 50

What may the epithelium of intraduct papillomas show?

Answer 50

May show proliferative activity = usual type hyperplasia, atypical ductal hyperplasia, ductal carcinoma in-situ