Histopathology and staging of breast cancer
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Histopathology and staging of breast cancer Prof T J Stephenson. Physiological conditions. Pregnancy and lactation Gynaecomastia Involution. Fibrocystic change. Adenosis Fibrosis Cysts Epithelial hyperplasia (+/- atypia) Apocrine metaplasia. Inflammatory conditions. Acute mastitis

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Histopathology and staging of breast cancer Prof T J Stephenson

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Histopathology and staging of breast cancer prof t j stephenson

Histopathology and staging of breast cancer

Prof T J Stephenson


Physiological conditions

Physiological conditions

  • Pregnancy and lactation

  • Gynaecomastia

  • Involution


Fibrocystic change

Fibrocystic change

Adenosis

Fibrosis

Cysts

Epithelial hyperplasia (+/- atypia)

Apocrine metaplasia


Inflammatory conditions

Inflammatory conditions

  • Acute mastitis

  • Abscess

  • Duct ectasia

  • Fat necrosis


Benign tumours

Benign tumours

  • Fibroadenoma

  • Adenoma

  • Intraduct papilloma

  • Connective tissue neoplasms


Fibroadenoma

Fibroadenoma

Commonest benign tumour

Biphasic

Very characteristic clinico-pathological features


Histopathology and staging of breast cancer prof t j stephenson

← Circumscribed lesion

Epithelium and stroma →


Intraduct papilloma

Intraduct papilloma

  • Middle aged women

  • Blood stained nipple discharge from large ducts

  • Typical papillary structures with fibrovascular cores


Histological risk factors

Histological risk factors


Lobular carcinoma in situ

Lobular carcinoma in situ

  • 6% of breast malignancies

  • Premenopausal

  • Impalpable

  • Up to ⅓ develop invasive cancer if only biopsied

  • Equal risk in both breasts, unless PLCIS which behaves like DCIS


Ductal carcinoma in situ

Ductal carcinoma in situ

  • Mass / Paget’s / discharge / screening

  • Different histological types / grades

  • All have slightly different characteristics


Risk factors

Risk factors

  • Female gender

  • Cancer in other breast

  • Long interval between menarche and menopause

  • Age at first full-term pregnancy

  • Not breast feeding

  • Obesity and high fat diet

  • Family history

  • Geographical factors

  • Histological risk factors


Breast cancer

Breast cancer

20% of all cancers in women, (second only to lung)

Commonest cancer in the UK

Commonest cause of death in women 35 – 55

In UK, women have 1:8 lifetime chance of developing it (but 1:33 by 50)

48417 new cases per year (2009) and rising

11556 deaths in UK per year (2010) and falling


Histopathology and staging of breast cancer prof t j stephenson

Insertion of guide wire


Histopathology and staging of breast cancer prof t j stephenson

UK has worst figures


Histopathology and staging of breast cancer prof t j stephenson

World variations in mortality


Invasive carcinomas

Invasive carcinomas


Elston ellis modification of bloom and richardson grading

Elston/Ellis modification of Bloom and Richardson Grading

Detailed Criteria used in Histologic Grade

Glandular (Acinar)/Tubular Differentiation

Score 1: >75% of tumor area forming glandular/tubular structures

Score 2: 10% to 75% of tumor area forming glandular/tubular structures

Score 3: <10% of tumor area forming glandular/tubular structures

Nuclear Pleomorphism

Score 1: Nuclei small with little increase in size in comparison with normal breast epithelial cells, regular outlines, uniform nuclear chromatin, little variation in size

Score 2: Cells larger than normal with open vesicular nuclei, visible nucleoli, and moderate variability in both size and shape

Score 3: Vesicular nuclei, often with prominent nucleoli, exhibiting marked variation in size and shape, occasionally with very large and bizarre forms

Mitotic Count

The mitotic count score criteria vary depending on the field diameter of the microscope used by the pathologist. The pathologist will count how many mitotic figures are seen in 10 high power fields. Using a high power field diameter of 0.50 mm, the criteria is as follows:

Score 1: less than or equal to 7 mitoses per high power field

Score 2: 8-14 mitoses per high power field

Score 3: equal to or greater than 15 mitoses per high power field

Overall Grade

Grade 1: scores of 3, 4, or 5

Grade 2: scores of 6 or 7

Grade 3: scores of 8 or 9


Spread and staging

Spread and Staging

  • Local

  • Intra-cavity

  • Lymphatic

  • Blood stream


Histopathology and staging of breast cancer prof t j stephenson

Lymph drainage


Histopathology and staging of breast cancer prof t j stephenson

  • TNM definitions

  • Primary tumor (T):

    • TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in situ; intraductal carcinoma, lobular carcinoma in situ, or

      • Paget's disease of the nipple with no associated tumor. Note: Paget's disease associated with a tumor is classified according to the size of the tumor.

    • T1: Tumor 2.0 cm or less in greatest dimension

      • T1mic: Microinvasion 0.1 cm or less in greatest dimension T1a: Tumor more than 0.1 but not more than 0.5 cm in greatest dimension T1b: Tumor more than 0.5 cm but not more than 1.0 cm in greatest dimension T1c: Tumor more than 1.0 cm but not more than 2.0 cm in greatest dimension

    • T2: Tumor more than 2.0 cm but not more than 5.0 cm in greatest dimension

    • T3: Tumor more than 5.0 cm in greatest dimension

    • T4: Tumor of any size with direct extension to (a) chest wall or (b) skin,

      • only as described below. Note: Chest wall includes ribs, intercostal muscles, and serratus anterior muscle but not pectoral muscle. T4a: Extension to chest wall T4b: Edema (including peau d'orange) or ulceration of the skin of the

        • breast or satellite skin nodules confined to the same breast T4c: Both of the above (T4a and T4b) T4d: Inflammatory carcinoma*


Histopathology and staging of breast cancer prof t j stephenson

  • TNM definitions

  • Regional lymph nodes (N):

    • NX: Regional lymph nodes cannot be assessed (e.g., previously removed) N0: No regional lymph node metastasis N1: Metastasis to movable ipsilateral axillary lymph node(s) N2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other or

      • to other structures N3: Metastasis to ipsilateral internal mammary lymph node(s) Pathologic classification (pN):

    • pNX: Regional lymph nodes cannot be assessed (not removed for pathologic

      • study or previously removed) pN0: No regional lymph node metastasis pN1: Metastasis to movable ipsilateral axillary lymph node(s)

      • pN1a: Only micrometastasis (none larger than 0.2 cm) pN1b: Metastasis to lymph node(s), any larger than 0.2 cm

        • pN1bi: Metastasis in 1 to 3 lymph nodes, any more than 0.2 cm and all

          • less than 2.0 cm in greatest dimension pN1bii: Metastasis to 4 or more lymph nodes, any more than 0.2 cm and

          • all less than 2.0 cm in greatest dimension pN1biii: Extension of tumor beyond the capsule of a lymph node

          • metastasis less than 2.0 cm in greatest dimension pN1biv: Metastasis to a lymph node 2.0 cm or more in greatest dimension pN2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other

      • or to other structures pN3: Metastasis to ipsilateral internal mammary lymph node(s)


Histopathology and staging of breast cancer prof t j stephenson

  • TNM definitions

  • Distant metastasis (M):

    • MX: Presence of distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis present (includes metastasis to ipsilateral

      • supraclavicular lymph nodes)


Prognosis

Prognosis

  • PI = 0.2(cm size) + grade (1, 2 or 3) + LN stage* (1, 2 or 3)

  • LN stage:

    1 = not involved

    2 = 1 – 3 nodes involved

    3 = 4 or more nodes involved or level 3


Prognosis1

Prognosis


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