pathology of breast disease Flashcards by Evie withington

normal structure of the breast - lobes and lobules

each breast has 8-10 lobes (arranged like daisy petals)
inside each lobe are smaller structures called lobules
at the end of each lobule are bulbs that can produce milk

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changes to breasts in puberty - ducts

before puberty - breasts in both sexes, ducts

variable degrees of branching, lack lobules
15-25 lactiferous ducts
start at the nipple and branch until terminal ductal lobular unit
hormonally responsive

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lymph ducts in the breast

drain fluid carrying WBCs fromt he breast tissue into LNs in the axilla and behind the sternum

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lymph nodes in the breasts

filter harmful bacteria

play a key role in fighting off infection

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give 5 examples of benign breast conditions

fibrocystic change 
fibroadenoma 
intraduct papilloma - lactiferous ducts, nipple discharge
fat necrosis - traumatic
duct ectasia - nipple discharge

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examples of fibrocystic change

fibrosis 
adenosis 
cysts 
apocrine metaplasia 
ductal epithelial hyperplasia (usal type, atypical)

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what is a fibroadenoma

well circumscribed, freely mobile, non-painful mass

proliferation of epithelial and stromal elements

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how common are fibroadenomas

most common breast tumour in adolescent and young adult women

peak age - 3rd decade

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what can happen to fibroadenomas if untreated

may regress with age if left untreated

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growth pattern in fibroadenomas

ducts distorted and elongated –> slit like structures, intracanalicular pattern, ducts not compressed –> pericanalicular growth pattern

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intraductal papilloma

who
key symptom
features

usually middle aged women
nipple discharge
can show epithelial hyperplasia which may be atypical

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fat necrosis - what can it result in

can stimulate carcinoma - clinically and mammographically

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what causes fat necrosis

hx of antecedent trauma, prior to surgical intervention

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histological features of fat necrosis

mammography features

histiocytes with foamy cytoplasm
lipid-filled cysts

fibrosis, calcifications, egg shell on mammography

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what is Phyllodes tumour

fleshy tumour, leaf like pattern and cysts on cut surface

circumscribed, connective tissue and epithelial elements

1-15cm

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how common are Phyllodes tumour

<1% of breast tumours

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what type of tumours are Phyllodes tumour

what about the mets

benign, borderline, malignant

mets are hematogenous

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breast cancer incidence

2.3mln new cases 2020
incidence increasing in most countries
685 000 deaths
commonest cancer in UK (15%)

55200 new cases p/a UK, 4700 scotland

390 male breast cancer p/a UK, 31 scotland

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risk factors for breast cancer

gender
age 
menstrual hx
age at 1st pregnancy
radiation
FHx
personal hx
hormonal treatment
genetics
other: obesity, lack of physical activity, alcohol

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causes of hereditary susceptibility to breast cancer

gene, contribution to hereditary breast cancer

BRCA1 20-40%
BRCA2 10-30%
TP53 <1%
PTEN <1%
other 30-70%

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histological classification of breast cancer

non-invasive

invasive

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non-invasive breast cancers

ductal carcinoma in situ (DCIS)

lobular carcinoma in situ (LCIS/LISN)

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invasive breast cancers

invasive no special type (ductal) carcinoma, NST (~75%)
special types (rest) incl. invasive lobular carcinoma and variants (5-15%)

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features of in situ carcinoma

pre-invasive - no palpable tumour formed
not detected clinically - only x-ray in DCIS screening 
multi centricity and bilaterality (LCIS)
no mets - basement membrane 
risk of invasion depending on grade

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in situ cancer - risk of progression

low grade DCIS - 30% in 15yrs high grade DCIS - 50% in 8yrs LCIS - 19% in 25yrs and bilaterality

histological classification - pure special types

``` >90% of tumour showing characteristic features of a specific type: tubular carcinoma cribiform carcinoma mucinous carcinoma carcinoma w/ medullary features metaplastic carcinoma others ```

histological classification - NST and mixed carcinoma

NST carcinoma - up to 75% of cases invasive tumour shows none of <50% of special type features mixed carcinoma: heterogenous morphology 50-<90% special type morphology

what is shown

normal breast tissue

what is shown

normal breast tissue

what is shown

involution - progressive decrease in the size of an organ usually associated with a decline in function

what cells can be seen here

epithelial and myoepithelial cells

what type of change can be seen here

fibrocystic change

what tumour type is shown here

fibroadenoma

what tumour type is shown here

intraductal papilloma

what change is shown here

fat necrosis

what tumour type is shown here

Phyllodes tumour

what carcinoma is shown here

LCIS

what carcinoma type is shown here

NST carcinoma

what grade would this carcinoma be

what carcinoma is shown here

ILC

what carcinoma is shown here

tubular carcinoma

what carcinoma type is shown here

tubular carcinoma

what carcinoma type is shown here

medullary

what carcinoma type is shown here

mucinous

what carcinoma type is shown here

micropapillary

diagnostic procedures for breast cancer

``` clinical examination radiology - mammogram, US, MRI FNA cytology needle core biopsy diagnostic excision ```

what is included in the histology report

``` invasive vs non-invsaive histological type - ductal (85%) vs lobular grade - estimate of aggressiveness under microscope size margins LNs estrogen/progesterone receptor (2/3 +ve) HER-2/neu ```

how can breast cancer spread

local - skin, pectoral muscles lymphatic - axillary and internal mammary nodes blood - bone, lungs, liver, brain

spread of breast cancer - what is shown here

LVSI Lymphovascular space invasion

spread of breast cancer - what is shown here

LN mets

determining prognosis of breast cancer

``` patient related and tumour related node status - best prognostic indicator tumour size (<2cm) type grade (1,2,3) age lymphovascular space invasion oestrogen receptors (ER), progesterone receptors (PR) HER-2 proliferative rate of tumour gene expression profiling NPI - tumour size, grade, nodal status ```

what is the overall 5YS for breast cancer

64%

molecular markers for breast cancer and clinical applications

ER/PR - strong predictors of response to hormonal therapies ER/PR-ve tumours do NOT respond HER-2: ~20-30% +ve, predicts response to trastuzumab (herceptin)

what is shown here

oestrogen receptors

what is shown here

HER-2

molecular classification of cancers

gene expression technology 5 subtypes biologically diverse disease predictive gene signatures/potential to improve therapy complement current clinicopathological features

molecular classification - what are the 5 subtypes

``` ER+ luminal A lumina B basal HER 2+ normal breast like ```

luminal A features and prevalence

ER +ve HER 2 -ve low Ki67 55%

luminal B features and prevalence

ER+ve HER2 +ve (or -ve w/ high Ki67) 15%

triple -ve/basal like features and prevalence

ER -ve PR -ve HER2 -ve 10-15%

HER2 type features and prevalence

ER -ve PR -ve HER2 +ve 15-20%

what is true recurrence

carcinoma survives initial treatment and recurs

what is a new 1y

a 2nd cancer which is biologically different from 1st cancer

what % of breast cancer patients will develop a 2nd cancer

~10% of pts undergoing breast conservation for breast cancer will develop a 2nd cancer within 10yrs <10yrs - majority are true recurrences 10 yrs - 50/50 >10yrs - majority are new 1ys

when is the incidence of recurrence more

more in triple -ve breast cancer compared to ER or HER2 +ve cancers

prognosis with true recurrence

poorer prognosis that new 1ys (depending on stage of new cancer) pathological features are inaccurate in 40%

what is Paget's disease of the nipple

result of intraepithelial spread of intraductal carcinoma

histological features of Paget's disease of the nipple

large pale staining cells within the epidermis of the nipple

clinical features of Paget's disease of the nipple

limited to the nipple or can extend to the areola pain/itching, scaling, redness - mistaken for eczema ulceration, crusting, serous/bloody discharge

what is shown here

Paget's disease

gynaecomastia

most common clinical and pathologic abnormality of the male breast increase in subareolar tissue in 30-40% of adult males, both breasts are affected in many cases

what is gynaecomastia associated with

``` hyperthyroidism liver cirrhosis chronic renal failure chronic pulmonary disease hypogonadism use of hormones - oestrogens, androgens drugs - digitalis, cimetidine, spironolactone, marijuana, tricyclic antidepressants ```

carcinoma of the male breast prevalence

uncommon | <1% of all breast cancers

pathology of breast disease Flashcards

(73 cards)