S7 L2 Breast Pathology Flashcards Preview

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Flashcards in S7 L2 Breast Pathology Deck (35)
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1
Q

What does normal breast tissue look like histologically and what are some physiological changes?

A

- Dual layer of epithelium: cuboidal and myoepithelial

  • Menarche causes increase number of lobules and increased interlobular stroma
  • After ovulation cell proliferation and stromal oedema
  • Pregnancy causes increase in size and number of lobules, decrease in stroma
2
Q

What happens to breast tissue as we get older?

A

- Terminal duct lobular units decrease in number and size

- Interlobular stroma replaced by adipose tissue so mammograms are easier to interpret as less dense and palpation easier

3
Q

What breast conditions cause a palpable mass and when is this worrying?

A
  • Normal nodularity before menstruation
  • Invasive carcinomas
  • Fibroadenomas
  • Cysts

Worry if hard, craggy, fixed or rapidly increasing in size

4
Q

What breast conditions cause mammographic abnormalities?

A

- Densities: invasive carcinomas, fibroadenomas, cysts

- Calcifications: ductal carcinoma in situ (DCIS) and benign tissues

5
Q

Who is eligible for the breast screening programme in the UK and what are the challenges with this programme?

A

- Women between 47 and 73 every 3 years

  • Very high risk (gene carriers) have annual MRIs and mammograms
  • Moderate risk (FH) start screening 40-50
  • Many women decline first invite
  • Breast screening team are quite old so retiring soon
6
Q

What are some common lumps in the breast and what age groups do these occur in?

A

- Fibroadenomas: usually in reproductive age <30 years

- Phyllodes Tumour: in 60’s, can be benign or malignant

- Breast cancer: rare before 25, most people diagnosed at 64. Men are 1% of breast cancer cases

7
Q

Apart from acute mastitis, what are some other inflammatory conditions that can occur in the breast?

A

Fat Necrosis

  • Can present as mass, skin change or mammographic density
  • Can mimic carcinoma clinically and mammographically but usually history of trauma or surgery
8
Q

What are the histological features of fibrocystic change?

A
  • Cyst formation
  • Fibrosis
  • Apocrine metaplasia
9
Q

What are some stromal tumours of the breast?

A
  • Fibroadenoma
  • Phyllodes tumour
  • Lipoma
  • Leiomyoma
  • Hamartoma
10
Q

What are the histological and macroscopic feaures of a fibroadenoma?

A

- Macroscopically: rubbery, greyish white, mobile

- Histology: mix of stromal and epithelial cells hyperplasia

Can look like carcinoma clinically and mammographically

11
Q

What is gynaecomastia and what is the general reason for it’s occurence?

A

- Enlargement of the male breast

  • Often seen in puberty and elderly
  • Cause by relative decrease in androgen and increase in oestrogen
  • No increased risk of cancer but can mimic carcinoma, especially if unilateral
12
Q

What are some causes of gynaecomastia?

A
  • Neonates due to maternal oestrogen
  • Transient puberty
  • Klinefelter’s syndrome
  • Gonatrophin excess e.g leydig tumours
  • Cirrhosis of liver causing oestrogen to not be metabolised

- Drugs: spironolactone, chlorpromazine, alcohol, marijuna, cimetidine, heroin, anabolic steroids

13
Q

What is the most common type of breast cancer?

A

- ​95% are adenocarcinomas

  • 50% occur in the upper outer quadrant
  • Other tumours like angiosarcomas are rare
14
Q

What are some risk factors for breast cancer?

A

- Geographic influence: higher incidence in US and UK though to be linked to diet, alchol consumption etc

  • Previous breast cancer
  • Previous radiation exposure, especially as a kid

- Genetics

15
Q

What are the genes associated with breast cancer?

A

- BRCA1 and BRCA2: tumour suppressor genes

- Li-Fraumeni Syndrome: p53

  • 60-85% lifetime breast cancer risk with this gene and diagnosis 20 years earlier than sporadic cases
  • Carriers may undergo prophylatic mastectomy and hysterectomy
16
Q

How do we classify breast carcinomas?

A
  • Lobular or Ductal
  • Invasive or In Situ
17
Q

What is in situ breast carcinoma and why is DCIS a problem?

A
  • Neoplastic cells limited by basement membrane, myoepithelial cells in tact so cannot metastasise or invafe
  • DCIS can show us as calcifications and can spread through ducts and lobules to be very extensive when it breaks through
18
Q

What does DCIS look like histologically?

A

Often central comedo necrosis with calcification

19
Q

What is Paget’s disease of the nipple?

A
  • Unilateral eczematous nipple that can be retracted
  • Often a sign of invasive breast cancer behind the nipple
20
Q

What visible changes can occur to the breast with breast cancer?

A
  • Often axillary lymph node metastases when palpable breast lump
21
Q

How can invasive breast carcinoma be classfied?

A

- Invasive ductal carcinoma, no special type: 70-80% of cases with 35-50% 10 year survival

- Invasive lobular carcinoma: 5-15% of cases, similar prognosis

- Other: tubular and mucinous (good prognoses)

22
Q

What does invasive breast carcinoma look like histologically?

A
23
Q

How does breast cancer metastasise and what are the most common sites of metastases?

A

- Via lymphatics, usually to ipsilateral axillary nodes

- Distant metastases via blood vessels: bones (most common site), lungs, liver, brain

- Invasive lobular carcinoma: odd sites like peritoneum, retroperitoneum, leptomeninges, GI tract, overies, uterus

24
Q

What factors determine the prognosis of breast cancer?

A
  • In Situ or Invasive
  • Tumour grade
  • TNM stage
  • Histologic subtype (IDC NST has poorer prognosis)
  • Molecular classifcation (HER2)
  • Gene expression profile
25
Q

In regards of the receptors present on breast cancers, what receptors indicate a better prognosis?

A
  • 1st test is for oestrogen receptors and if present better prognosis
  • Then test for HER2 gene so can use herceptin
  • Triple Negative (PR, ER and HER2) is poorest prognosis
26
Q

How do we investigate and diagnose suspected breast cancer?

A

Triple Approach

- Clinical: history, family history, examination

- Radiographic imaging: mammogram and ultrasound scan

- Pathology: core biopsy and fine needle aspiration cytology

27
Q

What are some of the treatments for confirmed breast diagnosis?

A

- Breast surgery: mastectomy or lumpectomy depending on patient choice, size and site of tumour and size of breast

- Axillary surgery: sentinel node sampling or axillary dissection

- Post operative radiotherapy to chest and axilla

- Chemotherapy

- Hormonal treatment

28
Q

What is sentinel lymph node biopsy?

A
  • Done to reduce risk of post op morbidity
  • Inject dye into tumour, first node that drains this remove and biopsy, if cancer present do axilla dissection, if not don’t
29
Q

What are some hormonal treatments for breast cancer?

A

- Tamoxifen if ER+

- Herceptin if HER2 positive (humanised monoclonal antibodies against HER receptor)

30
Q

How can we improve survival from breast cancer?

A

- Early detection: encourage screening and self examination

- Neoadjuvant chemotherapy to prevent metastases

  • Gene expression profiles
  • Prevention in familial cases e.g prophylatic mastectomy
31
Q

What is a genetic expression profile and what is the relevance of this to breast cancer?

A

Using a DNA microarray in breast cancer patients to see that 17 marker genes are present that can tell you which women would develop metastases

32
Q

What are the challenges patients may face when they are diagnosed with DCIS?

A
  • Classed as pre-invasive cancer so could spread or could stay the same and never cause issues
  • Offered mastectomy so have to weigh up benefit v risk
  • Therefore could be having unnecessary cancer treatment
33
Q

What is the Angelina Jolie effect?

A
  • Rise in internet searches of BRCA genes
  • Rise in prophylatic mastectomies
34
Q

What is the likely pathway of investigation for a patient with suspected DCIS?

A
  • Ultrasound of axilla then ultrasound guided needle biopsy if abnormal lymph nodes present
  • Only offer MRI and triple therapy screening if suspect invasive
35
Q

What are the benefits of a drastic mastectomy operation for DCIS vs a lumpectomy?

A
  • Lumpectomy followed by radiation is likely to be equally as effective as mastectomy for people with only one site of cancer in the breast and a tumor under 4 centimeters
  • Ask patient how anxious they are about cancer coming back as higher reoccurence with this
  • Need more radiotherapy which can interrupt reconstruction time

- Breast cannot tolerate radiation if reocurrence of cancer in same breast