Benign Breast Diseases 2024 RCSI Past Paper PDF

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Benign Breast Diseases Class Year 2 Course Pathology Lecturer Professor Paul Murray Date February 2024 LEARNING OBJECTIVES Describe the Normal Anatomy of the breast Describe the Histology and P...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Benign Breast Diseases Class Year 2 Course Pathology Lecturer Professor Paul Murray Date February 2024 LEARNING OBJECTIVES Describe the Normal Anatomy of the breast Describe the Histology and Physiology of the breast Describe the Clinical Assessment of a breast lump Explain Mastitis List and discuss Benign Breast Lumps TERMINAL DUCTAL LOBULAR UNIT  GALACTORRHOEA Milk production outside of lactation Not a symptom of breast cancer Nipple stimulation, prolactinoma of the anterior pituitary and drugs SUPERNUMERARY NIPPLES/BREASTS Common congenital anomaly Supernumerary nipples may be associated with underlying breast tissue. This breast tissue can have many of the histological characteristics of normal breast tissue. As a result, breast adenomas and cancers can arise in the breast tissue underlying supernumerary nipples The embryonic milk line is the line of potentially appearing breast tissue as observed in many mammals CLINICAL PRESENTATION OF BREAST DISEASE Breast pain (mastalgia) Palpable mass Nipple discharge Mammographic abnormality Other presentations: – Skin-(peau d’orange)- The most common cause of breast peau d'orange is inflammatory breast cancer. oedema due to lymphatic obstruction – Nipple retraction  BREAST LUMP Discrete lump or diffuse lumpiness? Age? Other symptoms (pain, discharge, skin) Solid or cystic? Smooth or irregular? Hard or firm? Mobile or tethered/fixed? Single or multiple? Bilateral or cyclical? Refer if for example… – New lump – Persistent asymmetrical nodularity – Unresolving inflammation – Lump remains following cyst aspiration – Family history  CLINICAL ASSESSMENT History and examination Inspection and palpation Examination of the axillae Ultrasound – Cysts, outlines mass lesions, young patients, guided biopsy Mammography – Difficult in younger women (also with HRT) because breast tissue is more dense MRI (high sensitivity but low specificity)  TRIPLE ASSESSMENT Triple assessment (clinical, radiology and pathology) If all three components conclusively indicate that the breast lump is benign may decide to monitor the lump without intervention May require intra-operative confirmation of carcinoma by frozen section (exceptional)  In Ireland, mammograms for women aged 50-69 every two years If abnormality is detected patient is referred for further clinical examination, mammography and ultrasound Only a small number of women will need to proceed to a biopsy/pathological diagnosis. MAMMOGRAPHIC SIGNS OF MALIGNANCY Densities Calcifications Small, irregular, clustered, linear or branching lesions Architectural distortion Asymmetry  PATHOLOGICAL DIAGNOSIS Fine needle aspiration (FNA) cytology- not the method of choice – Solid and cystic masses – Quick- aspiration spread onto slides, staining, interpretation – No anaesthetic, in the outpatient department – Cost effective – Operator dependent and expertise in interpretation Needle core biopsy – Thin cores of tissue – Slower, but easier to interpret Open biopsy – If uncertainty following triple assessment (not all elements of assessment in agreement) – Possibility of intra-operative frozen section DIAGNOSTIC CATEGORIES (FNA AND CORE BIOPSY) Inadequate Benign Lesion of uncertain malignant potential Suspicious Malignant  INFLAMMATORY CONDITIONS Acute mastitis – Cracked nipple during lactation allows bacteria (esp. Staph. aureus) to invade the breast parenchyma – Fever, erythema, pain, purulent nipple discharge – Treated with antibiotics/ rarely surgical Chronic inflammation- scarring may mimic malignancy – Periductal mastitis – Mammary duct ectasia – Fat necrosis – Granulomatous mastitis – Lymphocytic mastitis  PERIDUCTAL MASTITIS Associated with smoking (vitamin A deficiency) Squamous metaplasia results in keratin production which plugs the duct and causes inflammation Painful subareolar mass, inverted/retraction nipple (due to fibrosis) Inflammatory cells and granulomatous inflammation Surgical excision of the involved duct  MAMMARY DUCT ECTASIA Occurs predominantly in fifth and sixth decades Poorly defined palpable peri-areolar mass with thick green/brown nipple discharge Can mimic carcinoma clinically and on mammogram Inflammation and dilation of subareolar ducts Inspissated (thickened) secretions in large ducts which plug the ducts and “spill” into the surrounding stromal tissue leading to chronic inflammation with inflammatory cells (arrowed) including plasma cells +/- granulomas  FAT NECROSIS Usually follows trauma (may be iatrogenic, as in surgical biopsy) Obese and post-menopausal women Present as a mass on examination or calcification on mammography Biopsy shows necrotic fat, calcification and macrophages with giant cells  OTHER CONDITIONS Lymphocytic mastitis: – Often associated with type I insulin dependent diabetes (diabetic mastopathy), some cases have autoimmune basis – palpable mass, usually subareolar, often bilateral Granulomatous mastitis – Idiopathic or associated with systemic granulomatous disease (e.g. sarcoidosis)  GALACTOCOELE Cystic dilatation of duct during lactation Caused by obstruction May become infected (acute mastitis) with abscess formation  FIBROCYSTIC CHANGES Common disorder – Present in 50% of women – Clinical symptoms in 10% of women Accounts for the majority of surgical procedures performed on the female breast Usually occurs at 20-40 years of age Due to oestrogen/progesterone imbalance Oestrogen Dominance: An imbalance where there is relatively more oestrogen compared to progesterone. Oestrogen promotes the growth and proliferation of breast tissue. Progesterone Insufficiency: Progesterone helps regulate the growth of the uterine lining during the menstrual cycle and has a counterbalancing effect to oestrogen. FIBROCYSTIC DISEASE: CLINICAL FEATURES May be asymptomatic Discomfort (cyclical) Nodularity Discrete lump (firm, rubbery) – If cyst, may be tense or fluctuant Nipple discharge  FIBROCYSTIC DISEASE Morphological changes affect glandular and stromal elements of the breast: – Cysts (ductal dilatation) Apocrine metaplasia – Fibrosis of the stroma – Adenosis- Increase in the number of acini per lobule Apocrine metaplasia Apocrine metaplasia is the replacement of normal glandular cells with cells that resemble those found in apocrine sweat glands. It is benign and often due to irritation/ inflammation  FIBROCYSTIC CHANGES Proliferative changes – Epitheliosis- epithelial hyperplasia (more than 2 cell layers) No atypia (Usual type) Atypical, sharing some architectural and cytological features of in- situ carcinoma – Sclerosing lesions – Intraduct papilloma  FIBROADENOMA Most common benign tumour of the female breast Occurs after puberty and usually before 30 years of age Most commonly present as solitary, well defined, freely moveable mass (‘breast mouse’) Usually solitary (20% multiple) Combined proliferation of epithelium and connective tissue Fibrous stroma compressing glands Respond to oestrogen and progesterone and thus size may fluctuate with the menstrual cycle  PHYLLODES TUMOUR Larger and older (>45 years) compared to most fibroadenomas Morphologically resembles fibroadenoma but may grow to large size (10-15 cm in diameter) and thus are also called giant fibroadenomas “Leaf-like” clefts and slits and thus are also called cystosarcoma phyllodes Combined proliferation of epithelium and connective tissue (predominantly stroma)  PHYLLODES TUMOUR Can be benign or malignant in their behaviour Morphologically the malignant variants exhibit increased stromal cellularity, pleomorphism and mitotic rate and infiltrative growth pattern Malignant variants tend to recur locally and may also metastasise (15% of cases) CLINICAL SIGNIFICANCE OF BENIGN EPITHELIAL CHANGES Non-proliferative changes: No increased risk of breast ca Proliferative disease without atypia: Mild risk (1.5-2x) Proliferative disease with atypia: Moderate risk (4-5x)  SCLEROSING LESIONS Extensive fibrosis/sclerosis and adenosis May mimic carcinoma on radiology and histology – Sclerosing adenosis (often part of fibrocystic change or may form a discrete lesion) – Radial scar/complex sclerosing lesion Radial scar/complex sclerosing lesion  INTRADUCTAL PAPILLOMA Benign neoplastic papillary growth occurring within lactiferous duct Pre-menopausal women Fibrovascular projections lined by epithelial and myoepithelial cells Presents with serous or bloody nipple discharge Can recur (especially if inadequately excised)  GYNECOMASTIA Enlargement of the male breast Unilateral in 70% Oestrogen excess: cirrhosis, puberty, testicular tumours, treatment, idiopathic (older men) Drugs: Spironolactone, Chlorpromazine, Cimetidine, Androgens, alcohol, marijuana and heroin, Prolactin excess: pituitary- hypothalamus