Histopathology 3 - Breast pathology

Question 1

What does a triple assessment involve in breast disease?

Answer 1

clinical examination

imaging - sonography, mammogram, MRI (v small lesions that may be missed by US or mammograph

pathology - cytopathology(cells)/histopathology(tissue) - via FNA/core biopsy

Question 2

Recall the C1-C5 code that is used to grade fine needle aspirate in breast cancer investigation

Answer 2

C1 - Inadequate sample
C2 - Benign
C3 - Atypia, probably benign
C4 - Suspicious of malignancy
C5 - Malignant

Question 3

What is the gold standard for breast cancer diagnosis?

Answer 3

Histopatholgy

Question 4

In which type of breast cancer is MRI most useful?

Answer 4

Lobular

Question 5

Describe what this image shows. What do the purple stains/pink area/blue arrow show?

Answer 5

terminal duct lobular unit (TDLU)

• from nipple → branches → end in TDLU
• consist of SNIs and ducts

purple = glandular tissue

pink = stroma

large pink circle = duct with acini around duct

blue arrows = myoepithelial cells - helps pump milk. epithelial (luminal) cells are on inside of myoepithelial cells

Question 6

define duct ectasia

Answer 6

inflammation and dilatation of large breast ducts

BENIGN

risk factor = smoking

Question 7

Recall some symptoms of duct ectasia

Answer 7

Pain, mass, nipple inversion and discharge

Question 8

What would be seen upon cytological analysis of nipple discharge in duct ectasia?

Answer 8

Proteinaceous material and inflammatory cells only

Question 9

What are some histological features of duct ectasia?

Answer 9

duct distension with proteinaceous material in it

foamy macrophages

Question 10

What is the most common pathogen identified in acute mastitis?

Answer 10

Staphylcoccal (polymicrobial)

commonly lactational (milk stasis)

Question 11

What would cytology show in breast mastitis?

Answer 11

neutrophils (acute) - trinucleated dark

and foamy macrophages

Question 12

How would you treat acute mastitis?

Answer 12

Drainage and Abx

continued expression of milk

Question 13

What is the cause of fat necrosis of the breast?

Answer 13

Trauma/surgery/radiotherapy

an inflammatory reaction to damaged adipose tissue:

Question 14

s/s of fat necrosis of the breast

Answer 14

benign painless breast mass

Question 15

What would you see on cytology in fat necrosis of the breast?

Answer 15

fat cells (empty space) surrounded by macrophages

Question 16

What is the cause of fibrocystic disease of the breast?

Answer 16

Normal, but exaggerated, response to hormonal influences

causes breast lumpiness (no increased risk Ca)

Question 17

Histology of fibrocystic disease of the breast

Answer 17

ducts dilated → accumulate stagnant secretions →

ducts calcified (seen on mammogram)

Question 18

Define fibroadenoma

Answer 18

benign fibroepithelial neoplasm of breast

well circumscribed mobile breast lump

young women; 20-30yo

Question 19

How can fibroadenoma be cured?

Answer 19

‘Shelling out’

Question 20

What would you see on FNA cytology in fibroadenoma?

Answer 20

arrows pointing to myoepithlial

glandular epithelial and myoepithelial cells present → benign

Question 21

What are some histological featuers of fibroadenoma

Answer 21

well circiumscribed edge

compressed glandar component

glandular and stromal cells

Question 22

Which breast tumours can be described as ‘leaf like’?

Answer 22

Phyllodes tumours

Question 23

What is a phyllodes tumour?

Answer 23

Potentially aggressive fibroepithelial neoplasm of the breast - but usually benign

Question 24

How do phyllodes tumours tend to present?

Answer 24

Usually as an enlarging breast mass in women >50 - often in pre-existing fibroadenomas

Question 25

What is some histological features of the Phyllodes tumours?

Answer 25

overlapping cell layers, difficult to see monolayer cellularity leaf like appearance - broad based papillae level of malignancy determined on cellularity of stroma High cellularity + stromal overgrowth → malignant

Question 26

Define intraductal papilloma

Answer 26

a benign papillary tumour arising within the duct system of the breast Small terminal ductules - peripheral papilloma Large lactiferous ductules - central papilloma

Question 27

How does intraductal papilloma present?

Answer 27

COMMON (mainly in 40-60 years) Central papillomas → bloody nipple discharge Peripheral papillomas may remain clinically silent

Question 28

cytology of intraductal papillomas?

Answer 28

finger like projections clusters of cells, potential increased risk with multiple papillomas of carcinoma

Question 29

What are some histological features of intraductal papilloma?

Answer 29

dilated ducts; polypoid mass in the middle Fibrovascular core (which nourishes polyp) Blood vessels within stroma

Question 30

How would you treat intraductal papilloma?

Answer 30

Excision of duct

Question 31

Define radial scar

Answer 31

benign sclerosing lesion → central zone of scarring surrounded by radiating zone of proliferating glandular tissue

Question 32

How does radial scar present?

Answer 32

stellate masses on screening mammograms (may closely resemble carcinoma)

Question 33

How can radial scars of the breast be cured?

Answer 33

Excision

Question 34

What would you see on histology of radial scar?

Answer 34

Two distinct areas: Central stellate area Peripheral proliferation of ducts and acini

Question 35

Define proliferative breast disease

Answer 35

diverse group of microscopic intraductal proliferative lesions a/w ↑ risk development of invasive breast carcinoma microscopic lesions - produce no symptoms (found on biopsy) 1. usual epithelial hyperplasia (Atypical ductal carcinoma) 2. flat epithelial atypia 3. in situ lobular neoplasia

Question 36

What is the key histopathological feature of usual epithelial hyperplasia of the breast?

Answer 36

Irregular lumens

Question 37

Define ductal carcinoma in situ

Answer 37

neoplastic intraductal epithelial proliferation risk of progression to breast cancer

Question 38

What are some signs of symptoms of ductal carcinoma in situ?

Answer 38

85% are detected on mammography (areas of microcalcification) 10% will produce clinical features (lump, Paget's disease of nipple); 5% diagnosed incidentally

Question 39

What are the histological features of DCIS?

Answer 39

Calcified

Question 40

How should DCIS be managed?

Answer 40

Complete excision with surgical margins

Question 41

What is the biggest risk factor for invasive breast carcinoma?

Answer 41

Osetrogen exposure Early menarche Late menopause Obesity Alcohol OCP FHx (5% inheritance) BRCA mutations (up to 85% increased lifetime risk)

Question 42

What are some subtypes of invasive breast carcinomas?

Answer 42

ductal, lobular, tubular, mucinous

Question 43

What is the histological appearance of invasive ductal carcinoma vs lobular carcinoma?

Answer 43

Ductal: Large pleiomorphic cells with huge nuclei Lobular: Linear, MONOmorphic cells

Question 44

Which type of invasive breast carcinoma is associated with radial scar?

Answer 44

tubular

Question 45

What is the histological appearance of invasive tubular carcinoma/.

Answer 45

elongated tubules invading the stroma

Question 46

Describe the histological appearance of invasive mucinous carcinoma

Answer 46

empty spaces contain lots of mucin

Question 47

Which type of breast pathology would show an "Indian file pattern" of cells under the microscope?

Answer 47

Invasive lobular carcinoma

Question 48

Which type of breast carcinoma has the worst prognosis?

Answer 48

Basal-like carcinoma propensity → vascular invasion and distant metastases

Question 49

Describe the histological features of basal like carcinoma

Answer 49

sheets of markedly atypical cells, prominent lymphocytic infiltrate, central necrosis

Question 50

How can basal-like breast carcinomas be identified using immunohistocheistry?

Answer 50

Positive for 'basal' cytokeratins eg CK5/6/14

Question 51

What 3 features of a breast malignancy are examined to decide its histological grading?

Answer 51

**Nottingham Modification of Bloom-Richardson System:** Tubule formation Nuclear pleiomorphism Mitotic activity

Question 52

Which receptors are tested for in breast cancer diagnosis, and why?

Answer 52

ER PR HER2 ER/PR positive = good prognosis = response to tamoxifen HER2 = bad prognosis

Question 53

What is the most important prognostic factor in breast cancer?

Answer 53

Axillary lymph nodes status

Question 54

What age group is invited to breast cancer screening in the UK?

Answer 54

47-73 years are screened every 3 years

Question 55

Recall the B1-B5 code used for core biopsies of breast masses

Answer 55

``` B1 = normal B2 = benign B3 = uncertain B4 = suspicious B5 = malignant (5a = DCIS, 5b = invasive) ```

Question 56

How is E-cadherin used to differentiate invasive ductal and lobulra carinoma?

Answer 56

E-cadherin -ve = invasive lobular carcinoma E-cadherin +ve = invasive ductal carcinoma

Question 57

describe the histological features of male gynaecomastia

Answer 57

epithelial hyperplasia of ducts with finger-like projections extending to duct lumen + periductal stroma often cellular and oedematous [similar to fibroadenoma]