Histopathology Breast Pathology Flashcards Preview

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Flashcards in Histopathology Breast Pathology Deck (74):
1

Anatomy of the Breast Disease

• The breast is a modified sweat gland covered by skin and subcutaneous tissue
• It rests on the pectoralis muscle from which it is separated by a fascia
• Dense connective tissue extends from the underlying pectoralis fascia to the skin of the breast called Cooper’s ligament. These ligaments hold the breast upward.

2

Histology →

1. Histologically breast consists of glandular (parenchymal) and supporting (connective) tissue.
2. Glandular element is divided into branching duct system and terminal duct lobular units (TDLU)
• Epithelial element → functional and therefore called parenchymal.

• Accini (collection of lobules (numerous).
q

3

The TDLU Formed by →

The lobule and terminal ductile and represents the secretory portion of the gland.

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The TDLU → Connects with the

Sub-segmental duct, which in turn leads to a segmental duct and this to a collecting/lactiferous duct which, empties into the nipple. The latter are 15-30 in number on each side.

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Histology of the ductal –lobular system

The breast is lined by two cell types
• The inner epithelial cells
• The outer myoepithelial cells – contraction function to propel fluid.

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Histology knowledge is clinically important because

For treatment:
In situ can’t metastisise to maxilla (lymph): excision = cure
Invasive (into BM) can

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Gland without myo-epithelial layer means

Pathological as malignant cant build moepithlial layer but can have BM (check this)

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Reliable marker of epithelial cells

Various types of cutokeratins and epithelial membrane antigen.

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Best marker for myoepitheial cells is

p63

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BM stain

Reticulin stains, ultra structurally or with immune-histochemical reactions for laminin or type IV collagen.

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Diseases of Breast → Classification

1. Inflammatory
2. Proliferative
3. Neoplasia

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Inflammatory

Acute mastitis
Chronic mastitis – lymphocytic lobulitis
Mammary duct ectasia (dilatation)
Fat necrosis – tissue death (various types) (Type 1)

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Proliferative

Fibrocystic change
Radial Scar

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Lymphocytic Lobulitis definition and histological

Chronic inflammation that presents like cancer → commonly seen in diabetics = hard mass.
Histologically: dese fibrosis and lymphocyte infiltration.

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Mammary duct ectasia features

Bloody nipple discharge biopsy reveals inflammation and ectasia

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Chronic granulomastitis description and treatment

Collection of epithelial histocytes
Cause:
1. TB
2. Leprosie
3. Sarcoidosis
4. Syphilis
5. Idiopathic (common)

Conservative. By operating it triggers a flare

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Fat necrosis description

Death of fat cells. Release fat and macrophage eat up = lipid containing. Calcification can occur.
This is similar to cancer as it has irregular density with calcification.

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Proliferative:
Radial Scar

Radiologically: exaggerated form of sclerosis adenosis. Fibrosis of epithelial glands produces fibrosheaths (stellate shaped). This looks like a carcinoma as it has an irregular border.

Tubules with 2 cell layers meaning it is benign

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Proliferative:
Tubular carcinoma

Biopsy radial scare looks very similar

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Proliferative:
Protocol for radial s
carring

Remove all

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Neoplastic: Types

Benign
Malignant

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Neoplastic: Benign types

Benign
Malignant

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Neoplastic: Benign types

Adenoma –epithelial differentiation
Fibroadenoma – mixed glands and neoplastic prolif of fibroelastic element
Papilloma – finger like structures

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Malignant types

Carcinoma – epithelial differentiation
Sarcoma – mesenchymal origin
Pagets disease (nipple and vulva)
Phylloides tumour – mixed – prolif or epi + mesenchymal elements

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Neoplastic:
Signs and symptoms:

Lump typed and associated underlying pathology

Nipple changes and associated underlying pathology
Breast Pain
Skin features
Micro-calcification

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Lump typed and associated underlying pathology

Diffuse – fibrosis/ fibrocystic change
Discrete – neoplasm/ cyst/abscess/ hamartoma (dev. malformation
Mobile – Benign neoplasm
Tethered – Carcinoma
* See Pie chat pg 117

27

Nipple changes and associated underlying pathology

Discharge
• Milky – Pregnancy
• Bloody – duct papilloma/carcinoma
Retraction – invasive arcinoma (due to fibroelastic reaction)
Erythema – Pagets disease or eczema and scaling

28

Breast Pain

Cyclical – benign breast diseases
On palpation – inflammatory

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Skin features

Oedema –peau d’orrange – carcinoma (lymph cells blocked lymph drainage)

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Micro-calcification

DCIS or fat necrosis

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Adenoma: Fibrocystic change

Different terminology
Common in 25-45 yrs age group
Pathogenesis – hormones

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Adenoma: Fibrocystic changes microscopic picture

• TDLU
• Cysts formation
• Fibrosis – surrounding tissue from cyst rupture
• Apocrine metaplasia – epithelial cells modify themselves
• Calcification secretions

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Fibroadenoma: Epi

Commonest benign breast tumour
B/W the ages of 20-35 yrs

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Fibroadenoma: Morphology

Increases in size during pregnancy
Decrease in size with age

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Fibroadenoma:

Composed of both proliferating ducts and connective tissue stroma.
Proliferation of mesenchymal and epithelial cells – no atipia or mitotic activity

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Fibroadenoma: Rx

Surgery is not recommended

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Phylloides tumour: Description

Phylloides is a Greek word means leaf-like

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Phylloides tumour: Epi

Usually occurs in 4th and 5th decade of life.

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Phylloides tumour: M/s

It is composed of epithelial and mesenchymal elements

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Phylloides tumour: Epithelial cell spread

Takes lymphatic route

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Phylloides tumour: Mesenchymal cells spread

Travel via blood and therefore in this don’t excise the lymph nodes therefore this is the malignancy element.

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Phylloides tumour: Presentation

It can be benign borderline and malignant

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Phylloides tumour: Benign

Circumscribed
Low mitotic activity

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Phylloides tumour:
Malignancy

It is the mesenchymal component which is malignant and produce metastasis through haematogenous route.

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Phylloides tumour:
Malignant

Irregular margins
High mitotic count
Stromal overgrowth

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Phylloides tumour:
Treatment

Wide local excision
Recurrence is common

47

Carcinoma:Epi

• 20% of all cancers in women
• In the UK 1 in 8 women develop breast cancer
• Commonest cause of death in women in 35-55 yrs age group.

48

Carcinoma: Risk Factors

• Female sex and age
• Reproductive history (increased estrogen exposure)
→Early menarche
→ Late menopause
→ Nulliparous women
→ 1st pregnancy after 30 yrs of age
• Obesity
• Family history in 1st degree relative
→1.5-2x if 1 relative

• Geography
• Atypical hyperplasia (increased risk of breast cancer)

49

Carcinoma: Aetiological mechanisms

• Hormonal Factors
• Genetic factors
→ BRCA 1, ch 17, ovary and breast
→ BRCA 2, ch 13
• Environmental influences

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Carcinoma: Classification

Carcinoma of breast are broadly classified on the basis of two criteria
• Invasion of BM
• Morphology

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Carcinoma: Invasion of BM

In-situ
Invasive

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Carcinoma:Morphology

Ductal
Lobular

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Carcinoma: Insitu Carcinoma

Ductal Carcinoma in situ
Lobular Carcinoma in situ

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Carcinoma: Invasive Carcinoma

Invasive ductal carcinoma NST (75-85%)
Invasive lobular carcinoma (10%)
Others (5%)

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Carcinoma: DCIS

High grade – invasive disease

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Carcinoma: Ductal vs. lobular

Behave differentially
DCIS – develops invasively im
LCIS – can develop into invasive disease (can develop in another breast or other quadrant.

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LCIS histology

Lobule w/ epithelial proliferation – myoepithelium containing the cells in accini.

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Treatment

Surgery – DCIS, invasive carcinoma
Chemotherapy – reduce in size and clearer margins
Radiotherapy – Conservative
Hormonal treatment – tamoxifen or element X inhib. (post menopause)/ |Herceptin

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Prognosis

Size of tumour
Grade of the tumour
Histological type of tumour
Vascular invasion
Stage of the tumour – nodal status
Receptor status of the tumour

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Pagets disease of the nipple: Associated with

Underlying (2%) ductal carcinomas

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Pagets disease of the nipple: M/s

There is involvement of epidermis by malignant ductal carcinoma cells.

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Pagets disease of the nipple: Clinically there is

Roughing
Reddening and slight ulceration of skin

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Pagets disease of the nipple: Histologically

Stratified Squamous – proliferation of neoplastic cells in epidermis

64

What is the marker for breast cancer →

Micro-calcification

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Where do we see this micro-calcification histologically?

It is usually associated with DCIS mostly high grade with central necrosis.

66

It is always malignant?

No, micro-calcification can be associated with benign fibrocystic change.

67

Do all breast cancers have micro-calcification?

No

68

What other mammographic appearances can one have with breast cancers?

Stellate lesion
Circumscribed soft tissue density/mass lesion

69

Are these appearances specific for breast cancer?

No

70

What other lesions can mimic breast cancer radio logically?

Micro-calficification
Stellate lesion
Circumscribed soft tissue density

71

Micro-calcification

Fibrocystic change
Fat necrosis
Calcified eggs of parasites (nearly)

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Stellate Lesion

Radial scar

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Circumcised soft tissue density

Fibroadenoma and Phylloides tumour

74

What is Triple Approach?

All breast cases are discussed in a multidisciplinary meeting every week.
Breast Clinicians, Radiologists and thus we use triple approach to triple approach to reach a final diagnosis and decide best management for the patient

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