1. Histopathology and staging of breast cancer
Prof T J Stephenson

2. Physiological conditions
Pregnancy and lactation
Gynaecomastia
Involution

5. Fibrocystic change Adenosis Fibrosis Cysts
Epithelial hyperplasia (+/- atypia)
Apocrine metaplasia

9. Inflammatory conditions
Acute mastitis
Abscess
Duct ectasia
Fat necrosis

10. Benign tumours Fibroadenoma Adenoma Intraduct papilloma
Connective tissue neoplasms

11. Fibroadenoma Commonest benign tumour Biphasic
Very characteristic clinico-pathological features

12. ← Circumscribed lesion
Epithelium and stroma →

13. Intraduct papilloma Middle aged women
Blood stained nipple discharge from large ducts
Typical papillary structures with fibrovascular cores

15. Histological risk factors
Risk x normal
FH-
FH+
Hyperplasia
1.9
2.4
With atypia
5.3 10
DCIS
9-12

16. 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

18. Ductal carcinoma in situ
Mass / Paget’s / discharge / screening
Different histological types / grades
All have slightly different characteristics

21. 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

22. 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 22

26. Insertion of guide wire

29. UK has worst figures

30. 30

31. World variations in mortality

37. Invasive carcinomas Type % Invasive ductal 85 Invasive lobular 10
Mucinous 2
Tubular
Medullary
<1
Papillary
Others

38. 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

39. Spread and Staging
Local
Intra-cavity
Lymphatic
Blood stream

40. Lymph drainage

42. 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*

43. 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)

44. 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)

46. 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

47. Prognosis PI % symptomatic patients % 15 year survival <3.4 29 80
3.5 – 5.4 54 42
>5.4 17 13