Histopathology - Breast

Question 1

Breast cytopathology

C1
C2
C3
C4
C5

Answer 1

	C1 = inadequate 
	C2 = benign
	C3 = atypia, probably benign
	C4 = atypia, probably malignant
	C5 = malignant

Question 2

Gold standard for the dx of breast cancer

Answer 2

Histopathology

Shows the architectural and cellular detail

H nuclei purple
E cytoplasm pink

Question 3

Normal breast histology

Answer 3

Ductal lobular system lined by inner glandular epithelium

Question 4

Mammary duct ectasia buzzwords

Answer 4

Smoking

Multiparous 40-60

Inflammation + dilation of large breast ducts

Benign

Question 5

Mammary duct ectasia presentation

Answer 5

o Brown/green secretion
o periductal mastitis/ abscess/ fistula formation
o Mass beneath areola
o May cause slit like nipple retraction

Question 6

Mammary duct ectasia

Histology

Cytology of nipple discharge

Answer 6

Histology
o Duct distension with proteinaceous material in it
o Foamy macrophages

Cytology
o Proteinaceous material
o Foamy macrophages

Question 7

Acute mastitis cytology

Answer 7

Foamy macrophages

Abundance of neutrophils

Question 8

Fat necrosis

presentation
cyotlogy

Answer 8

painless mass
skin tethering/ nipple retraction

fat cells surrounded by macrophages, lymphocytes, empty spaces, histocytes, giant cells

Question 9

What is fibroadenoma and what happens to it during pregnancy and after menopause

Answer 9

Arise from interlobular stroma
Proliferation of glands and fibrous tissue

Increases in size during pregnancy
calcifies after menopause

Young women
20-30

Question 10

What are phyllodes tumours + histology

Answer 10

Group of potentially aggressive fibroepithelial neoplasms
can be benign, borderline or malignant
arise from interlobular stroma

enlarging mass in >50

Histology - overlapping cells, cellularity

Question 11

Peripheral vs central intraductal papilloma

Answer 11

 Small terminal ductules  peripheral papilloma  clinically silent

 Large lactiferous ductules  central papilloma  bloody nipple discharge, occlusion of the duct system, erosion

Question 12

Intraductal papilloma

cytology
histology

Answer 12

cytology
clusters of cells
polyp/finger like projections

Histology
Dilated ducts
papillary mass within dilated duct lined by epithelium 
fibrovascular core
blood vessels within the stroma

Question 13

A benign lesion that most commonly mimics breast cancer on radiology?

Answer 13

Radial scar

also, mammary duct ectasia can mimic cancer on mammgrams

Question 14

Which benign lesion cannot be seen on mammogram?

Answer 14

Intraductal papilloma

Question 15

What is a radial scar?

Answer 15

Benign sclerosing lesion with a

central zone of scarring surrounded by a radiating zone of proliferating glandular tissue in stellate pattern

caused by exaggerated reparative phenomenon in response to areas of tissue damage within the breast

Question 16

Symptoms of proliferative breast disease

Answer 16

Produce no symptoms

Question 17

Is usual epithelial hyperplasia pre-malignant?

Answer 17

o Not a true pre-malignant change

o Not considered a precursor lesion

Question 18

Which is the first pre-malignant change?

Answer 18

Flat epithelial atypia/ atypical ductal carcinoma

may represent a precursor to low grade DCIS

Question 19

Which proliferating breast diseases are pre-malignant?

Answer 19

flat epithelia atypia/ atypical ductal carcinoma < in situ lobar neoplasia

Question 20

flat epithelia atypia/ atypical ductal carcinoma vs in situ lobar neoplasia

Answer 20

flat epithelia atypia/ atypical ductal carcinoma
o multiple layers of epithelial cells
o irregular lumens with punched out areas

in situ lobar neoplasia
o higher risk of invasive carcinoma
o occurs within acinar unit of breast
o cell proliferation with small residual areas where you can still see the lumen

Question 21

How does early pregnancy protect from breast cancer?

Answer 21

(pregnancy – terminal differentiation of milk-producing luminal cells, removing these from the pool of potential cancer precursors)

Question 22

breast cancer screening programme in the UK

Answer 22

43-73

every 3 years

Question 23

Most common malignant breast tumour

Answer 23

Invasive ductal carcinoma

Question 24

• E-cadherin +ve vs

* E-cadherin -ve

Answer 24

• E-cadherin +ve  invasive ductal carcinoma

* E-cadherin -ve  invasive lobular carcinoma

Question 25

invasive ductal carcinoma vs invasive lobular carcinoma

Answer 25

Invasive ductal carcinoma - most common malignant breast tumour + much higher risk of progressing to invasive cancer - E-cadherin +ve - Microcalcification, can be seen on mammogram - Only 10% present with clinical sx invasive lobular carcinoma - E-cadherin -ve - No microcalcifications - cannot be seen on mammograms, incidental finding - 20-40% are bilateral

Question 26

Low grade vs high grade DCIS histology

Answer 26

Low - cribiriform/ punched out DCIS - Lumens compact/ regular - size of nucleus similar to size of RBC High grade - few lumens - central lumen necrotic material

Question 27

Invasive ductal carcinoma vs invasive lobular carcinoma vs invasive tubular carcinoma vs invasive mucinous carcinoma histology

Answer 27

Invasive ductal carcinoma - Cells form groups, nests, cysts - Tumour invades into fat spaces + stroma Invasive lobular carcinoma - - Cells aligned in single file chains/ strands (Indian File pattern) Invasive tubular carcinoma - Elongated tubules invading the stroma Invasive mucinous carcinoma - Produce abundant quantities of extracellular mucin which dissects into surrounding stroma

Question 28

Which type of breast cancer is unlikely to be treated with chem?

Answer 28

Carcinoma in situ

Question 29

Which type of breast cancer is likely to be treated with chem?

Answer 29

Basal like carcinoma

Question 30

Basal like carcinoma histology + immunochemistry

Answer 30

Sheets of atypical cells Central necrosis Lymphocytic infiltrate stains positive for basal cytokeratins CK5/6/14

Question 31

Which parameters are included in the histological grading of a breast tumour?

Answer 31

``` Tubule formation (/3) (the more tubules, the better) Mitotic activity (/3) Nuclear pleomorphism (/3) ```  3-5 = grade 1 = well differentiated  6-7 = grade 2 = moderately differentiated  8-9 = grade 3 = poorly differentiated

Question 32

Receptor status All invasive cancers are screened for

Answer 32

ER RP Her2

Question 33

Receptor status Low grade High grade Basal like carcinomas

Answer 33

 Low grade • ER/PR positive – response to tamoxifen, good prognosis • Her2 negative  High grade • ER/PR negative • Her2 positive – bad prognosis  Basal-like Carcinomas • ER/PR/Her2 negative  triple negative (hard to treat)

Question 34

Breast cancer - most important prognostic factor

Answer 34

Status of axillary lymph nodes

Question 35

Biopsy coding

Answer 35

o B1 = normal breast tissue o B2 = benign abnormality o B3 = lesion of uncertain malignant potential (e.g. intraductal papilloma, radial scars) o B4 = suspicious of malignancy o B5 = malignant  B5a = DCIS  B5b = invasive carcinoma

Question 36

Risk of breast cancer in carriers of BRCA

Answer 36

Risk BRCA2 > BRCA1

Question 37

Histology of gynaecomastia

Answer 37

Hallmark - concentric fibrous thickening around ducts epithelial hyperplasia of ducts with finger like projections extending into the duct lumen periductal stroma fibrous + oedematous [similar to fibroadenoma]