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Pathology practical specimen tellin viva
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I now have excellent material. Let me compile the full viva answer for this carcinoma breast specimen.
Carcinoma Breast - Pathology Practical Viva
Specimen label: CARCINOMA BREAST (BR 21) - This is a Modified Radical Mastectomy (MRM) specimen preserved in formalin, showing the breast tissue with the tumor mass.
1. IDENTIFY THE SPECIMEN
"This is a modified radical mastectomy specimen showing carcinoma of the breast, preserved in 10% formalin."
Structures to identify:
- Breast mound with overlying skin (+/- nipple-areola complex)
- Axillary tail (with lymph nodes in MRM)
- Cut surface showing the tumor mass - usually gray-white, hard, irregular, with stellate/spiculated margins
2. GROSS DESCRIPTION (Describe what you see)
| Feature | Typical Finding |
|---|---|
| Specimen type | Modified radical mastectomy |
| Size | State overall dimensions |
| Skin | May show dimpling, peau d'orange, nipple retraction |
| Cut surface | Gray-white/chalky-white, hard, gritty on cutting (grating sound), irregular stellate margins |
| Tumor | Size, location (outer upper quadrant most common - 60%), borders |
| Desmoplasia | Dense fibrous stroma around tumor (scirrhous carcinoma) |
| Axillary nodes | Number identified, any gross involvement |
What you see here: Two halves of the breast with a firm gray-white tumor mass with irregular borders - classic invasive carcinoma of no special type (previously called invasive ductal carcinoma NOS).
3. VIVA QUESTIONS - Expected Q&A
Q: What type of specimen is this?
Modified Radical Mastectomy (MRM) - removal of breast + axillary lymph nodes (levels I & II), preserving pectoralis major. Halsted's radical mastectomy (removed pec major/minor) is now obsolete.
Q: What is the most common histological type of breast carcinoma?
Invasive carcinoma of no special type (NST) (previously called invasive ductal carcinoma/IDC) - accounts for ~75% of all invasive breast carcinomas. The gross cut surface is characteristically hard, grayish-white, with chalky streaks from desmoplastic stroma, producing a grating sound when cut.
Q: What is the most common site in the breast?
Upper outer quadrant (60%) due to the greatest amount of breast tissue (axillary tail of Spence).
Q: What are the microscopic features?
- Irregular nests, cords, and single cells infiltrating dense fibrous stroma
- Desmoplastic stromal reaction (key feature)
- Graded by Nottingham Histologic Score (Elston-Ellis modification):
- Tubule formation (1-3)
- Nuclear pleomorphism (1-3)
- Mitotic count (1-3)
- Grade 1 (3-5): Well differentiated
- Grade 2 (6-7): Moderately differentiated
- Grade 3 (8-9): Poorly differentiated
Q: What are the molecular/biological subtypes?
| Subtype | ER | PR | HER2 | Prognosis |
|---|---|---|---|---|
| Luminal A | + | + | - | Best |
| Luminal B | + | +/- | +/- | Intermediate |
| HER2-enriched | - | - | + | Intermediate |
| Triple Negative (TNBC) | - | - | - | Worst |
Q: What are the risk factors?
- Hormonal: Early menarche, late menopause, nulliparity, late first pregnancy, exogenous estrogen (OCP, HRT)
- Genetic: BRCA1 (chromosome 17q), BRCA2 (chromosome 13q) - account for ~half of single-gene mutation cases; also PALB2, TP53
- Other: Fibrocystic disease with atypical hyperplasia, prior breast cancer, radiation, obesity, alcohol
Q: What is Paget's disease of nipple?
Extension of carcinoma cells (from underlying DCIS or invasive carcinoma) into the nipple epidermis. Paget cells = large pale cells with abundant pale cytoplasm within the epidermis. Presents as eczematoid change of nipple.
Q: What is lymphatic spread of breast carcinoma?
- Primary route: Axillary lymph nodes (>75%)
- Parasternal/internal mammary nodes (medial tumors)
- Supraclavicular nodes (late)
- "Contralateral axillary nodes" via cross-lymphatics
Q: What is the precursor lesion (in situ carcinoma)?
- DCIS (Ductal Carcinoma In Situ): Confined to ducts, does NOT invade basement membrane. Precursor to invasive ductal carcinoma. Often detected by mammographic calcifications.
- LCIS (Lobular Carcinoma In Situ): Marker of increased bilateral risk. Loss of E-cadherin (diagnostic feature).
Q: What are the sites of distant metastasis?
Bone (most common, lytic lesions), Lung, Liver, Brain, Adrenal, Ovary. "Bone" mnemonic: Bone, Lung, Liver, Brain.
Q: What is inflammatory breast carcinoma?
Clinically presents with peau d'orange (orange-peel skin), erythema, warmth, rapid enlargement - due to dermal lymphatic permeation by tumor cells. NOT inflammation - it is carcinoma obstructing dermal lymphatics. Most aggressive presentation (T4d). Diagnosed clinically.
Q: What is sentinel lymph node biopsy?
First draining lymph node from the tumor - mapped by blue dye (isosulfan blue) or technetium-labeled colloid. If SLN negative, full axillary dissection can be avoided.
Q: What is the staging system?
TNM staging (AJCC 8th edition) - uniquely, the 8th edition combines anatomic stage with molecular group (ER, PR, HER2, grade) into prognostic stage groups.
Q: What is scirrhous carcinoma?
A macroscopic term for the hard, fibrous texture due to pronounced desmoplastic reaction - dense fibrous stroma produced in response to invasive tumor cells. Appears gray-white, gritty, with chalky streaks. This is the classic gross appearance in the specimen before you.
4. KEY GROSS FEATURES TO SAY IN VIVA
- Cut surface - gray-white, firm, irregular stellate margins
- Grating/chalky sound on cutting (desmoplasia + calcification)
- Skin changes if present - dimpling (Cooper's ligament involvement), peau d'orange (lymphatic blockage), nipple retraction
- Axillary nodes - number, size, matted or discrete
- Margins - comment on surgical margins
5. QUICK REVISION MNEMONICS
Risk factors - "ABCDE + FGHIJ":
- A = Age (>50), Alcohol
- B = BRCA1/2
- C = Contraceptives (OCP), Childlessness
- D = Dense breast tissue, Diet (high fat)
- E = Early menarche, Exogenous estrogen
Routes of spread - "DLHB":
- Direct, Lymphatic (axillary #1), Haematogenous (Bone #1), Blood-borne
Source: Robbins, Cotran & Kumar - Pathologic Basis of Disease (Invasive Carcinoma of the Breast, Ch. 23); Robbins & Kumar Basic Pathology
Good luck in your viva! The specimen (BR 21) labeled "CARCINOMA BREAST" is a classic teaching specimen - focus on describing the gross cut surface (stellate, firm, gray-white, desmoplastic), the type (invasive NST/IDC), staging (TNM), and the molecular subtypes.
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