1. Breast Notes PDF

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Scientific Basis of Clinical Practice SBCP - Breast Pathology...

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SBCP: BREAST NORMAL BREAST STRUCTURE:  Breast contains variable amounts of fat & glandular tissue  varies with age. Older women have more fatty, younger women more glandular  Glandular tissue consists of ducts & lobules  Lobules have secretory functions – lined by epithelial peripheral layer of myoepithelial cells  with a muscle function & have a contractile function to move the secretions along the lobules  Intralobular ducts  extralobular ducts  lactiferous ducts lactiferous sinuses (where some milk is stored during pregnancy

CLINICAL PRESENTATIONS OF BREAST DISEASE – PAIN & NIPPLE DISCHARGE Breast pain –cyclical mastalgia  Pain usually greatest pre-menstrual & resolves with period  has to be taken LT for benefits  May be very severe, some response to evening primrose oil or simple analgesia  Important to reassure that rarely associated with malignancy  some px request mastectomies if pain is so bad  Clinic to reassure it isn’t a malignancy  most are accidental diagnosis  No pathological changes in the tissue Nipple discharge – single duct or multiple ducts  Single duct or multi-duct?  some Px can express discharge by applying Pa in 1 area (single) OR if any area pa applied.  Clear, opaque or blood -stained?  Clear – physiological – rarely prolactinoma from pit.gland releasing prolactin releasing hormone  Multiple ducts – duct ectasia o Older women during reproductive years o Assoc with smoking – v.rare in non-smokers o Treatment not often necessary but may need to consider duct excision o No increased risk of malignancy  Single duct – papillary lesion, rarely underlying malignancy - concern o Intraductal papilloma - may be significant.  partial infarction can occur from when it twists o May be intermittently blood stained o On occasions may find malignancy arising with papilloma CLINICAL PRESENTATIONS OF BREAST DISEASE – BREAST LUMPS: Clinical Assessment: Clinical Hx:  Duration of lump – increasing / decreasing size (if decreasing = ok)  Cyclical or constant  Pain (normally innocent finding – benign)  Skin changes – inflammation / tethering (dimple forming) Clinical Examination:  Location – benign lesions less frequent in medial aspect of breast  most malignant in the medial aspect  Size  Consistency – soft / firm / hard (most breast cancers = hard) - most are also fatty  Character – focal (something & need investigation), vague, smooth (benign), irregular (likely to be malignant)  Skin changes – raise arms 1

SBCP: BREAST  Axilla; normally will have palpable lesions in the axilla. If it’s a fixed mass = axillary nodal metastases indication Radiology:  Mammography - x-ray of breast tissue - taken at 2 angles; cranio-caudal and oblique to see as much breast tissue as possible. More effective in older px (breast tissue = fattier & therefore lumps / masses are more apparent). Medial aspect of breast less likely to be seen in the mammogram o L breast = normal , R = has a speculation & fibrosis & skin pulled in (would have skin dimpling) – also fatty lymph nodes on the superior aspect – likely to have a fatty node replaced by a metastatic one 

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Ultrasound – not useful as a screening tool, but can be very helpful when a lump is present o Can tell if cystic or solid o Can outline lesion o Useful for image guided biopsy o Black area = area containing fluid; so would be a cyst Needle biopsy – fine needle aspiration, core needle biopsy

BENIGN BREAST LUMPS: Simple cysts  Near the skin surface: epidermal inclusion cyst  In the breast parenchyma; dilated duct or lobule Fibrocystic change  V. common condition  Usually doesn’t produce signs or symptoms  Clinical presentation of lumps, thickening, or bumps  Often detected in breast screening programme due to propensity for calcification  Non-proliferative abnormality  Calcification = cyst formation , fibrosis, ,adenosis Fibroepithelial lesions  Fibroadenoma  Phyllodes tumour  Fibroadenoma  benign phyllodes tumour  malignant phyllodes tumour o V. common o Palpable mass (young), or mammographic abnormality (older) o Epithelial & stromal elements o Hormonally responsible o Treat by excision Papilloma  Benign epithelium covering CT cores  Branching pattern  Grows within a duct  Presentation – lump or nipple discharge Fat necrosis  Usually a painless lump  Often secondary to trauma - surgery / biopsy / seat belt  Picked up during screening  calcification BREAST CANCER: Epidemiology: 25% of all cancers in women, more cases = invasive carcinoma than in situ carcinoma  Incidences rise with age & increased diagnosis over yrs  2nd most common cancer cod for women in UK 2

SBCP: BREAST  Mortality rates = decreasing  earlier diagnosis & improved tx  Risk factors = increasing age, FHx, genetic – BRCA1,2. Previous Hx of breast cancer, increased breast density o Early menarche, late menopause, older age at first childbirth, OCP, breast feeding is protective, o Obesity / alcohol / smoking / ionising radiation NHS screening programme: Age 50-70yr Diagnosis: Triple assessment: Clinical  radiological  pathological Clinical Assessment: History:  Lumps & bumps  Skin changes  Nipple discharge  Systemic symptoms  FHx  RF Examination:  Overall physical condition  Breast lumps  Skin & nipple changes  Axillary palpitations Radiological:  Mammography  Ultrasound  MRI Pathological:  Fine needle aspirate o Quick & easy o Limited info

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Core biopsy o More difficult o More useful information

Breast cancer classifications:  In situ carcinoma o Neoplastic cells o Confined by BM o No potential for metastic spread o Will probably progress to invasive carcinoma if untreated  Invasive carcinoma o Neoplastic cells 3

SBCP: BREAST o BM breached o Can metastasise  Cell type (mainly ductal & lobular)

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Grade o Tubule formation o Mitotic activity o Nuclear pleomorphisms o Grade 1: score 3-5 o Grade 2: score 6-7 o Grade 3: score 8-9 Stage – TNM system o T- stage: increases with increasing size, and skin / chest wall involvement o N-stage: increases with increasing lymph node involvement o M-stage: denotes presence / absence of distant metastasis Hormone receptor expression Molecular classification

PROGNOSTIC FACTORS: Tumour type  Favourable prognosis: tubular / lobular / mucinous / medullary  Poor prognosis: most ductal NOS / rare aggressive types Histological grade  Tubule formation  Pleomorphism  Mitotic activity Size:  T1 - >20mm / T2 =20-50mm / T3 = 50-100mm / T4 >100mm Nodal involvement  N0 – node negative  N1 – nodes involved, mobile  N2 – nodes involved, fixed  N3 – supraclavicular nodes or oedema Hormone receptor status  There are specific approaches for breast cancer based on some features of the tumour  Oestrogen receptor status  HER-2 (human epidermal growth factor) Other factors?  Early detection is one of the main factors for reducing mortality - screening routinely (50-70yo), high risk px to benefit for follow up  BRCA 1 & 2 Mutations: o Genetic testing o Prophylactic surgery – breast & ovaries  Family history without BRCA mutation o First degree relatives o Risk up to x9 4

SBCP: BREAST o Important to create anxiety  Pre-existing breast conditions: o Breast cancer o Atypical ductal hyperplasia x2 o Hyperplasia of usual type x2 o LCIS x4 o DCIS x6-8 o Mammography o Tamoxifen

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